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‘Patient found in pool of blood’ – serious incidents in GP out-of-hours


2015 – Case received from 111. Five minutes later, clinician calls and speaks with paramedic. Passed as routine home visit after examination. Less than two hours later, patient passed away.

2015 – Patient spoke with his own GP surgery on 11 and 12 June. Telephone advice was given. OOH was contacted on 13th June at 8:14 hours and a home visit was arranged. The visiting ANP arrived at 10.44 hours. On 14 June 2015, patient arrested at Ipswich Hospital at 06.34 hours, with ambulance crew. Patient later died in ITU at approx 09.41am.

2015 – Prescribed buprenorphine patch which is seven times the strength of that which would normally be used on an opiate-naive patient.

2015 – A patient with a history of bladder cancer and a recent hospital admission was visited by a paramedic practitioner and diagnosed with a UTI. The following morning the patient collapsed and patient passed away.

2015 -The GP advised that a patient with a temperature and heat rash on their chest had the flu. The following morning the patient was unresponsive and in a state of fitting. The patient was subsequently in ITU for ten days on a ventilator and was diagnosed with bacterial mengititis.


2016 – A 60 year old female presented to the GP in A&E with a complaint of back pain. A diagnosis of “musculoskeletal pain, lower back,” was made. Verbal advice was given as well as diazepam. Two days later a family member found the woman dead in her home.

2016 – Patient found deceased whilst awaiting a visit from out of hours in a pool of vomited blood.

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2016 – An information governance breach occurred where a folder was noticed on a patient’s downstairs table with two prescription pads, including one completed prescription and some patient records, including name, address, contact details, medical history, current complaints and details of examination. This was left by the visiting GP.

2016 – Folder belonging to a doctor was found in the car park at a hospital, and was handed into a hospital ward.

2016 – Mother of baby spoke with 111. Call transferred to OOH immediately – contact Primary Care Service within 2 hours. Symptoms outlined. Patient booked for routine base visit, advised to call back if worsens, to go to A&E if any rash that doesn’t disappear under a glass, and other symptoms, advised to give paracetamol. Arrived at PCC – seen by GP. Baby was taken to hospital. Re-presented at four days with concerns. Diagnosed with meningitis.


2017 – A 90 year old patient had been left unresponsive without medical support. The patient was subsequently hospitalised with sepsis and passed away.

2017 – Medication boxes were identified as being untagged and had medications missing on checking


? – An 84 year old woman called the ambulance service who referred to the out-of-hours service. The patient had abdominal pain and her urine had tested positive for a urinary tract infection therefore, the paramedics were requesting an out of hours GP to prescribe antibiotics. The out of hours GP did not call back the patient until one and a half days later whereby the GP was unable to get through on the telephone. The GP therefore changed to a non-urgent visit. Our visiting GP did not arrive until fourteen hours later where he was unable to get a response, he was about to leave the property when a neighbour advised that the patient had passed away the day before.