Phil Whatling is a GP partner in North Devon with interests in continuity, system behaviour and the everyday realities of general practice. He is on LinkedIN
When the independent review into the Nottingham mental health homicides was published last year, it landed heavily. The report described a young man with a long history of serious mental illness, repeated contact with services, disengagement interpreted as “choice”, and a pattern of risk that built slowly before ending in catastrophe.1
For many clinicians, it was shocking, and for many GPs, it felt painfully familiar.
Because Nottingham didn’t expose a one‑off failure. It exposed something deeper: a system pattern in which risk accumulates over time, contacts multiply, fragments of information sit in different places, and the full picture only becomes visible after tragedy.
Once you notice that pattern, it becomes difficult not to see it elsewhere.
The review described years of contact across primary care, mental health services, crisis teams, and the criminal justice system. Concerns were recognised but not connected. Disengagement became treated as the end of the story rather than part of it. No single service held the full chronology. Risk gathered quietly in the spaces between organisations.
It was a story made up of episodes, but without anyone seeing the trajectory.
The deaths of Victoria Climbié, Peter Connelly, Daniel Pelka, Arthur Labinjo‑Hughes, and Star Hobson were not sudden events. Each involved multiple contacts and missed opportunities…
And this structure isn’t unique to Nottingham. It appears again and again in child protection reviews, Domestic Homicide Reviews, Safeguarding Adult Reviews, and serious mental health incidents. Different settings, different circumstances, but the same broad features: repeated contacts, concerns raised more than once, referrals opened and closed, information scattered across agencies, and no one holding the whole story.
The deaths of Victoria Climbié, Peter Connelly, Daniel Pelka, Arthur Labinjo‑Hughes, and Star Hobson were not sudden events. Each involved multiple contacts and missed opportunities – warning signs visible in isolation but not understood together. These were long stories that systems struggled to read.2,3
Domestic homicide reviews show the same pattern: repeated police attendance, emergency department visits, coercive control, unstable housing, escalating mental health concerns, fragmented follow‑up. Every missed opportunity generates further contacts. The chain becomes longer, more complicated, and harder to interpret. The trajectory only becomes visible to everyone at the point of collapse.4
What Nottingham highlighted is that risk is rarely a single moment. More often, it builds over time.
There are usually underlying conditions first: poverty, trauma, serious mental illness, domestic abuse, unstable housing, addiction, social isolation. Then come the early signals: repeated attendance, behavioural change, family concern, police involvement, missed appointments, deterioration that feels worrying but not yet dramatic.
The problem is that systems are built around episodes rather than trajectories. Each organisation sees one part of the picture and responds to that fragment alone. Thresholds are applied repeatedly. Contacts are interpreted in isolation. Continuity is lost. Nobody owns the developing pattern.
One practical response to this way of thinking is Jess’s Rule, developed after the death of Jess Brady following 20 healthcare contacts in five months. The rule suggests that repeated presentations for the same unresolved issue should trigger a different level of clinical attention.2
It’s usually described as a safety‑netting tool, but it’s more useful to think of it as a trajectory detector.
Repeat attendance is not background noise. It is neighbourhood intelligence.
Every GP recognises the patient who keeps returning with pain, insomnia, missed reviews, vague deterioration, family concern, or worsening distress. No single consultation looks catastrophic, but over time the shape of the story changes. Something begins to feel different before anyone can fully articulate why.
That instinct matters.
General practice is often the only part of the system that sees patients longitudinally. We see the repeated attendance, the family context, the gradual deterioration, the social pressures underneath the medical presentation. We are often seeing the trajectory before anyone else does.
But modern systems don’t always support trajectory‑based thinking. They reward throughput, thresholds, and episodic resolution. Continuity becomes fragmented. Signals lose coherence as they move between services.
This matters particularly in deprived communities. Inequality lengthens and complicates the causal chain. Patients living with poverty, insecure housing, trauma, digital exclusion, or immigration insecurity often experience more fragmented care and reduced continuity. They interact with more agencies while being less visible as whole people within the system.5
No single consultation looks catastrophic, but over time the shape of the story changes. Something begins to feel different before anyone can fully articulate why.
None of this means general practice can predict catastrophe, but we are often closer than most parts of the system to recognising when a situation is becoming unstable in a cumulative way.6,7
Continuity helps protect against this. A clinician who knows the patient over time is more likely to notice when the pattern changes. It reduces the risk of repeatedly resetting the clock at every encounter.8,9
That may be the real lesson from Nottingham: not simply that a tragedy occurred, but that the trajectory towards it was visible in fragments long beforehand.
The challenge is recognising when repeated contacts and unresolved problems are becoming something more serious.
Because by the time these stories reach the front page, the chain is already complete.
References
- NHS England. Independent Review into the Case of Valdo Calocane. NHS England; 2024. Available from: https://www.england.nhs.uk/2025/02/independent-mental-health-homicide-report-into-the-treatment-of-valdo-calocane/(accessed 22 May 2026).
- Department of Health and Social Care. Jessica Brady’s legacy inspires new life‑saving GP safety rule. London: DHSC; 2024. Available from: https://www.gov.uk/government/news/jessica-bradys-legacy-inspires-new-life-saving-gp-safety-rule (accessed 22 May 2026).
- Laming H. The Victoria Climbié Inquiry Report. Department of Health; 2003. Available from: https://assets.publishing.service.gov.uk/media/5a7c5edeed915d696ccfc51b/5730.pdf (accessed 22 May 2026)
- Home Office. Domestic Homicide Reviews: Key Findings from Analysis of Domestic Homicide Reviews. Home Office; 2023. Available from: https://www.gov.uk/government/publications/key-findings-from-analysis-of-domestic-homicide-reviews/key-findings-from-analysis-of-domestic-homicide-reviews (accessed 22 May 2026).
- Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot Review 10 Years On. Institute of Health Equity; 2020. Available from: https://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/the-marmot-review-10-years-on-full-report.pdf (accessed 22 May 2026).
- Reason J. Managing the Risks of Organisational Accidents. Aldershot: Ashgate; 1997.
- Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety Management. Farnham: Ashgate; 2014.
- Freeman G, Hughes J. Continuity of care and the patient experience. London: The King’s Fund; 2010. Available from: https://assets.kingsfund.org.uk/f/256914/x/c22b0594f7/gp_inquiry_continuity_care_2010.pdf (accessed 22 May 2026).
- Bate P, Robert G. Bringing User Experience to Healthcare Improvement. Oxford: Radcliffe Publishing; 2007.
Featured Photo by Luis Villasmil on Unsplash
