Hospital failures to send patient documents to GPs harmed patients, finds safety review

Hospitals’ failures to send patient information to GPs have led to patient harm, the NHS safety investigation body has found.

‘Vital information’ about diagnoses, medications and necessary follow-up care is ‘often delayed’, incomplete ‘or missed altogether’, leading to incidents of patient harm after hospital discharge, according to the Health Services Safety Investigation Body (HSSIB).

The independent arm’s length body of the Department of Health and Social Care looked into the risks associated with the electronic discharge summary – the primary tool for transferring clinical information about patients from hospitals to primary and community care.

It cited Pulse’s award-winning investigation into hospitals failing to send more than 700,000 patient documents to GPs, which uncovered that clinical information was not passed and acted on as a result, causing a threat to patient safety and increased GP workload.

The HSSIB identified ‘several incidents’ where summaries, among other correspondence, had been created but not sent.

It also found incidents where a ‘lack of complete information led to patient harm’, including when a patient died of pancreatitis following a stay in hospital where they underwent a bile-duct procedure.

The report said: ‘Pancreatitis is a complication of such procedures. After leaving hospital the patient consulted their GP because of ongoing pain. The GP was unaware of the details of the patient’s hospital admission because the discharge summary did not include information about the bile-duct procedure.

‘The discharge summary was drafted before the patient’s procedure took place and the information was not updated before they left hospital. When drafting the summary, the software allowed the doctor to “mistakenly click on the completed button rather than the save button”.’

The HSSIB also pointed out one example where, following contact from a GP, a hospital identified several discharge summaries that ‘had not been sent’.

The issue had been happening for around a year so the hospital reviewed all affected summaries and identified ‘several near misses’ – where a patient had the potential to be harmed – and ‘one incident that had led to harm’.

This was due to the process for ‘sign off’ of discharge summaries on the unit where the incident originated not being ‘clearly defined and differed from that on other wards’.

The report said: ‘GPs described situations where discharge summaries had not been received or had been sent to them “blank”.

‘Incidents have also been described in the media where correspondence dating back several years had not been sent. The impact of not sending correspondence included missed care and increased workload to “chase” correspondence (Colivicchi, 2024).’

GPs also told the HSSIB that they were aware of several occasions where summaries had not been received but they had not always informed the hospital.

Reasons for not doing so included ‘unclear or absent routes’ by which to contact or inform secondary care, the time required to chase correspondence when services were already under pressure, and because on past occasions informing a hospital ‘had not led to any changes in practice or resolution of the problem’.

The HSSIB asked hospital staff who they understood to be the recipients of a discharge summary and found that hospital staff did not know what information GPs needed.

It said: ‘Most saw the GP as the recipient, with limited recognition that it was used by others. Staff described “assuming” what information a GP needed because they had never been told, had never worked in general practice and local guidance did not describe these needs.’

The report recommended that NHS England and the Department of Health and Social Care develop and validate new discharge correspondence templates for primary care and set ‘specific expectations’ for discharge correspondence to prevent patient harm (see box).

Senior safety investigator Nick Woodier said that NHS staff have expressed that it is ‘difficult and stressful’ to make decisions based on incomplete information, which ‘hinders their ability to deliver the highest standard of care’.

He said: ‘We heard throughout the investigation about the distressing impact on patients and families when care is not followed up.

‘The main issues stem from discharge planning not considering the organisation of the local health and care system, alongside a lack of integration – as evidenced by the limited collaboration between primary, community and secondary care – and IT systems not passing information seamlessly along.

‘The recent publication of the 10-year plan emphasises how important it is to ensure digital systems and electronic communications are invested in and fit for future delivery.

‘Our report is specifically calling for stronger oversight and accountability to ensure critical information is reliably communicated, supporting a safe discharge process for patients needing vital follow up care.’

A Department of Health and Social Care spokesperson told Pulse: ‘It is unacceptable that patients suffer harm while attempting to be discharged from hospital and our thoughts are with those who have been affected.

‘Our 10-year health plan will transform the NHS and bring it into the 21^st century. We are simplifying the systems intended to improve care and safety – merging organisations, clarifying remits and strengthening powers. This will lift the bureaucratic burden to boost the quality of care and put patient experience at the heart of the NHS.

‘Crucially, we will also harness the power of technology as part of a fundamental shift from analogue to digital and make the NHS App the digital front door to the NHS. This will be underpinned by a Single Patient Record ensuring seamless care for everyone – whether in a health setting or at home – which all healthcare staff will have access to no matter where they are.’

Pulse’s investigation revealed that hospital trusts across the country failed to deliver at least 724,000 patient letters to GPs, in several almost identical incidents, causing chaos for GPs and safety issues for patients.

FOI data from hospital trusts in England, obtained by Pulse, discovered similar incidents across the country dating back to 2013, with at least 18 trusts experiencing IT failures which led to thousands of letters not reaching GPs.