Researchers said incidents involving death or serious harm were “rare” and that the “vast majority of remote clinical consultations in general practice” were safe.
Experts from the University of Oxford examined 95 serious safety incidents in Britain since 2020 in which patients came to harm.
Errors made over the phone included missed diagnoses or an underestimation of the severity of a range of serious conditions including sepsis, cancer, congenital heart disease and diabetic foot complications.
They said they “would likely have been readily diagnosed with an in-person examination”, and found there was more risk of patients coming to harm if they had urgent conditions including new chest or abdominal pain, palliative care, physical injuries or diabetes, or if they were particularly young or old.
In one case, a 16-year-old girl was diagnosed with glandular fever by a GP over the phone, but died of sepsis shortly afterwards.
In another, a new mother died from a missed pulmonary embolism, while NHS 111 staff diagnosed a pregnant woman with “urinary problems” rather than the premature rupture she was having.
Communication problems with GP receptionists also caused deaths, the study revealed, with one woman in her 70s who was suffering from sudden breathlessness being told she would be called back, only for the receptionist to be distracted by a patient in the waiting room. The patient died at home that afternoon.
Researchers also revealed that remote consultations were more likely to lead to family doctors being swayed by what had been said to the patient before and repeating a previous diagnosis. They said less qualified staff may be less likely to act on signs of illness.
The report recommends that doctors are not distracted while conducting phone calls and go over treatment plans and next steps with patients at the end of a consultation, giving them opportunity to ask questions.
It says patients should be seen in person if they are not improving after previous remote appointments.