As previously raised in Report to Prevent Future Deaths dated 23 December 2021, incoming correspondence to the GP practice continues to be dealt with by administrative staff who decide whether or not it is placed before a GP. The concern is that there is no robust system in place to ensure that communication to the surgery which may require action to be taken by medical staff is brought to their attention.

Adverse medication markers are not being placed on computerised medical records and this creates the risk that contraindicated medications may be inadvertently prescribed.