Recurring concern

Unreliable GP appointment triage for determining clinical urgency

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First reported 4 Dec 2013•Latest report 4 Apr 2025

Definition

What this concern includes

Includes deficiencies in GP surgery appointment triage that affect recognition, assessment or escalation of clinical urgency, including failures involving guidance for non-clinical staff, collection of urgency information, or selection of the appropriate clinician or appointment priority.

Not included

Excludes generic staffing, training or documentation deficiencies unless they are specifically tied to GP appointment triage.
Excludes delays or failures in clinical care after an appointment has been arranged.
Excludes ambulance, hospital, specialist-service or non-GP referral triage processes.
Excludes general communication or information-sharing failures that do not concern determining GP appointment urgency or clinical access.

Reports: 9
Individual concerns: 10
Date range: 2013–2025
Stated actions: 21

Reports 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.

Department of Health and Social Care2

NHS England2

Ashton Medical Centre1

Black Country Family Practice1

College of Policing1

Devon Local Medical Committee1

Family of Richard Parkes1

gtd healthcare1

Hereford Medical Group1

Leeds Teaching Hospitals NHS Trust1

Livewell Southwest1

London Ambulance Service NHS Trust1

Medway NHS Foundation Trust1

NHS Greater Manchester Integrated Care Board1

One Medical Group1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

4 Apr2025
Manchester West
Concerns raised2
1. Failure to allocate medication enquiries to clinicians with appropriate competencies
2. Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Formalise and reinforce the policy prohibiting pharmacists from prescribing or altering medication for children, except where consultant letters explicitly authorise it.
  Stated by Ashton Medical Centre and SSP HealthStated completed
2. Action
  Review the centralised clinical competencies register, distribute it to care navigation teams, and review it biannually.
  Stated by Ashton Medical Centre and SSP HealthStated in progress
3. Action
  Review the clinicians’ capabilities matrix and conduct a further review by June 2025.
  Stated by Ashton Medical Centre and SSP HealthStatus at response
1. Action
  Reinforce the process for directing paediatric medication requests away from pharmacists and provide related staff training reminders.
  Stated by Ashton Medical Centre and SSP HealthStated completed
2. Action
  Develop and share a learning document on safe, effective referrals to treating clinicians with Greater Manchester practices.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
3. Action
  Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
4. Action
  Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
5. Action
  Audit care navigator decisions and task-completion checks quarterly.
  Stated by Ashton Medical Centre and SSP HealthStated completed
Respondent positions 3
1. Position
  The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
  Stated by Ashton Medical Centre and SSP HealthDisputes the concern
1. Position
  Existing pathways, triage guidance, staff training, policies and escalation procedures provide a clear and adequate response to urgent patient calls.
  Stated by Ashton Medical Centre and SSP HealthExisting arrangements considered sufficient
2. Position
  The recorded request appears to have been for an alternative antibiotic, not an appointment requiring clinical assessment.
  Stated by Ashton Medical Centre and SSP HealthDisputes the concern
AI-generated summary

Hailey Anne Thompson · 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

Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.

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 allocate medication enquiries to clinicians with appropriate competencies
Wider context from the report
“2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her. 3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice. 4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock. 5. No evidence was provided to: a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice, b. whether a list of clinician competencies and whom to refer tasks to was held c. Care Navigator training d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery. 6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to. 7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances. ”
Source location
Hailey Anne Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor
Wider context from the report
“2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her. 3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice. 4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock. 5. No evidence was provided to: a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice, b. whether a list of clinician competencies and whom to refer tasks to was held c. Care Navigator training d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery. 6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to. 7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances. ”
Source location
Hailey Anne Thompson · 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
Formalise and reinforce the policy prohibiting pharmacists from prescribing or altering medication for children, except where consultant letters explicitly authorise it.

Verbatim wording from the response
“• Our pharmacists do not prescribe for children. This has been further reinforced within our teams and further formalised in a policy, preventing pharmacists who work with the practice from issuing or altering antibiotics or medications for children, except when stated explicitly in consultant letters.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 2 · response
Published 11 April 2025
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 the centralised clinical competencies register, distribute it to care navigation teams, and review it biannually.

