Recurring concern

Unreliable rapid assessment and treatment for walk-in Emergency Department patients

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First reported 18 Apr 2017•Latest report 11 Aug 2020

Definition

What this concern includes

Includes failures in the dedicated rapid-assessment and treatment arrangements for walk-in or otherwise unscreened Emergency Department patients, including early senior clinical assessment, clinically appropriate observations, initiation of investigations, treatment and escalation, and equivalent safety controls where different front-door models are used.

Not included

  • Excludes general Emergency Department capacity, crowding and waiting-time deficiencies where the specific rapid-assessment and treatment process is not deficient.
  • Excludes failures in specialist assessment, treatment or follow-up after the patient has received appropriate front-door assessment and initial management.
  • Excludes generic public confusion about the roles of walk-in centres, urgent care centres and GP services unless it directly results in an unsafe rapid-assessment and treatment process.
  • Excludes generic triage failures that do not concern the dedicated early assessment and treatment of walk-in or unscreened patients.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2017–2020

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

BrisDoc Healthcare Services Limited1
Bristol NHS Foundation Trust1
Care Quality Commission1
HCRG Care Coventry LLP1
NHS Coventry and Warwickshire Integrated Care Board1
NHS England1
Royal College of Radiologists1
Tameside and Glossop Integrated Care NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Sylvia Scully · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sylvia Scully became unwell with sudden abdominal pain and vomiting and attended Tameside General Hospital on 9 February 2020. A radiologist initially reported another patient’s scan in error, and the correct diagnosis of hollow viscus perforation was made after her condition had deteriorated so severely that she could not withstand emergency surgery; she died in hospital on 10 February 2020. Concerns included variations in radiologists’ access to systems and equipment for out-of-hours reporting, the absence of a formal investigation into her care, and the lack of a Rapid Assessment and Treatment Model for walk-in emergency patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use a Rapid Assessment and Treatment Model for walk-in Emergency Department patients

    Wider context from the report

    “2. A Rapid Assessment and Treatment Model was not in use at the Trust’s Emergency Department at the time of Mrs Scully’s attendance in respect of ‘walk-in’ patients. Such a paradigm would have seen Mrs Scully assessed early on by a senior doctor who had the experience and authority to promptly initiate all relevant investigations (including ordering CT Scans) and commence treatment, in advance of review by the surgical team. ”

    Source location

    Sylvia Scully · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Allocate a Lead Consultant to ensure priority 1 and 2 Emergency Department patients receive timely senior assessment and prompt investigations.

    Verbatim wording from the response

    “models and their applications and have continuously reviewed them along with staffing requirements in light of the COVID-19 pandemic. The Trust have adopted new ways of working to ensure patients who are categorised as a 1 or 2 are seen in a timely manner. Between Monday to Friday, 08.00 hours to 22.00 hours and on weekends between 10.00 hours to 18.00 hours, there is a “Lead Consultant” allocated to ensure these urgent patients are seen within 30 minutes following Triage. This is to ensure these patients are seen by the appropriate team and appropriate investigations are requested quickly. When a Triage Nurse has undertaken her initial assessment, it is then their responsibility to immediately highlight them to the Team Leader.”

    Source location

    2020-0156-Response-from-NHS-Tameside-and-Glossop-Integrated-Care_Redacted.pdf
    Page 5 · response
    Published 21 October 2020

    Open published response

  2. Coventry

    AI-generated summary

    Vanessa Ferkova · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Vanessa Ferkova, aged 2, attended a GP walk-in centre with fever and vomiting and later developed a rash. She was subsequently recognised as very unwell and likely suffering from meningococcal septicaemia, went into cardiac arrest in an ambulance, and died after unsuccessful resuscitation. The principal concern was that the walk-in centre did not provide clinical triage or a required timeframe for initial assessment, despite concerns that earlier observations could have identified and treated shock.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments

    Wider context from the report

    “I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen. I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool. Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place; a situation which is seeming accepted by the regulator. I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged. ”

    Source location

    Vanessa Ferkova · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Avon

    AI-generated summary

    David Lee BIRTWISTLE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of front-door ED streaming to include basic physiological measurements

    Wider context from the report

    “1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements. ”

    Source location

    David Lee BIRTWISTLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026