Recurring concern

Unreliable receipt and routing of clinical correspondence by GP practices

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First reported 1 May 2014•Latest report 23 Sep 2025

Definition

What this concern includes

Includes GP-practice arrangements for receiving, routing, redirecting, logging and confirming receipt of clinically important correspondence, including post between co-located practices and faxed correspondence from clinicians or services.

Not included

  • Excludes failures to review, interpret or act on correspondence after it has been reliably received; those belong to a downstream correspondence-review concern.
  • Excludes outgoing clinical correspondence from healthcare services to GPs where the deficient process is preparation or dispatch rather than GP-practice receipt or routing.
  • Excludes generic postal, fax, IT or administrative failures without a direct clinical-correspondence safety consequence.
  • Excludes correspondence unrelated to patient care or clinical follow-up.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2
Barts Health NHS Trust1
Bexley Medical Group1
Mundesley Medical Centre1
NHS Norfolk and Suffolk Integrated Care Board1
NHS North Norfolk Clinical Commissioning Group1
NHS Tower Hamlets Clinical Commissioning Group1
Oxford Health NHS Foundation Trust1
Tredegar Practice1
White Horse Medical Practice1

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.

  1. Wiltshire and Swindon

    AI-generated summary

    Christopher John Bird (“Chris”) · 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

    Christopher John Bird died by suicide on 19 September 2024 after placing his head on a railway line near South Marston and being struck by a freight train. The report found that a mental-health response sent to primary care was not received, and that this communication failure meant he was not updated about his referral and more likely than not exacerbated his mixed anxiety and depression. It also raised concern about the reliability of nhs.net email for transmitting important information between mental-health and primary-care services.

    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 nhs.net email to reliably deliver important information to GP practices

    Wider context from the report

    “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice. She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024. If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost; During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again. It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter. ”

    Source location

    Christopher John Bird (“Chris”) · 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

    Use DocMan instead of email for DWF Hub referral-outcome communication with GPs, except when the referrer explicitly requests email.

    Verbatim wording from the response

    “2. Primary Care Mental Health Hubs The manager of the Didcot, Wantage and Faringdon Hub (”DWF Hub”) attended the inquest and provided you with some evidence on the day. They have introduced an immediate change to the practice at the DWF Hub. The change is that the DWF Hub has changed its practice, and now also uses the DocMan system as the means of communication with GPs with regard to the outcome of a referral. The team no longer uses email, save where there is an explicit request for email to be used by the referrer.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 29 September 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

    Evaluate the DWF Hub’s DocMan process and use Trust governance processes to decide whether to adopt it across the other Hub teams.

    Verbatim wording from the response

    “There are seven other Hub teams in Oxfordshire (eight in total with the DWF Hub being one). The plan is for the Trust to evaluate the use of DocMan by the DWF Hub and we will then utilise Trust governance processes to make a decision on whether the new process is adopted in each of the hubs.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 29 September 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 AMHT communication practice, identify available changes and assess which options could strengthen controls against GPs missing important communications.

    Verbatim wording from the response

    “Service Managers agreed to talk to their teams about how communication with GPs is happening and whether anything can/should be done to make an”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 29 September 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

    Undertake Clinical Safety Cases, Hazard Logs and Data Protection Impact Assessments before national NHSmail deployment.

    Verbatim wording from the response

    “Prior to the roll out of NHSmail across England, Clinical Safety Cases, Hazard Logs, and Data Protection Impact Assessments were undertaken to support the delivery of the service at a national level. Clinical Safety Cases are used to ensure any clinical risks, hazards and potential harms are identified prior to deployment and these are managed within either product development or within system adoption methodologies. The model uses joint data controllers and clearly sets out in the requirements of organisations using the service, that they have similar local-level policies in place.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 September 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 Trust will not change AMHT communication practices until it understands available options, utility and potential consequences.

    Verbatim wording from the response

    “improvement. Email communication with GPs is commonplace across AMHTs and the Trust must apply diligence to any decision to direct staff to change their practice. That is particularly so because managers are not aware of any similar incidents between AMHTs and GPs and the Trust is reticent to make what could be a significant change without being confident that it will have utility for service users of AMHT services.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 3 · response
    Published 29 September 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 forensic search found that the mental health email was received by the GP practice and copied into the patient's clinical record.

    Verbatim wording from the response

    “Forensic discovery has confirmed that a referral letter was sent from the White Horse Medical Practice via the electronic referral service (e-RS) to the community mental health team at 8:40am on 28 August 2024 by the GP administration team.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 29 September 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

    NHSmail is considered reliable and resilient, with monitoring, recovery mechanisms, support arrangements and established clinical safety controls.

    Verbatim wording from the response

    “NHSmail is considered a reliable and resilient email platform, specifically designed and maintained for NHS business communications, with systems put in place to protect and recover from common IT failures like outages. While occasional incidents do occur, such as delayed arrival of emails in the destination mailbox, the overall reliability is strong, and service status is closely monitored and reported on the NHS support webpage, with disruptions usually resolved quickly and service continuity prioritized. All users of NHSmail are encouraged to contact their local administrator or service desk if they are experiencing any issues. If these cannot be resolved by the user’s local IT team, then there is a national NHSmail helpdesk which operates 24 hours a day.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 September 2025

    Open published response
  2. Inner South London

    AI-generated summary

    Feni 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

    Feni Lee, who had Behçet’s syndrome, took an excessive quantity of colchicine over a two-week period in September 2017 and died in hospital on 17 September 2017 after developing severe side effects, including liver necrosis. The concerns included the thoroughness of the medication review, the failure to address her loss to hospital follow-up, and delays and ineffective processes for redirecting correspondence between two GP practices.