Verbatim wording from the response
“• Our centralised competencies register is under review for all clinical staff, including pharmacists, which will be distributed to care navigation teams and reviewed biannually.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 2 · response
Published 11 April 2025
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 the clinicians’ capabilities matrix and conduct a further review by June 2025.

Verbatim wording from the response
“• We reviewed the clinicians’ capabilities matrix accessible by all staff, this will be further reviewed by June 2025.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 5 · response
Published 11 April 2025
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
Reinforce the process for directing paediatric medication requests away from pharmacists and provide related staff training reminders.

Verbatim wording from the response
“• The pharmacists manage prescription requests changes for adults not children, on this occasion the call-handler sent it through to the pharmacist. All staff have been reminded of the process to follow with training reinforced.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 5 · response
Published 11 April 2025
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 share a learning document on safe, effective referrals to treating clinicians with Greater Manchester practices.

Verbatim wording from the response
“I have reviewed the response from SSP Health to this part of your report and think there is some learning for primary care providers around ensuring efficient and effective access to the right clinician to treat them and the requirement to ensure accurate, detailed and timely record keeping. To this aim, I will ensure that:”

Source location
Response from Greater Manchester Integrated Care
Page 3 · response
Published 11 April 2025
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
Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.

Verbatim wording from the response
“NHS GM recognises the importance of staff training in all our primary care practices to ensure that patients are navigated correctly and in a timely way as appropriate for the symptoms they are presenting with, including providing appropriate and timely treatment. NHS GM will”

Source location
Response from Greater Manchester Integrated Care
Page 3 · response
Published 11 April 2025
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
Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.

Verbatim wording from the response
“NHS GM recognises the importance of staff training in all our primary care practices to ensure that patients are navigated correctly and in a timely way as appropriate for the symptoms they are presenting with, including providing appropriate and timely treatment. NHS GM will”

Source location
Response from Greater Manchester Integrated Care
Page 3 · response
Published 11 April 2025
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
Audit care navigator decisions and task-completion checks quarterly.

Verbatim wording from the response
“• We have a quarterly audit, reviewing care navigator decisions and task completion checks.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 4 · response
Published 11 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.

Verbatim wording from the response
“We acknowledge the concerns raised regarding care navigation, governance, and communication processes, and would like to take this opportunity to provide assurances of the processes that are embedded into the practice. We note that you state that you concluded that the concerns you raised did not contribute to the death and would also point out that the structures and operating procedures which are used at the surgery are consistent with those used in the vast majority of doctors surgeries in the UK. As a result, we would ask you to consider if a Regulation 28 Report is appropriate in these circumstances.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 1 · response
Published 11 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing pathways, triage guidance, staff training, policies and escalation procedures provide a clear and adequate response to urgent patient calls.

Verbatim wording from the response
“• Ashton Medical Centre have a clear pathway of whom to refer a task to, action and triage tools that would recognise an allergic reaction or ‘red flag’ symptom. These tools are in the form of guidance sheets which are available to all admin staff at their desks, SOPs which are available in paper format and electronic copies held on the practices drive. All staff are trained on these at induction and regularly reminded.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 3 · response
Published 11 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The recorded request appears to have been for an alternative antibiotic, not an appointment requiring clinical assessment.

Verbatim wording from the response
“• Our well-embedded organisational policies suggest that the request was likely made to obtain an alternative medication following an adverse reaction to the original antibiotics.”

Source location
Response from SSP Health and Ashton Medical Practice
Page 5 · response
Published 11 April 2025
Open published response
17 Oct2024
Manchester South
Concerns raised1
1. Failure to provide competent triage and allocation of mental health appointments
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the induction process for agency staff to cover key patient-direction and clinician-allocation processes.
  Stated by gtd healthcareStated completed
2. Action
  Introduce an interim reception triage template guiding symptom questions, appointment allocation and escalation to the on-call GP.
  Stated by gtd healthcareStated completed
3. Action
  Introduce a digital front door requiring clinician review of online or staff-completed triage requests before appointment allocation.
  Stated by gtd healthcareStated completed
Respondent positions 1
1. Position
  Concerns about care and documentation should be addressed by the provider, rather than NHS England or the CQC.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Leslie Andrew Swindells · 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

Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.

