First reported 23 Aug 2013•Latest report 3 Jun 2026
Definition
What this concern includes
Includes failures in the dedicated process for receiving, routing, triaging, reviewing, acknowledging or acting on clinically significant correspondence sent to or received by healthcare services, including GP requests, hospital letters and correspondence containing medication or referral information.
Not included
Excludes failures involving information that was reviewed and acted upon correctly but communicated poorly to patients or other services afterward.
Excludes generic clinical record-keeping, staffing, training or communication deficiencies unless they directly impair review or action on incoming clinical correspondence.
Excludes failures limited to the substantive clinical decision made after correspondence was reliably reviewed.
Excludes correspondence processes for non-clinical administrative matters or unrelated public-safety domains.
Reports
18
Distinct published reports
Individual concerns
22
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
23
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.
Department of Health and Social Care2
NHS England2
The Croft Shifa Health Centre2
Barts Health NHS Trust1
Beeston Health Centre1
Bexley Medical Group1
Brinnington Surgery1
Brook Medical Centre1
Care Quality Commission1
Clevedon Medical Centre1
Cornerstone Family Practice1
Derriford Hospital1
Droylsden Road Family Practice1
Farnham Park Health Group1
General Medical Council1
Healthcare site14
NHS trust8
Integrated care board3
Clinical commissioning group2
Executive non-departmental public body2
Ministerial department2
Health and care professional regulator1
Health and social care service regulator1
Health professional body1
Multi-service care provider1
Social-care provider1
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.
Nottingham and Nottinghamshire
Concerns raised1
Failure to review radiology reports received after ED discharge
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Create and operate a closed-loop workflow to identify, review, communicate, escalate and track ED imaging results after discharge.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Action
Create a multidisciplinary Patient Safety Priority Working Group to address post-discharge ED imaging-result review.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Manual review of post-discharge radiology reports is not deliverable or sustainable with current systems and capacity.
Stated by Nottingham University Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing coding processes are considered sufficient to mitigate interim high-risk post-discharge radiology risks while a fuller workflow is developed.
Stated by Nottingham University Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Blackpool and the Fylde
Concerns raised1
Failure to ensure medically informed review and escalation of potentially significant NHS 111 information
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.
Manchester South
Concerns raised1
Failure of correspondence triage to identify excessive use of controlled drugs
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Amend incoming-correspondence handling so administrative staff identify controlled-drug prescriptions and ensure prompt GP review without routing letters to absent GPs.
Stated by The Partners of the Brinnington SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
Action
Create and implement a workflow map linking incoming correspondence types to relevant protocols and controlled-drug GP-review requirements.
Stated by The Partners of the Brinnington SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
Action
Audit the amended incoming-correspondence process and undertake further audits every three to six months.
Stated by The Partners of the Brinnington SurgeryStated plannedThe respondent said that this action was planned when they made their response on 15 November 2024.
Action
Continue auditing opioid prescribing and reducing opioid doses or strengths where possible, alongside usual medication reviews.
Stated by The Partners of the Brinnington SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 15 November 2024.
South Yorkshire (Western)
Concerns raised1
Failure of referral communication channels to provide reliable access and confirmation
This report raised 6 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.
Staffordshire and Stoke-on-Trent
Concerns raised2
Failure to refer dosage-clarification correspondence to a clinician
Failure to refer medication-change correspondence to a clinician for consideration
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Update staff medication competency assessments to test clarification of unclear directions, MAR-label discrepancies and verbal medication changes.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Require GP review and triage of all neurology correspondence received by Brook Medical Centre.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Have a GP review and triage all neurology correspondence and clinic letters received by Brook Medical Centre.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A standardised clinic-letter template cannot be created immediately because implementation across the Trust requires substantial timeframes.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester North
Concerns raised1
Lack of a robust system for bringing potentially actionable correspondence to medical staff attention
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Update document-management procedures and route high-risk, urgent, medication-change and safeguarding correspondence to the appropriate GP.
Stated by The Croft Shifa Health CentreStated completedThe respondent said that this action was complete when they made their response on 29 November 2023.
Action
Assign two designated practice staff members responsibility for document management.
Stated by The Croft Shifa Health CentreStated completedThe respondent said that this action was complete when they made their response on 29 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing document-management procedures, designated staff and GP-routing arrangements are considered sufficient to identify and escalate clinically important correspondence.
Stated by The Croft Shifa Health CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised2
Failure to ensure review of correspondence from TalkPlus
Failure to confirm electronic letters are read and acted upon
This report raised 10 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Conduct a computer-system audit of TalkPlus letters to verify receipt and reading, and share the results, analysis and recommended actions with Clinical Governance.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The audit disputed uncertainty about whether TalkPlus letters were read, confirming that all three were read within recorded timeframes.
Stated by Farnham Park Health Group and Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised1
Lack of a system for identifying and bringing action-requiring correspondence to medical staff
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.
Manchester City
Concerns raised1
Inadequate GP system for recording and reviewing correspondence
This report raised 11 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The GP practice is to provide the response concerning medication prescribing, correspondence handling, pharmacy communication and escalation processes.
Stated by Greater Manchester Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised2
Failure to ensure incoming clinical correspondence is reviewed and actioned by a GP
Ineffective redirection of post between co-located GP practices
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Route all correspondence to GPs to ensure an audit trail and accountability.
Stated by Bexley Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
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Includes failures in the dedicated process for receiving, routing, triaging, reviewing, acknowledging or acting on clinically significant correspondence sent to or received by healthcare services, including GP requests, hospital letters and correspondence containing medication or referral information.
