“(brief summary of matters of concern) Regulation28AfterInquestDocumentTemplateUpdate…”

The coroner’s concerns

(brief summary of matters of concern) Regulation28AfterInquestDocumentTemplateUpdate d30/07/2021 To the Chief Executive, Atrumed Ltd, provider of Urgent GP Care (UGPC) services on the Luton and Dunstable University Hospital site: 1. In my view there was considerable reluctance on the part of Atrumed Ltd, led by CEO , to engage properly with my investigation. This resulted in the issue of a Schedule 5 Notice to , to attend a special court session, so that I did secure his attention and to impress on him the significance of a Coroner's investigation and that his co operation was not optional, in large part to ensure future learning. 2. The computer system in use at the Urgent GP Care Centre was prone at the time (April 2020) to glitches which rendered the use of the "Sepsis template" to be "advised" rather than mandatory. Sometimes it would display and other times not. It is my view that had the Sepsis template been fully operational and mandatory then the signs of sepsis shown by Mandy Dickerson would have likely altered the clinical decision making and resulted in prompt treatment for sepsis with probable survival. 3. There was fundamental confusion with regard to the management of patients, out of hours, who the treating UGPC clinician felt should be assessed by a relevant speciality, in this case medical, and where the relevant speciality felt assessment was unnecessary. It was understood by and by the treating UGPC nurse that once the speciality registrar had made a decision then that decision was final and the only option was to discharge the patient, unless they were in extremis, when a 222 call could be made for emergency assistance from the nearby hospital. I was told that if the patient was returned to the ED then the streaming nurse would simply refer them back. That view was flatly contradicted by Dr , Consultant in Emergency Medicine at the Luton and Dunstable University Hospital and Deputy Medical Director. He told me it was entirely open to the UGPC staff to refer back to ED if there was difficulty. He did not accept that the ED would refuse to see patients referred back, saying it happened all the time. 4. There was in my view a failure to record and then to convey key information to the medical registrar who consequently may have given advice which was ill-informed. The nurse practitioner told me, in oral evidence and in a statement provided at the eleventh hour the night before the Inquest, that the measurements had been performed but simply not recorded. However, the remainder of the note was particularly and contemporaneously detailed with these critical observations being conspicuous by their absence. I found that the observations had not been made. In addition, no record was made of the name of the medical registrar making investigation of this element difficult. To the Chief Executive, Bedfordshire Hospitals NHS Foundation Trust: 1. I heard detailed evidence of the "streaming" service where patients attending the ED were directed to the UGPC on the basis of very little information gained from their presenting complaint and basic "eyeballing" of the patient. I understood that there is a difference between streaming to UGPC and triage for entry into the ED. I also understood the impact of the pandemic on the provision of services. However, it was apparent that very little documentation of the process with regard to each patient is made, kept or conveyed. 2. I have referred in (3) above to the situation with respect to the referrals to the speciality registrars out of hours. I was provided with information about many different policies and procedures but I did not hear evidence as to any policy directing how a speciality registrar should respond to a request for assessment when even allowing for the missing important observations, enough information was conveyed to mandate (in Dr and Dr opinions) a medical assessment.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0100

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0