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 provide competent triage and allocation of mental health appointments
Wider context from the report
“3. The appointment had been booked via the reception team with no triage by a doctor following a telephone call to the practice. The evidence was that a shortage of trained reception/admin staff meant that an agency worker was screening calls that day and had a limited understanding of how patients needed to be allocated. ”
Source location
Leslie Andrew Swindells · 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
Review the induction process for agency staff to cover key patient-direction and clinician-allocation processes.

Verbatim wording from the response
“• We have reviewed the induction process for agency staff to ensure that they are aware of all key processes within the practice for directing patients to the appropriate clinicians.”

Source location
Response from GTD Healthcare
Page 4 · response
Published 17 October 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
Introduce an interim reception triage template guiding symptom questions, appointment allocation and escalation to the on-call GP.

Verbatim wording from the response
“• We introduced an interim reception triage template to assist reception staff with their initial data gathering and to ensure that the right type of appointment was booked with an appropriate clinician. This template prompts the receptionist to ask key questions and then guides them to an appropriate outcome, for example, urgent same-day appointments with a registered clinician are recommended in cases where the patient is demonstrating severe mental health problems (including suicidal ideation, new hallucinations, delusions or paranoia). In any cases where they are uncertain about the appropriate outcome or concerned about the patient's symptoms, receptionists are required to discuss the patient with the on-call GP.”

Source location
Response from GTD Healthcare
Page 4 · response
Published 17 October 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
Introduce a digital front door requiring clinician review of online or staff-completed triage requests before appointment allocation.

Verbatim wording from the response
“• We introduced a 'digital front door' at Hattersley Group Practice on the 18th November 2024. This online tool, which has already been successfully launched in other gtd practices, requires the patient or a family member to complete an online triage form. This is then reviewed by a doctor or an advanced clinical practitioner to determine the appropriate pathway for the patient to manage their request. Where a patient is unable to access the online forms, they can contact the practice directly and the staff will go through the questions and complete the form on their behalf so that the form can then be processed in the same way as had the patient completed it themselves. Forms are reviewed daily and the system is integrated with the Electronic Patient Record, EMIS, so that requests are saved directly to the patient's record with one click.”

Source location
Response from GTD Healthcare
Page 5 · response
Published 17 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Concerns about care and documentation should be addressed by the provider, rather than NHS England or the CQC.

Verbatim wording from the response
“Upon review, many concerns fall within the remit of the provider and their responsibility as an employer to meet the fundamental standards set out in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

Source location
Response from DHSC
Page 1 · response
Published 17 October 2024
Open published response
4 Oct2023
Herefordshire
Concerns raised1
1. Failure of triage clinicians to be aware of routine appointment waiting times
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Communicate routine and soon appointment availability to all staff weekly through the staff newsletter.
  Stated by Hereford Medical GroupStated planned
2. Action
  Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.
  Stated by Hereford Medical GroupStated completed
Respondent positions 1
1. Position
  The existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.
  Stated by Hereford Medical GroupExisting arrangements considered sufficient
AI-generated summary

Ronald Leslie HARRIS · 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

Ronald Leslie Harris’s family contacted the practice in April 2023 about worsening mental health difficulties and requested further help, but a routine appointment was offered with a stated 4–6 week wait and no follow-up call was made. He died by suicide on 5 June 2023. Concerns included incomplete triage documentation, failure to make the requested call, and the triage doctor’s lack of awareness of the waiting time and the telephone-call transcript; a review of mental-health triage protocols was noted, but no revised protocol had been advised by the inquest.

