Skip to content
recurance

Allan Hamilton

23 Aug 2024 · Coroner Alison Mutch · South Manchester

The coroner's concerns

  1. 1. lack of clear and robust triage and audit processes in GP practices

    “The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place”

Responses

2024-0468-Response-from-DHSC.pdf ↗· Department of Health and Social Care

Stated action · 08 October 2024

“The Department, NHS England, and practices alike must be cognizant of the fact that there are now multiple channels by which a patient may contact a GP practice. This includes by direct face to face contact at a surgery, by telephone, by customised online systems or by email. While more options have opened up more opportunities for patients to access care they need, we understand that it may also open up more opportunity for patients to slip through the cracks, which is unacceptable. We want to”

2024-0468-Response-from-SSP-The-Pike-Practice.pdf ↗· Department of Health and Social Care

Stated action

“we have updated the automated response to clearly reinforce what is commonly understood, i.e. that emails are for non-urgent enquiries only and the emergency services should be contacted in such circumstances. Please”
  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error