Recurring concern

Unreliable triage in walk-in and minor-injury centres

First to latest report 26 Jan 2018 — 10 Aug 2025

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 5

What this concern includes

Includes failures in front-door triage at walk-in centres, minor-injury units and comparable unscheduled primary-care assessment centres, including delayed or absent triage, omission of clinically relevant observations, failure to consider the presenting complaint broadly and failure to identify the appropriate urgency or investigations.

What is not included

Excludes emergency-department triage and ambulance-call triage where the assertion concerns a separately operated triage system.
Excludes failures in diagnostic investigation, treatment or referral after triage has been completed appropriately.
Excludes generic staffing, communication or documentation deficiencies unless they directly make walk-in or minor-injury-centre triage unreliable.
Excludes public confusion about the roles of walk-in centres and other services unless the asserted unsafe condition is the operation of the centre's triage process.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Cornwall Partnership NHS Foundation Trust1

HCRG Care Coventry LLP1

Lifestar Medical Limited1

NHS Coventry and Warwickshire Integrated Care Board1

NHS England1

South Western Ambulance Service NHS Foundation Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

10 Aug2025
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to undertake sufficiently broad triage investigation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Cornwall Partnership NHS Foundation Trust
Lifespan Medical Limited
South Western Ambulance Service NHS Foundation Trust
Stated actions 5
1. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.
2. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
3. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
1. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.
2. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Require CFT MIU clinicians to complete a full physical assessment after ambulance-based triage and continue monitoring implementation through documentation audits and observations of care.
AI-generated summary

Brian Ingram · 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

Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.

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 undertake sufficiently broad triage investigation
Wider context from the report
“4) Brian was seen by a triage nurse who ordered a knee x-ray only. ”
Source location
Brian Ingram · 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
Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.

Verbatim wording from the response
“2.3 Whilst CFT was not aware that Mr Ingram’s daughter was waiting in the ambulance in this case, we appreciate that had our Minor Injuries Unit (MIU) staff come to the ambulance to carry out an initial assessment of Mr Ingram and consider his suitability for review and/or treatment in the MIU, they would have discovered her waiting there, and had the opportunity to take any relevant history. It is established MIU practice to assess patients in the ambulance, prior to checking them in. This is expressly stated in the MIU Operational Policy, which sets out the procedure for patients being brought into the MIU by ambulance, as follows:”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 3 · response
Published 14 October 2025
Open published response
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
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.

Verbatim wording from the response
“2.6 There has been a team-wide communication to all MIU staff, reiterating the requirement for all patients arriving by ambulance (SWAST or otherwise), to be physically assessed and have a handover and history taken in the back of the ambulance, before the patient is accepted into the MIU. It has been clarified that the patient should only be booked in to the MIU, once the clinician has confirmed their acceptance with the admin team. Patients arriving by ambulance are not to be booked in until they have been assessed as suitable for treatment at the MIU.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 4 · response
Published 14 October 2025
Open published response
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
Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.

Verbatim wording from the response
“3.8 From the perspective of CFT, all MIU staff have been reminded that the PCR, whether this is in paper form or any electronic PCR, should be received from the ambulance crew before the patient is booked in. Learning has been identified following the inquest in relation to patient handover at the MIU. It is acknowledged by CFT that there was an over-reliance on a verbal handover from the ambulance crew (believed by MIU staff to be paramedics), which had an impact on the initial assessment by the MIU practitioner. All staff have been reminded of the importance of taking a full patient history and all available patient documentation, prior to accepting the patient on to the MIU. This learning and required actions have been shared with staff via email and have featured on the agenda of MIU staff meetings over the last 12 months.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 7 · response
Published 14 October 2025
Open published response
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
Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.

Verbatim wording from the response
“2.5 The facts relating to Mr Ingram’s inquest have also been used as a case study and presented at the Learning from Experience (LFE) Forum, a meeting attended by all MIU clinical leads, to discuss any collective issues to be addressed, and to share learning and best practice across CFT. It was reiterated at the LFE Forum, that in accordance with policy, all patient arrivals via ambulance should be initially assessed in the ambulance, and a full assessment of the patient should be carried out by an MIU clinician (discussed further below).”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 4 · response
Published 14 October 2025
Open published response
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
Require CFT MIU clinicians to complete a full physical assessment after ambulance-based triage and continue monitoring implementation through documentation audits and observations of care.

Verbatim wording from the response
“7.1 We recognise that this was an important missed opportunity. CFT has taken clear and decisive steps to ensure that all staff are aware of the requirement to carry out a full physical assessment when patients are brought to the MIU (assuming they are initially deemed to be suitable following an ambulance-based triage). This has been communicated in MIU team meetings, LFE Forums, clinical supervision meetings, and across CQaGG and other patient safety forums attended by team leads across the spectrum of community services. CFT will continue to monitor the implementation of this learning, when carrying out documentation audits and observations of care, as part of our ASPIRE accreditation requirements.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 10 · response
Published 14 October 2025
Open published response
26 Jan2018
Coventry
Concerns raised2
1. Failure to include clinical observations in walk-in centre triage
2. Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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 include clinical observations in walk-in centre triage
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
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services
Wider context from the report
“I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children. I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment. The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services. ”
Source location
Vanessa Ferkova · Prevention of Future Deaths report
Page 2 · concerns
Open source report