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 of triage clinicians to be aware of routine appointment waiting times
Wider context from the report
“(3) The Inquest was advised the triage Doctor was not aware of the waiting time for a routine appointment (4-6 weeks) nor did he consider the transcript of the telephone call. ”
Source location
Ronald Leslie HARRIS · 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
Communicate routine and soon appointment availability to all staff weekly through the staff newsletter.

Verbatim wording from the response
“We have taken significant measures to reduce the wait time for routine appointments by increasing the number of available routine appointments. The wait for a routine appointment is under continuous review and our current wait is around approximately 4 weeks. In future, this information will be communicated to all staff on a weekly basis using the staff newsletter.”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
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 the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.

Verbatim wording from the response
“We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.

Verbatim wording from the response
“We can confirm that the triage protocol was reviewed as part of the Significant Event meeting on 9th August 2023. No significant changes were seen to be needed from the GP triage protocol except for”

Source location
Response from Hereford Medical Group
Page 2 · response
Published 18 October 2023
Open published response
3 Dec2021
West Yorkshire Eastern
Concerns raised1
1. Failure to obtain sufficient information to assess appointment urgency and priority
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Provide bespoke training for reception and non-clinical staff on red flags, sepsis recognition and responding to patient concerns.
  Stated by OneMedical GroupStated completed
2. Action
  Deliver refresher red-flag training to all GP receptionists and non-clinical staff.
  Stated by OneMedical GroupStated completed
3. Action
  Audit GP practice telephone calls to assess whether reception staff appropriately probe appointment urgency.
  Stated by OneMedical GroupStated completed
1. Action
  Establish a five-year General Practice Development Programme supporting practice capacity and capabilities.
  Stated by Department of Health and Social CareStated completed
Respondent positions 3
1. Position
  Further receptionist probing was unlikely to have identified symptoms requiring an urgent appointment because meningitis symptoms probably were not present then.
  Stated by OneMedical GroupDisputes the concern
1. Position
  Annual refresher training for reception and non-clinical staff is considered sufficiently frequent and appropriate to maintain vigilance.
  Stated by OneMedical GroupExisting arrangements considered sufficient
2. Position
  Clinician-led initial consultation and triage provide a higher level of clinical safety, so receptionist questioning is not needed.
  Stated by Royal College of General PractitionersExisting arrangements considered sufficient
AI-generated summary

Alexander George Theodossiadis · 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

Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.

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 obtain sufficient information to assess appointment urgency and priority
Wider context from the report
“(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time. He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request. Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection. (2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and clinicians. ”
Source location
Alexander George Theodossiadis · Prevention of Future Deaths report
Page 1 · 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 bespoke training for reception and non-clinical staff on red flags, sepsis recognition and responding to patient concerns.

Verbatim wording from the response
“One Medical Group is acutely aware of the importance of appropriate training and has implemented a rigorous training programme. As explained in the letter dated 13 August 2020 from ████████, Director of Professions at One Medical Group (pages A.95 – A.98 of the inquest bundle), NHS England identified in the 2016 'GP Forward View' Guidance² that training for reception and non-clinical staff was a "high impact" action. As a result of this 2016 Guidance, One Medical Group developed and implemented bespoke training for its reception and non-clinical staff.”

Source location
2021-0412-Response-from-OneMedical-Group_Published
Page 3 · response
Published 10 December 2021
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 refresher red-flag training to all GP receptionists and non-clinical staff.

Verbatim wording from the response
“One Medical Group takes its learning obligations extremely seriously and you heard evidence from ████████ that, since Alex's death, refresher red flag training has been undertaken with all GP receptionists and non-clinical staff. In addition, an audit of telephone calls to the GP Practice was undertaken from September – November 2021. This audit found that all calls were handled in a friendly and professional manner, and reception staff asked appropriate questions to ascertain the urgency of the appointment i.e. appropriate probing occurred. You also heard evidence from ████████ that in mid-2020 more receptionists were employed by the GP practice in order to cope with pandemic-related additional demand and the intention is for these employees to remain in their role post-pandemic.”

