4 Apr 2025 Hailey Anne Thompson · Prevention of Future Deaths report Manchester West
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Concerns raised 3 Failure to allocate medication enquiries to clinicians with appropriate competencies View source Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor View source Failure to record clinical task communications on the medical records system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hailey Anne Thompson · 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
Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashton Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate medication enquiries to clinicians with appropriate competencies
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist , which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashton Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock .
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice ,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery .
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to .
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashton Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical task communications on the medical records system
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist . On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” Open source report
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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 use of auditable systems for all clinical communication and prohibit screen messages for clinical referrals.
Verbatim wording from the response “• We have reinforced the requirement for auditable documentation across all communication channels.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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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 Review the clinicians’ capabilities matrix and conduct a further review by June 2025.
Verbatim wording from the response “• We reviewed the clinicians’ capabilities matrix accessible by all staff, this will be further reviewed by June 2025.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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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 the process for directing paediatric medication requests away from pharmacists and provide related staff training reminders.
Verbatim wording from the response “• The pharmacists manage prescription requests changes for adults not children, on this occasion the call-handler sent it through to the pharmacist. All staff have been reminded of the process to follow with training reinforced.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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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 Formalise and reinforce the policy prohibiting pharmacists from prescribing or altering medication for children, except where consultant letters explicitly authorise it.
Verbatim wording from the response “• Our pharmacists do not prescribe for children. This has been further reinforced within our teams and further formalised in a policy, preventing pharmacists who work with the practice from issuing or altering antibiotics or medications for children, except when stated explicitly in consultant letters.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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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 Review the centralised clinical competencies register, distribute it to care navigation teams, and review it biannually.
Verbatim wording from the response “• Our centralised competencies register is under review for all clinical staff, including pharmacists, which will be distributed to care navigation teams and reviewed biannually.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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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 Audit care navigator decisions and task-completion checks quarterly.
Verbatim wording from the response “• We have a quarterly audit, reviewing care navigator decisions and task completion checks.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
Verbatim wording from the response “We acknowledge the concerns raised regarding care navigation, governance, and communication processes, and would like to take this opportunity to provide assurances of the processes that are embedded into the practice. We note that you state that you concluded that the concerns you raised did not contribute to the death and would also point out that the structures and operating procedures which are used at the surgery are consistent with those used in the vast majority of doctors surgeries in the UK. As a result, we would ask you to consider if a Regulation 28 Report is appropriate in these circumstances.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing pathways, triage guidance, staff training, policies and escalation procedures provide a clear and adequate response to urgent patient calls.
Verbatim wording from the response “• Ashton Medical Centre have a clear pathway of whom to refer a task to, action and triage tools that would recognise an allergic reaction or ‘red flag’ symptom. These tools are in the form of guidance sheets which are available to all admin staff at their desks, SOPs which are available in paper format and electronic copies held on the practices drive. All staff are trained on these at induction and regularly reminded.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The recorded request appears to have been for an alternative antibiotic, not an appointment requiring clinical assessment.
Verbatim wording from the response “• Our well-embedded organisational policies suggest that the request was likely made to obtain an alternative medication following an adverse reaction to the original antibiotics.” Source location Response from SSP Health and Ashton Medical Practice
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations