3 Apr 2022 Mandy Jane DICKERSON · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 8 Failure to make, retain and convey documentation of ED streaming decisions View source Failure of the sepsis template to operate reliably and mandatorily View source Lack of a policy directing specialty registrar responses to out-of-hours assessment requests View source Failure to perform critical clinical observations View source Insufficient information gathering during emergency-department streaming to UGPC View source Confusion over escalation and return-to-ED arrangements for out-of-hours specialty referrals View source Failure to convey key clinical information to medical registrars View source Failure to record the identity of medical registrars providing advice View source See 5 more concerns
Responses linked to these concerns
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Mandy Jane DICKERSON · 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
Mandy Jane Dickerson attended the Urgent GP Care Centre on 26 April 2020 after several days of diarrhoea and vomiting, but was discharged without assessment by the medical team. She died at home on 30 April 2020 from sepsis. The principal concerns included a non-mandatory and unreliable sepsis template, inadequate recording and communication of key observations, and confusion about referral responsibilities when specialist assessment was requested.
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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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to make, retain and convey documentation of ED streaming decisions
Wider context from the report “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 .
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of the sepsis template to operate reliably and mandatorily
Wider context from the report “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 .
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy directing specialty registrar responses to out-of-hours assessment requests
Wider context from the report “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.
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to perform critical clinical observations
Wider context from the report “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 in 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.
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Insufficient information gathering during emergency-department streaming to UGPC
Wider context from the report “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.
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Confusion over escalation and return-to-ED arrangements for out-of-hours specialty referrals
Wider context from the report “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 specialty , 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 would 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.
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to convey key clinical information to medical registrars
Wider context from the report “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 in 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.
” 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 Atrumed Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to record the identity of medical registrars providing advice
Wider context from the report “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 in 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.
” 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 Audit patient records monthly for compliance with specialty-consultation recording requirements and discuss identified issues at joint clinical governance meetings.
Verbatim wording from the response “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.” Source location 2022-0100 - Response from Atrumed Healthcare
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 Revise the referral protocol to clarify that the Urgent GP Care Centre may refer patients back to hospital for further assessment without specialty agreement, and disseminate it to clinicians and consultation rooms.
Verbatim wording from the response “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.” Source location 2022-0100 - Response from Atrumed Healthcare
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 Upgrade the software module and add a Sepsis Screening tool that flags abnormal observations indicating sepsis risk.
Verbatim wording from the response “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.” Source location 2022-0100 - Response from Atrumed Healthcare
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 Require practitioners to record the names and times of specialty clinicians consulted in patient records.
Verbatim wording from the response “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.” Source location 2022-0100 - Response from Atrumed Healthcare
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 clinical practitioners to use the Sepsis Screening tool under Atrumed’s local policy.
Verbatim wording from the response “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.” Source location 2022-0100 - Response from Atrumed Healthcare
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 underlying System One sepsis-template function is outside Atrumed’s control, limiting its ability to alter that software directly.
Verbatim wording from the response “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.” Source location 2022-0100 - Response from Atrumed Healthcare
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations