Mandy Dickerson

Dear Dr Cummings Re: Mandy Dickerson - Regulation 28 Report to Prevent Future Deaths I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued on 3rd April 2022, following the Inquest into the death of Mandy Dickerson which concluded on 1st December
2021. I would like to begin by extending my sincere condolences to the family of Ms Dickerson for their loss. I appreciate this will still be a very difficult time for the family. In response to evidence heard at the Inquest you raised some concerns in relation to the care and treatment provided by Bedfordshire Hospitals NHS Foundation Trust's ("the Trust"), specifically around the streaming process carried out on arrival at the Emergency Department. This letter sets out the Trust's formal response. Regulation 28 Concern Matters of concern were raised and are responded to as follows:
1. "I heard detailed evidence ofthe "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" ofthe patient. f 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 ofservices. However, it was apparent that very little documentation ofthe process with regard to each patient is made, kept or conveyed."

Streaming has been implemented within primary care to assist on arrival at the Trust Emergency Department (ED) in deciding whether a patient will be seen in ED or in the Urgent GP Clinic (UGPC) which is run by Atrumed Healthcare. Streaming is undertaken by a designated nurse who is employed by the Trust. The role of the streaming service is to visually assess patients presenting at the ED to allow for a quick decision as to whether they can best be supported by urgent or acute care services. Streaming is an initial allocation assessment. The streaming nurse records a brief summary on a slip of paper of the 1 minute consultation that is carried out. This slip is handed to the ED receptionist. Where the patient is streamed to UGPC, the receptionist enters details onto SystmOne, UGPC's patient management software. The clinical information on the slip of paper is also added to SystmOne. Since this Inquest, the Trust are now able to access SystmOne. It could previously only be accessed by UGPC and the patient's own GP. The streaming information is therefore now available for all to access and review. A fully documented hands-on initial assessment is then carried out by triage in ED or at UGPC, the streaming system does not replace this as the first substantive assessment. 11
2. / have referred in {3) above [concerns raised to Atrumed Healthcare] to the situation with respect to the referrals to the speciality registrars out ofhours. 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 opinions) a medical assessment." On arrival at the Trust, Ms Dickerson was streamed to the UGPC by the streaming nurse. When she was seen in UGPC, the assessing clinician felt she required further acute assessment. Given the time of day, a referral was sent to the Speciality Registrar in accordance with the UGPC guidelines. Based on the information provided to him, the Specialty Registrar concluded no acute assessment was required and Ms Dickerson was sent home. At the Inquest, you heard evidence that the option was always open to the UGPC clinician to refer a patient back to ED if they remained concerned. However, it became clear that UGPC clinicians did not consider this as an option and considered the Speciality Registrar's opinion to be final. The Trust has worked with Atrumed Healthcare to update the 'Streaming Guidelines for the Urgent GP Clinic (UGPC)' (appendix 1) to ensure more clarity in the system for referral from UGPC to the Hospital. As was previously the case, where the UGPC clinician identifies that further acute assessment is required, they refer to the GP Liaison or the Specialty Registrar if out of hours, as in Ms Dickerson's case. The Specialty Registrar then uses their own judgement to consider the information provided and advise on the next steps for the patient's care, as they would with any patient they are asked to review. The plan for next steps is to be agreed with the UGPC clinician.

T e update to this policy emphasises that the UGPC clinician and the Speciality registrar must be in agreement that the proposed action is acceptable and clinically appropriate. It then adds a written step that if agreement cannot be reached, the UGPC clinician must record this in the notes before immediately sending the patient to ED. Although this step is new in the sense that it has been newly written into the policy, this option for UGPC clinicians to refer to ED has always been available in practice. The policy has been updated to give a clear written pathway for clinicians to refer to. This addition is to be known as 'Mandy's Rule'. It clarifies that UGPC clinicians should act and seek the further assessment when they feel it is required, regardless of the view of the speciality registrar. When recording the lack of agreement in preparation to send the patient to the ED, Mandy's Rule can be quoted and the patient must then be accepted by ED. This will ensure that UGPC clinicians feel confident in referring patients to ED so that no patient misses out on further assessment where a clinician believes this to be necessary. The updated policy is joined by an addendum (appendix 2) setting out this rule in detail. It is made clear that a patient must not be sent home where the clinician feels they need immediate hospital attention. In all cases where a patient is referred to ED under this rule, an investigation will be carried and cases will be discussed at the regular UGPC/ED Joint Clinical Governance meetings to ensure learning and the continuous improvement of this system. We have reached out to the family regarding the naming of this rule after Ms Dickerson, who responded on 23rd May 2020 giving their permission to name the rule after her. I hope that this response provides assurance to Ms Dickerson's family and yourself that the Trust has taken the learning from the Inquest very seriously. The Trust continues to improve its policies and put in place measures to ensure safe and effective services.