Source location
2021-0412-Response-from-OneMedical-Group_Published
Page 2 · response
Published 10 December 2021
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
Audit GP practice telephone calls to assess whether reception staff appropriately probe appointment urgency.

Verbatim wording from the response
“One Medical Group takes its learning obligations extremely seriously and you heard evidence from ████████ that, since Alex's death, refresher red flag training has been undertaken with all GP receptionists and non-clinical staff. In addition, an audit of telephone calls to the GP Practice was undertaken from September – November 2021. This audit found that all calls were handled in a friendly and professional manner, and reception staff asked appropriate questions to ascertain the urgency of the appointment i.e. appropriate probing occurred. You also heard evidence from ████████ that in mid-2020 more receptionists were employed by the GP practice in order to cope with pandemic-related additional demand and the intention is for these employees to remain in their role post-pandemic.”

Source location
2021-0412-Response-from-OneMedical-Group_Published
Page 2 · response
Published 10 December 2021
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 five-year General Practice Development Programme supporting practice capacity and capabilities.

Verbatim wording from the response
“The 2016 General Practice Forward View strategy² provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, the five-year General Practice Development Programme was established. It included total funds of £45 million for allocation by Clinical Commissioning Groups to general practices for training of reception and clerical staff to undertake active signposting and document management. The active signposting training included an expectation for receptionists to be skilled and confident in sensitively ascertaining the nature of the patient’s need and exploring with them safe and appropriate options, including sources of advice and support outside the practice as well as within.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 10 December 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Further receptionist probing was unlikely to have identified symptoms requiring an urgent appointment because meningitis symptoms probably were not present then.

Verbatim wording from the response
“friendly" conversation in which Alex did not convey any urgency about the need for an appointment. This is consistent with your finding that, at the point Alex spoke to the GP receptionist, all involved (including Alex) felt he was suffering from flu like symptoms and did not consider it necessary to press the GP for an urgent appointment or to take him elsewhere to be cared for. On the balance of probabilities, therefore, had the receptionist probed to obtain further information she would likely have concluded that Alex did not require an urgent appointment.”

Source location
2021-0412-Response-from-OneMedical-Group_Published
Page 2 · response
Published 10 December 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Annual refresher training for reception and non-clinical staff is considered sufficiently frequent and appropriate to maintain vigilance.

Verbatim wording from the response
“It is therefore apparent that, during the training, significant emphasis is placed on the relevant red flag symptoms for meningitis and other conditions and that non-clinical staff are required to err on the side of caution if they have any concerns. One Medical Group considers the training is comprehensive and thorough and notes that no concerns have been raised about the content of the training provided.”

Source location
2021-0412-Response-from-OneMedical-Group_Published
Page 4 · response
Published 10 December 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Clinician-led initial consultation and triage provide a higher level of clinical safety, so receptionist questioning is not needed.

Verbatim wording from the response
“The system has moved from requests to receptionists to clinicians as initial point of consultation and triage. This is not the same as the suggested option of receptionists asking for information but should provide a higher level of clinical safety and service. There is no formal requirement for practices to consult in this way and they could still offer open face to face appointments, but most do not. The telephone clinician appointments are usually more rapidly available. This is in line with your request for more information to be gathered from patients when booking appointments.”

Source location
2021-0412-Response-from-Royal-College-of-GPs_Published
Page 2 · response
Published 10 December 2021
Open published response
28 Sep2021
South London
Concerns raised1
1. Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide care-navigation training materials and funding to support receptionist-led information gathering and emergency-symptom identification.
  Stated by NHS EnglandStated completed
2. Action
  Develop a training programme with Health Education England for clinical and non-clinical staff supporting care navigation and emergency-symptom identification.
  Stated by NHS EnglandStated in progress
3. Action
  Provide Digital First Primary Care guidance for implementing online consultations, including clinical safety, risk management, incident reporting, and limits on online triage.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  Each individual GP practice is responsible for ensuring its staff are suitably trained and experienced for delegated tasks.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Richard Boateng · 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

Richard Boateng became very unwell after contacting his GP surgery and was later found on a street bench. Police and ambulance services attended, but he died from Covid 19 shortly after arriving at hospital; concerns included the handling of urgent GP calls, communication between ambulance and police services, and practical guidance for police when ambulances were unavailable.