    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

    Ineffective redirection of post between co-located GP practices

    Wider context from the report

    “(3) You informed the inquest that there are two GP practices at Erith Health Centre on Pier Rd. They are based in the same building and the receptionists from both practices work in close proximity. The letter from Guys relating to the outpatient clinic on 20 October 2015 was appropriately sent to Erith Health Centre on Pier Rd but had the name of a GP from the other practice. You accepted that there was considerable delay in this letter being forwarded to your practice and that it was scanned onto your system some 2 to 3 months after it was sent. You also accepted that it was placed onto your system without being seen or actioned by a GP. My concern is that there does not appear to be an effective means whereby post is re-directed between the two GP practices. I am therefore copying this report to the other GP practice, which I understand to be the practice of ████████ and ████████ ”

    Source location

    Feni Lee · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  3. Inner North London

    AI-generated summary

    Stephen Atherton · 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

    Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.

    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 a system at the GP practice to ensure successful receipt of important correspondence

    Wider context from the report

    “(1) It was clear from the evidence at the inquest that Mr Atherton’s GP was concerned that he should be seen for orthopaedic review more quickly than had been planned. However, was concerned that, given the importance of this further correspondence, there was no system in place at the GP practice to ensure successful receipt of the fax. ”

    Source location

    Stephen Atherton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Norfolk

    AI-generated summary

    DARREN LEE ARNOUP · 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

    Darren Arnoup was found hanging in the garage of his home on 27 October 2013 and was declared deceased at the scene. The report raises concern that correspondence containing information about a patient's suicide risk or self-harming behaviour might not be brought to a GP's attention, because it may be treated as information-only correspondence and filed without medical review.

    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 GP practice guidelines to require referral of correspondence concerning a patient’s suicide risk or self-harming behaviour to a doctor or GP

    Wider context from the report

    “In the light of that evidence I am concerned that there is a continuing risk that letters containing information about a concern for the suicide risk or self-harming behaviour of a patient will not be noted. Whilst it is not known whether in the case before me had the GP noted the content of the letter the tragic outcome would have been different I can readily envisage situations where it could. I am therefore concerned that guidelines operated by GP practices/surgeries, including the Mundesley Medical Centre may need to be reviewed to ensure that in future correspondence which refers to a concern for the suicide risk or self-harming behaviour of a patient is required to a Doctor/GP so that the Doctor/GP is aware of the concern. ”

    Source location

    DARREN LEE ARNOUP · 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

    Develop clear communication channels with NCH&C staff to alert the practice and summarise relevant concerns or actions.

    Verbatim wording from the response

    “Her recommendations which are listed below will be implemented.”

    Source location

    2014-0199-Response
    Page 2 · response
    Published 1 May 2014

    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

    Inform a GP when outside agencies make direct mental-health referrals, including relevant substance-misuse, safeguarding or domestic-violence concerns.

    Verbatim wording from the response

    “2. Due to the nature and impact of Mental health illness and substance abuse upon physical health and variability of risk factors and coping strategies for patients, if other professionals contact the practice to inform that a referral has been made in relation to these areas the GP should be alerted so that any subsequent consultations can be undertaken with this awareness. Safeguarding/Domestic violence concerns highlighted should also be managed in the same way.”

    Source location

    2014-0199-Response
    Page 2 · response
    Published 1 May 2014

    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

    Show correspondence about vulnerable people at risk of suicide or deliberate self-harm to a GP.

    Verbatim wording from the response

    “In addition we have amended our procedures and protocols as summarised below:”

    Source location

    2014-0199-Response
    Page 3 · response
    Published 1 May 2014

    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 neuropsychological report was not passed to a GP because it recorded historical self-harm and stated there was no current suicidal intent.

    Verbatim wording from the response

    “1. A neuropsychological report from the Colman Centre dated 21.05.13 makes reference to the suicide attempt in September 2012. This report was not passed to a GP as it was documenting historical information and it goes on to say “at this time (ie May 2013) Mr Arnoup denied any intention to kill himself”.”

    Source location

    2014-0199-Response
    Page 2 · response
    Published 1 May 2014

    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 referral letter was filed because it indicated no action for the practice and did not identify current suicide risk requiring GP review.

    Verbatim wording from the response

    “2. We received a copy of a letter (as did Norfolk Recovery Partnership, NRP) on 12.06.13 from the Colman Centre addressed to the Access and Assessment Team (AAT) mental health care trust. This documented previous self-harm and suicidal ideation; however as a referral was being made between the 2 agencies (the Colman Centre and the AAT) and only being copied to the GP with no action indicated, this was filed by an administrator. In addition, Mr Arnoup had been assessed by the AAT on 06.09.13 and there was no mention of any past or current suicidal ideation or deliberate self-harm in a letter to Mundesley Medical Centre. No formal follow up was arranged by the AAT but he was directed to self-referral into the Wellbeing Service if required.”

    Source location

    2014-0199-Response
    Page 2 · response
    Published 1 May 2014

    Open published response
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Data last updated 7 September 2026