Recurring concern

Unreliable escalation of patient telephone referrals to GPs

First to latest report 16 Dec 2013 — 11 Mar 2024

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 8

What this concern includes

Includes failures in the dedicated GP telephone-referral process to receive, identify, prioritise, interrupt or otherwise alert the GP to clinically important patient information or deterioration, including tracking and assurance that patient enquiries are escalated and acted upon.

What is not included

Excludes general GP appointment access, referral-route or consultation-capacity failures where telephone-referral escalation is not the deficient control.
Excludes failures to provide clinical assessment or treatment after the GP has been reliably alerted and has accepted responsibility.
Excludes generic communication, staffing, documentation or workload deficiencies unless they directly impair escalation of a patient telephone referral or enquiry to the GP.
Excludes non-GP referrals and communications with specialist or emergency services unless the assertion explicitly concerns the same GP telephone-referral escalation process.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Church Elm Lane Medical Practice1

Daughter of the deceased1

Hama Medical Centre1

Ministry of Justice1

NHS England1

Office of the Chief Coroner1

Sunderland Coroner's Service1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

11 Mar2024
East London
Concerns raised1
1. Failure to demonstrate improvement in escalation of patient enquiries to GPs
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Church Elm Lane Medical Practice
Stated actions 8
1. Church Elm Lane Medical Practice
  Provide staff training on using the auditable message book, direct clinician escalation and avoiding screen messaging for patient queries.
2. Church Elm Lane Medical Practice
  Stop using screen messaging for patient or clinical matters and use the tracked message book or direct clinician communication instead.
3. Church Elm Lane Medical Practice
  Provide Lead GP reception support for staff queries, message-book use and care navigation during busy periods.
1. Church Elm Lane Medical Practice
  Develop a reliable auditable communication system by using EMIS messaging, retaining tracked message-book processes and building an urgent-communication template.
2. Church Elm Lane Medical Practice
  Establish a comprehensive staff training programme, including provider engagement, identified learning needs and arrangements to release staff for training.
3. Church Elm Lane Medical Practice
  Deliver scenario-based triage training and schedule recurring biannual sessions, with additional training when needed.
4. Church Elm Lane Medical Practice
  Review and update communication, escalation and emergency policies through team engagement and a review process.
5. Church Elm Lane Medical Practice
  Develop and use a Message Book protocol and telephone call supervision audit.
AI-generated summary

Keith Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Keith Smith experienced worsening back and chest pain in early July 2023 and sought help from his GP on 3, 4 and 5 July. GP call-backs did not occur, and on 5 July his family contacted 111, after which an ambulance diagnosed a myocardial infarction; he suffered cardiac arrest and died shortly after midnight on 6 July 2023. The principal concern was that the GP surgery could not provide persuasive evidence that procedures, staffing and training had improved the recording and escalation of calls or the monitoring of GP call-backs.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to demonstrate improvement in escalation of patient enquiries to GPs
Wider context from the report
“The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients. ”
Source location
Keith Smith · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide staff training on using the auditable message book, direct clinician escalation and avoiding screen messaging for patient queries.

Verbatim wording from the response
“Staff Training on Message Escalation: Training sessions were conducted to emphasize the importance of using the auditable message book for call escalation with direct communication with doctors for urgent concerns and screen messages not to be used for any patient-related queries. Two targeted internal training events with clinical and non-clinical staff have taken place to review and implement changes to the process of escalating clinical matters to the clinical team, and following up on this to see if this has been addressed and actioned (Appendix 1, 2, 3).”

Source location
Response from Church Elm Lane Medical Practice
Page 5 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Stop using screen messaging for patient or clinical matters and use the tracked message book or direct clinician communication instead.

Verbatim wording from the response
“Care Navigation and Escalation Training: Staff were instructed to immediately stop using the screen messaging system for patient or any clinical related matters or communication, favouring the message book and/or direct doctor communication. All staff encouraged to seek help and advice if they were concerned about any patient contact. We are currently in discussions with the ICB (Integrated Care Board) and CEPN (Community Education Provider Network) on how we can access this training on a regular basis, not just for our staff but all staff across Barking and Dagenham.”

Source location
Response from Church Elm Lane Medical Practice
Page 6 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide Lead GP reception support for staff queries, message-book use and care navigation during busy periods.

Verbatim wording from the response
“GP Observation of Reception Staff: To gain an immediate insight of the current situation, a Lead GP has spent time at reception to help staff with queries and to deal with any concerns regarding the message book. With the Lead GP present, staff have been able to ask questions immediately, provide and receive feedback, and gain confidence in the new procedure. To ensure understanding and compliance with training, we are looking at mechanisms to embed systems and processes for regular review and reporting of monitoring and training.”

Source location
Response from Church Elm Lane Medical Practice
Page 6 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a reliable auditable communication system by using EMIS messaging, retaining tracked message-book processes and building an urgent-communication template.

Verbatim wording from the response
“Objective: Implement a robust, failsafe communication system that ensures all patient calls and messages are logged, tracked, and audited effectively.”

Source location
Response from Church Elm Lane Medical Practice
Page 6 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a comprehensive staff training programme, including provider engagement, identified learning needs and arrangements to release staff for training.

Verbatim wording from the response
“Comprehensive Staff Training Program”

Source location
Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver scenario-based triage training and schedule recurring biannual sessions, with additional training when needed.

Verbatim wording from the response
“Listening to staff calls on a regular basis and assessing training needs. Following the Coroner's report, we audited a random selection of telephone calls and gave 1:1 feedback (Appendix 7). Scenario-based training on triage protocols to ensure staff are prepared to escalate calls appropriately was undertaken at our training session on 22/4/24, where all non-clinical staff were present. These sessions will be run on a biannual basis (Appendix 4). However, if we need to complete any ad hoc training – based on need, we will. We are also exploring other training offers on this by the ICS and ICB such as training on care navigation and pharmacy first. On Monday mornings which is our busiest times there is a GP at reception to observe and help with queries and navigations.”

Source location
Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and update communication, escalation and emergency policies through team engagement and a review process.

Verbatim wording from the response
“Policy and Procedure Review”

Source location
Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and use a Message Book protocol and telephone call supervision audit.

Verbatim wording from the response
“Following regular meetings with staff we have developed a Message Book protocol (Appendix 9) and a call supervision audit (Appendix 7)”

Source location
Response from Church Elm Lane Medical Practice
Page 7 · response
Published 14 March 2024
Open published response
16 Dec2013
Nottinghamshire
Concerns raised1
1. Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Cynthia Fretwell · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals
Wider context from the report
“(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”
Source location
Cynthia Fretwell · Prevention of Future Deaths report
Page 1 · concerns
Open source report