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
Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency
Wider context from the report
“(1) NHS England. A call to the GP surgery the day before Richard’s death was taken by a receptionist who arranged a routine appointment. She was not a clinician and only had on the job training. The surgery has since introduced a system called Klinik which is safer. It prompts questions and uses an algorithm to alert any urgent or emergency calls that are then flagged. All calls are also reviewed by clinicians. However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgments as to the urgency of appointments, and there is no guidance available to surgeries as to how to mitigate the risks of this. ”
Source location
Richard Boateng · Prevention of Future Deaths report
Page 1 · 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 care-navigation training materials and funding to support receptionist-led information gathering and emergency-symptom identification.

Verbatim wording from the response
“I can confirm that ‘Care Navigation’ as undertaken by receptionists, was fully supported in the NHS GP Forward View, with further training material and funding provided to support its implementation: https://www.england.nhs.uk/blog/plotting-the-right-path-with-care-navigators/.”

Source location
2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
Page 2 · response
Published 14 October 2021
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 training programme with Health Education England for clinical and non-clinical staff supporting care navigation and emergency-symptom identification.

Verbatim wording from the response
“We have developed a training pack for administrative staff which is intended to help support them with information gathering, care navigation and identifying emergency symptoms. The training pack is attached.”

Source location
2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
Page 2 · response
Published 14 October 2021
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 Digital First Primary Care guidance for implementing online consultations, including clinical safety, risk management, incident reporting, and limits on online triage.

Verbatim wording from the response
“Our Digital First Primary Care (DFPC) guidance for the implementation of Online Consultations puts a lot of focus on safety, though not specifically on the role of non-clinical staff: https://www.england.nhs.uk/wp-content/uploads/2020/01/online-consultations-implementation-toolkit-v1.1-updated.pdf. This provides guidance on:”

Source location
2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
Page 2 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Each individual GP practice is responsible for ensuring its staff are suitably trained and experienced for delegated tasks.

Verbatim wording from the response
“It is the responsibility of each individual GP practice to ensure all staff are suitably trained and experienced to undertake the tasks that they are delegated.”

Source location
2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
Page 2 · response
Published 14 October 2021
Open published response
19 Oct2018
Mid Kent and Medway
Concerns raised1
1. Lack of checking procedures for appointment priority errors
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John Edward LEE · 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

John Edward LEE died on the operating table during emergency open repair of a tender abdominal aortic aneurysm, following major blood loss, ventricular tachycardia and cardiac arrest. The report identifies a clerical error that resulted in his urgent vascular appointment being scheduled five weeks later than intended, and concerns about ambiguous appointment wording, insufficient clinical input into urgent bookings and the lack of a checking procedure for errors or misunderstandings of priority.

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
Lack of checking procedures for appointment priority errors
Wider context from the report
“(3) There should be consideration given to a checking procedure to guard against human error or misunderstanding of priority ”
Source location
John Edward LEE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Jul2018
Plymouth, Torbay and South Devon
Concerns raised1
1. Lack of triage of GP appointment requests for likely clinical difficulty
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Graeme Robert Mathieson · 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

Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.

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
Lack of triage of GP appointment requests for likely clinical difficulty
Wider context from the report
“At page 20 of my judgement I found that at the appointment on 10 August 2016 the time constraints under which ████████ was obliged to work meant that he was faced with trying to achieve the impossible. I said that I was sure that the very real constraints of time had had a direct impact on the outcome of the appointment. I said that it would have been better if the likely difficulties in this regard had been recognised at the point that Mr Matheson or his sister had asked to have an appointment. If there had been some sort of triage system in place, as I understand to be the case in other practices, this could have been recognised from the outset. I am aware that while some GP practices operate triage system there are plenty of others that do not. I think it may be beneficial for the facts of this case to be shared with all GPs in the area as a learning exercise. What I want to ensure, as far as possible, is that another GP is not placed in the same situation as ████████ on 10 August 2016 with the nearly inevitable conclusion that a patient’s serious psychiatric condition is not recognised. ”
Source location
Graeme Robert Mathieson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Feb2016
Black Country
Concerns raised1
1. Failure to assess the risks of excluding patients who are late for appointments on a case-by-case basis
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Richard Parkes · 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

