Minding the gap in transitions of care

Dr Siobhan O’Flaherty outlines the dangers of patients falling between primary and secondary care

In 2015, a High Court case highlighted the risks associated with the transition of care across the primary-secondary care interface. The case concerned a woman in her 60s, who died of acute liver failure after treatment for latent tuberculosis.

The coroner had previously returned a verdict of medical misadventure because monthly liver function monitoring was recommended, but did not happen. Sadly, it appears there was a breakdown in communication that led to incorrect assumptions about who was monitoring the patient’s liver function tests, which was necessary to monitor the medication she was being prescribed. Each of the clinicians involved in the woman’s care assumed others were carrying out the necessary monitoring. The result was that this aspect of her care fell between the cracks in the system and she ultimately died from liver failure.

Unfortunately, situations like this are not isolated. In Medisec’s experience, claims and/or complaints or near misses often arise due to a breakdown in communication between primary and secondary care, or between departments or teams, where there is a transfer of care.

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Key risk areas at the primary-secondary care interface

Several factors contribute to miscommunication or delayed communication, including differing systems, patient expectations, workload pressures, and unprecedented demands on healthcare services. The main areas of risk as a result of sub-optimal communication are as follows:

1. Admission to hospital

Insufficient or sub-optimal information included in a referral can result in confusion as to the reason for, or urgency of, the referral. At the more serious end, it can result in inappropriate downgrading of urgent referrals. Most GP referrals are now sent electronically via Healthlink using a standardised format, including whether it is being sent as urgent or routine. It also allows for attachment of relevant results and letters.

2. Medications

When patients are admitted to hospital, their treating team needs the full list of the patient’s usual medications, some of which may be amended or stopped during an admission, and new medications may be started. Medication error is one of the biggest risks to patient safety at times of transfer of care. This can occur due to duplication, omission, or incorrect dose, resulting in an adverse event or suboptimal management.

3. Discharge from hospital

On discharge, problems can arise when a patient is not informed or does not remember or comprehend changes to their care, what actions are outstanding, follow-up plans, and who is taking responsibility for these. Before discharge, there should be a meaningful conversation with the patient to discuss their illness, treatment plan, and medications (including any necessary monitoring arrangements), and any follow-up appointments due.

4. Clinical governance of test results

When the patient is discharged from secondary care and there are still test results pending, there is a danger that they will fall between two sectors of care. Each sector may assume the other has responsibility, with the potential for the patient to suffer harm.

The highlighted case is an example of this and a timely reminder to review our approach to continuity of care, and our ethical obligations.

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners outlines obligations as follows:

Paragraph 33.6 states:

Doctors must “communicate clearly and effectively with colleagues, sharing relevant information in a timely manner”.

Paragraph 33.7 states:

“Discharge of a patient from care must be accompanied by a timely and prompt discharge summary, which includes at least the minimum basic information, including:
► A summary of relevant medical and treatment history;
► Medication and medication changes;
► Any planned follow-up by the discharging service;
► Action required by primary care/community services (if involved);
► Action required by the receiving GP clearly documented.”

Paragraph 33.8 states:

“When discharging care to the patient’s GP, the doctor who orders diagnostic tests or investigations must follow up on the results to ensure these investigations have taken place, results are followed up and appropriate action taken, including communication to the GP.”

Although the healthcare system in the UK differs from here, the Royal College of General Practitioners (RCGP) has a useful guideline on the primary–secondary care interface. Guidance from the RCGP outlines the responsibilities of primary and secondary care clinicians as follows:

Responsibilities of primary care

“Clinicians should:
► Include appropriate clinical information with a sentence stating a clear reason for the referral in all referral letters;
► Ensure any appropriate pre-referral assessments have been completed, according to local pathways, provided access to diagnostics is available to primary care teams;
► Inform patients who they are referring them to and why, with clear advice on the next steps of the referral process;
► Continue to follow-up with patients with known long-term conditions and work with them to optimise the management of these conditions, explaining the importance of optimisation prior to surgery for any patients on waiting surgical lists.”

Responsibilities of secondary care

“Clinicians should:
► Ensure timely communication with primary care colleagues following patient assessments;
► Avoid asking GPs to undertake any tests that are required by secondary care as part of their diagnostic and treatment pathway, unless locally agreed and part of a clear pathway of care that benefits the patient;
► Provide fit notes to patients when required and for appropriate duration of time;
► Prescribe for immediately required medications from outpatients and wards rather than sending letters for primary care to action on their behalf;
► Check the local formulary before prescribing or recommending prescribing of medications to ensure primary care is able to continue any prescription started;
► Put in place clear plans for patients who self-discharge against medical advice;
► Review local pathways ending the automatic discharge of patients who DNA their appointments;
► Arrange onward referral, without referring back to the GP, where appropriate and locally agreed.”

Some useful Irish resources on the subject include:
► The Irish College of GPs’ Position Statement on Transitional Care and Patient Safety (2025).
► The RCPI quality improvement learning hub.
► Medisec’s risk reduction resources for GPs and consultants.
► HIQA national standards on referrals and discharges.

The highlighted case reminds us that most cases arise from systems failures rather than simply an individual’s actions. It would benefit both patients and healthcare professionals if we developed standardised shared care pathways that both primary and secondary care can agree on. Changes are underway to provide digital records that the patient can access and share their information at the point of care and it is hoped the HSE digital transformation will be complete by 2030. In the interim, we can review our own systems and improve our communication with our colleagues.

In Medisec’s experience, claims and/or complaints or near misses often arise due to a breakdown in communication between primary and secondary care…

References available on request