Dear Sir The inquest touching upon the death of Mandy Jane Dickerson Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroner (Investigations) Regulations 2013, dated 3 April 2022 and following the inquest touching the death of Mandy Jane Dickerson who sadly passed away on 30 April 2020. I would like to take the opportunity on behalf of Atrumed Ltd to offer my sincere condolences to Mrs Dickerson’s family and friends for their loss.

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 London Office Atrumed Ltd, International House, 142 Cromwell Road, Kensington, SW7 4EF

Luton Office Urgent GP Clinic, Luton and Dunstable Hospital, Lewsey Road, Luton, LU4 0DZ

Matters of Concern in respect of Atrumed Ltd “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 cooperation 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 Mr 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.

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 London Office Atrumed Ltd, International House, 142 Cromwell Road, Kensington, SW7 4EF

Luton Office Urgent GP Clinic, Luton and Dunstable Hospital, Lewsey Road, Luton, LU4 0DZ

4. 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 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.

5. 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.”

Response
1. I am sorry that you formed the view that there was reluctance on the part of either Atrumed Ltd and / or myself to engage with your investigation. I can assure you that this was not the case. As you are aware, Atrumed Ltd is closely aligned with Luton and Dunstable Hospital (run by Bedfordshire Hospitals NHS Foundation Trust – “the Trust”) in terms of the provision of the Urgent GP Care Centre. I have not previously been involved in inquest proceedings and I was initially under the impression that the Trust would co - ordinate with your office on both its own and our behalf . Immediately I became aware that you required assistance and information from Atrumed Ltd specifically, I provided it to you.

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 London Office Atrumed Ltd, International House, 142 Cromwell Road, Kensington, SW7 4EF

Luton Office Urgent GP Clinic, Luton and Dunstable Hospital, Lewsey Road, Luton, LU4 0DZ

2. The sepsis template and how it operates is part of the System One software. System One is a nationally used software and the function of its templates is outside the control of Atrumed Ltd. However, Atrumed Ltd has recently (1) changed the software module to an Urgent Care Module and (2) added a Sepsis Screening tool as a bolt on. This means that if a patient’s observations are abnormal such that there is a risk of sepsis, this will be flagged up on the system. It is Atrumed’s local policy (attached) that this tool is to be used by its clinical practitioners.

3. This paragraph addresses both paragraphs 3 and 4 of your concerns. Following the inquest and in conjunction with one another, Atrumed Ltd and the Trust reviewed the protocol that was in place for referrals between the hospital and the Urgent GP Care Centre and have revised it. The protocol now makes clear that the Urgent GP Care Centre can refer any patient back to the hospital for further assessment, whether or not it has the agreement of a speciality doctor. As a result, there is no longer any confusion between the Urgent GP Care Centre and the Trust in this regard. Protocol attached. The protocol has been shared with all clinicians and is available in all the consultation rooms and provided at induction.

4. As to paragraph 5 of your concerns, it is of course for each individual practitioner (in accordance with their relevant regulatory body and their professional obligations) to ensure that they record the key information about a patient and the patient’s presentation and that they accurately report the same to any other practitioner that they may contact in respect of a patient. It is now, however, part of Atrumed’s policy that practitioners must record (in a patient’s records) the name and times of any specialty clinicians that they speak to (please see attached) We carry out monthly audits of the records to ensure that this is happening and any issues that are identified are discussed with the Trust out our joint clinical governance meetings.

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 London Office Atrumed Ltd, International House, 142 Cromwell Road, Kensington, SW7 4EF

Luton Office Urgent GP Clinic, Luton and Dunstable Hospital, Lewsey Road, Luton, LU4 0D

I hope that the above information provides you with the reassurance that action has been taken by Atrumed Ltd in respect of the concerns that you raised during the course of the inquest and in your Regulation 28 report. Atrumed Ltd is committed to ensuring the high-quality provision of urgent GP care services and we will ensure that the lessons learnt as a result of this inquest continue to be implemented and monitored across our service.