Systematic Process to Determine Clinical Harm From Delayed Communication Between Primary and Secondary Healthcare




electronic patient record, delayed communication, patient safety


Visual Abstract

Introduction: Timely written communication between primary and secondary healthcare providers is paramount to ensure effective patient care. In 2020, there was a technical issue between two interconnected electronic patient record (EPR) systems that were used by a large hospital trust and the local community partners. The trust provides healthcare to a diverse multiethnic inner-city population across three inner-city London boroughs from two extremely busy acute district general hospitals. Consequently, over a four-month period, 58,521 outpatient clinic letters were not electronically sent to general practitioners following clinic appointments. This issue affected 27.9% of the total number of outpatient clinic letters sent during this period and 42,251 individual patients. This paper describes the structure, methodological process, and outcomes of the review process established to examine the harm that may have resulted due to the delay.

Methodology: Senior clinicians examined the letters following training to ensure a standardized consistent approach to the evaluation. They searched whether any actions that had been requested to be undertaken by primary care had been completed in a timely fashion. Thereafter, they indicated whether in their opinion there was any potential “predefined” harm. All letters that were identified as “potential” harm were reexamined by the leads to determine that the harm or inaction was truly accurate. The trust then contacted the patient to apologize and urgently expedite the outstanding action. Patients were not contacted in those situations where no actions were required or already undertaken (99.5%), as this could potentially cause unnecessary anxiety. If an actual harm was detected, it would then be declared as a serious incident and investigated appropriately, including a duty of candor (if the harm was moderate or severe). A “clinical harm review panel” convened regularly to monitor the quality of this process and thereby provide quality assurance. Governance of the process of review was assured by this panel being overseen by a regularly convened regionwide group.

Results: 58,521 letters were evaluated over three months by 36 evaluators. No serious untoward incidents were identified, but 1,323 inactions were identified from these letters. These were then all cross-checked with information from EPR. Consequently, only 327 were deemed to be inactions that required further contact with the patient (of the 58,521 letters evaluated, this constituted 0.56%). Certain departments made more requests compared to others (e.g., cardiology, dermatology, and gastroenterology). Most surgical specialties did not generate any actions. Reassuringly, no letters related to cancer had any outstanding actions. The frequency of actions not enacted due to the delay was as follows: did not attend (n=3), medication change (n=173), blood tests (n=73), other investigations (n=31), onward referral (n=47).

An audit trail of all outstanding actions has been maintained to allow monitoring in case there was any query in future. We also reviewed those patients who had died to investigate whether the death could be in any way linked to nonreceipt of the letter. There were 367 deaths, and an independent review revealed that no deaths were linked to the nonreceipt of the letter. Ten percent of the deaths (n=36) had a full structured clinical review to further validate the process.

Discussion: This paper has described a systematic process of analyzing a large cohort of electronic correspondence to determine any potential harm to patients that may occur due to the delay in communication between primary and secondary care. The structured methodology, well supported by relevant community stakeholders and closely monitored by the clinical harm review panel, could serve as a template to other organizations that may face similar incidents in future.

Author Biographies

Mehool Patel, FRCP, MD, Lewisham and Greenwich NHS Trust

Mehool Patel ( is a consultant physician in stroke and geriatric medicine and deputy medical director of Lewisham and Greenwich NHS Trust in London, where he has been involved in medical education, workforce and engagement, health services research, and patient safety projects.

Simon Parton, MRCP, Lewisham Clinical Commissioning Group

Simon Parton is a general practitioner and chair of Lewisham Clinical Commissioning Group in London, where he has been involved in commissioning of healthcare services, primary-secondary care interface, and professional communication.

Elizabeth Aitken, FRCP, Lewisham and Greenwich NHS Trust

Elizabeth Aitken is a consultant physician in geriatric medicine and chief medical officer of Lewisham and Greenwich NHS Trust in London, where she has been involved in patient safety and quality, the Getting It Right First Time (GIRFT) program, health services research, and health services management.


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How to Cite

Patel, M., Parton, S., & Aitken, E. (2022). Systematic Process to Determine Clinical Harm From Delayed Communication Between Primary and Secondary Healthcare. Patient Safety, 4(2), 43–47.



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