diff --git a/IMPLEMENTATION_PLAN.md b/IMPLEMENTATION_PLAN.md
index 8104904..39da9be 100644
--- a/IMPLEMENTATION_PLAN.md
+++ b/IMPLEMENTATION_PLAN.md
@@ -90,7 +90,7 @@ python -m reflex compile
 ## Phase 3: Test Full Pipeline
 
 ### 3.1 Test Refresh with Real Data
-- [ ] Run `python -m cli.refresh_pathways --chart-type all` with Snowflake
+- [~] Run `python -m cli.refresh_pathways --chart-type all` with Snowflake
 - [ ] Verify pathway_nodes table has both chart_type values:
   - `SELECT chart_type, COUNT(*) FROM pathway_nodes GROUP BY chart_type`
 - [ ] Verify indication hierarchy: Trust → Search_Term → Drug → Pathway
diff --git a/cli/refresh_pathways.py b/cli/refresh_pathways.py
index f248ce1..041b5cb 100644
--- a/cli/refresh_pathways.py
+++ b/cli/refresh_pathways.py
@@ -384,11 +384,8 @@ def refresh_pathways(
                             results[f"{config.id}:indication"] = []
                         continue
 
-                    # Get unique patient pseudonyms and their corresponding UPID/Directory
-                    patient_lookup = df[['UPID', 'PseudoNHSNoLinked', 'Directory']].drop_duplicates(
-                        subset=['PseudoNHSNoLinked']
-                    ).copy()
-                    patient_pseudonyms = patient_lookup['PseudoNHSNoLinked'].dropna().unique().tolist()
+                    # Get unique patient pseudonyms for GP lookup (avoid redundant queries)
+                    patient_pseudonyms = df['PseudoNHSNoLinked'].dropna().unique().tolist()
 
                     logger.info(f"Looking up GP diagnoses for {len(patient_pseudonyms)} unique patients...")
 
@@ -402,15 +399,24 @@ def refresh_pathways(
                     # Step 3: Build indication_df mapping UPID -> Indication_Group
                     # For matched patients: Indication_Group = Search_Term
                     # For unmatched patients: Indication_Group = Directory + " (no GP dx)"
+                    #
+                    # IMPORTANT: We need ALL unique UPIDs, not just unique PseudoNHSNoLinked.
+                    # A patient can have multiple UPIDs if they visited multiple providers.
+
+                    # Get all unique UPID records with their PseudoNHSNoLinked and Directory
+                    upid_lookup = df[['UPID', 'PseudoNHSNoLinked', 'Directory']].drop_duplicates(
+                        subset=['UPID']
+                    ).copy()
 
                     if gp_matches_df.empty:
                         logger.warning("No GP matches found - all patients will use fallback directory")
                         # All patients use fallback
                         indication_records = []
-                        for _, row in patient_lookup.iterrows():
+                        for _, row in upid_lookup.iterrows():
+                            directory = row['Directory']
                             indication_records.append({
                                 'UPID': row['UPID'],
-                                'Indication_Group': str(row['Directory']) + " (no GP dx)",
+                                'Indication_Group': str(directory) + " (no GP dx)" if pd.notna(directory) else "UNKNOWN (no GP dx)",
                                 'Source': 'FALLBACK',
                             })
                         indication_df = pd.DataFrame(indication_records)
@@ -421,23 +427,25 @@ def refresh_pathways(
                             gp_matches_df['Search_Term']
                         ))
 
-                        # Build indication records for each unique patient
+                        # Build indication records for each unique UPID
                         indication_records = []
-                        for _, row in patient_lookup.iterrows():
+                        for _, row in upid_lookup.iterrows():
                             pseudo = row['PseudoNHSNoLinked']
                             upid = row['UPID']
                             directory = row['Directory']
 
-                            if pseudo in match_lookup:
+                            if pd.notna(pseudo) and pseudo in match_lookup:
                                 indication_records.append({
                                     'UPID': upid,
                                     'Indication_Group': match_lookup[pseudo],
                                     'Source': 'DIAGNOSIS',
                                 })
                             else:
+                                # Use fallback: Directory + " (no GP dx)"
+                                fallback_label = str(directory) + " (no GP dx)" if pd.notna(directory) else "UNKNOWN (no GP dx)"
                                 indication_records.append({
                                     'UPID': upid,
-                                    'Indication_Group': str(directory) + " (no GP dx)",
+                                    'Indication_Group': fallback_label,
                                     'Source': 'FALLBACK',
                                 })
 
@@ -465,6 +473,9 @@ def refresh_pathways(
                         # It expects indication_df to have 'Directory' column (mapped from Indication_Group)
                         indication_df_for_chart = indication_df[['UPID', 'Indication_Group']].copy()
                         indication_df_for_chart = indication_df_for_chart.rename(columns={'Indication_Group': 'Directory'})
+                        # Ensure unique UPID index (build_hierarchy requires uniquely valued Index)
+                        # Keep first occurrence - DIAGNOSIS entries should come before FALLBACK
+                        indication_df_for_chart = indication_df_for_chart.drop_duplicates(subset=['UPID'], keep='first')
                         indication_df_for_chart = indication_df_for_chart.set_index('UPID')
 
                         # Process each date filter with indication grouping
diff --git a/data_processing/diagnosis_lookup.py b/data_processing/diagnosis_lookup.py
index fd511c8..0dbd58b 100644
--- a/data_processing/diagnosis_lookup.py
+++ b/data_processing/diagnosis_lookup.py
@@ -1348,12 +1348,13 @@ def get_patient_indication_groups(
 
         # Build the full query with cluster CTE
         # This finds the most recent matching diagnosis for each patient
+        # Note: Column names must be aliased to ensure consistent casing in results
         query = f"""
 {CLUSTER_MAPPING_SQL}
 SELECT
-    pc."PatientPseudonym",
-    aic.Search_Term,
-    pc."EventDateTime"
+    pc."PatientPseudonym" AS "PatientPseudonym",
+    aic.Search_Term AS "Search_Term",
+    pc."EventDateTime" AS "EventDateTime"
 FROM DATA_HUB.PHM."PrimaryCareClinicalCoding" pc
 INNER JOIN AllIndicationCodes aic
     ON pc."SNOMEDCode" = aic.SNOMEDCode