Table 1 Root cause thematic categories and examples

Minimal care n = 8 (22.2 %)

Readmission after lack of diagnosis and treatment of symptoms causing multiple prior admissions (3)

Poor integration of care between specialists and lack of outpatient follow-up (1)

Insufficient treatment and lack of follow-up after diagnosis of major health problem (1)

Lack of diagnosis and sufficient follow-up for major acute health condition (3)

Progression of disease n = 8 (22.2 %)

Failure of ambulatory treatment with oral antibiotics (1)

Condition presenting with atypical symptoms until severe (1)

Condition most appropriately managed in hospital, i.e. syncope (3), nose bleed not responding to usual measures (1)

Progression of disease despite appropriate treatment (2)

Home care access n = 6 (16.7 %)

Homebound patient unable to access timely medical services in home environment (2)

Homebound patient did not receive expected home visit from GP and unable to follow-up (1)

Lack of access to community nursing and poor co-ordination of care (2)

Patient did not want locum to come to home due to previous concern about late visit (1)

High complexity n = 5 (13.9 %)

Interaction between clinical care, patient behavior or characteristics, and inadequate social support (5)

Clinician error n = 5 (13.9 %)

Readmission after patient discharged before clinically stable (1)

Readmission due to medication dose remaining unaltered after major change in health status (1)

Readmission to hospital after failure to follow guidelines for treatment (1)

Misdiagnosis over the telephone with subsequent treatment failure (1)

Medication prescribing error (1)

Delayed care-seeking by patient n = 4 (11.1 %)

Patient with UTI on visit from country for several days refused to see daughter's GP (1)

Patient did not want to bother GP for home visit while experiencing increasing shortness of breath from COPD (1)

Delayed seeking of care for significant medical symptoms (2)