Mr Richard Parkes collapsed and died on 28 December 2015 after developing deep vein thrombosis with associated pulmonary thromboembolism. Concerns included poor record keeping, unavailable records from an August appointment, and the practice policy of not seeing patients more than ten minutes late, including on an occasion when Mr Parkes was not seen because he was late.

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 assess the risks of excluding patients who are late for appointments on a case-by-case basis
Wider context from the report
“1. There was evidence of poor record keeping at The Black Country Family Practice. Specifically records of the August appointment were not available and there was a policy of not seeing patients who were more than ten minutes outside their appointment time. Evidence emerged during the inquest that the GP who had seen Mr Parkes initially on the 12 October 2015 and arranged a further appointment on the 23 October 2015 and crucially, was aware of his medical history had decided not to see him on the latter date when he was late for his appointment. 2. Continuity of care and knowledge of medical history is extremely important in the management of patient care and this GP Practice may wish to consider reviewing their policy and management of record keeping. 3. In addition they may wish to consider reviewing the systems in place for excluding patients who are more than ten minutes or more late for appointments. There are inherent risks in adopting this policy and each case should be considered on a case by basis based on risk assessment. ”
Source location
Mr Richard Parkes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Dec2013
Norfolk
Concerns raised1
1. Lack of receptionist guidelines or triggers for booking a doctor's appointment instead of a nurse practitioner appointment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Discuss the under-one-year contact survey at a clinicians’ meeting to determine whether GP triage should apply.
  Stated by St Stephens Gate Medical PracticeStated planned
AI-generated summary

YUKI NORMAN-KNIGHT · 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

Yuki was a very young child who had a persistent cough and was seen at a walk-in centre and twice by practice nurses, receiving diagnoses of chest infection and courses of antibiotics. She later became unresponsive while with her father and died despite resuscitation efforts. Concerns related to checking her past medical history, guidance for practice nurses to refer children to a doctor, and appointment systems for securing a doctor’s assessment.

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
Lack of receptionist guidelines or triggers for booking a doctor's appointment instead of a nurse practitioner appointment
Wider context from the report
“(3) The evidence given to the Inquest was that when a caller telephoned the St Stephens Gate Medical Practice for an appointment the receptionist would ask the caller if they were happy with a nurse practitioner appointment. If the caller said they wanted a doctor then a doctor's appointment would be given. There appeared to be no guidelines for the receptionist or trigger for a doctor's appointment to be made in the absence of any specific request by the caller. I am therefore concerned that the systems for making appointments at the St Stephens Gate Medical Practice may need reviewing in particular whether there should be guidelines and/or triggers for a doctor's appointment as opposed to nurse practitioner when the appointment is for a very young child or baby. ”
Source location
YUKI NORMAN-KNIGHT · 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
Discuss the under-one-year contact survey at a clinicians’ meeting to determine whether GP triage should apply.

Verbatim wording from the response
“We have also undertaken a survey of contacts by parents/guardians of patients under one year that we have had, over a period of one month. We will then discuss the issue at a clinicians’ meeting to establish whether all under-one year olds should be triaged by a GP.”

Source location
2013-0321-Response-by-St-Stephens-Gate
Page 2 · response
Published 23 February 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to allocate medication enquiries to clinicians with appropriate competencies

Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to provide competent triage and allocation of mental health appointments

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of triage clinicians to be aware of routine appointment waiting times

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to obtain sufficient information to assess appointment urgency and priority

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 8

Respondent positions 3

Actions described in response 3

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 4

Respondent positions 3