Concerns raised 3 Lack of guidelines or triggers for practice nurse referral to a doctor View source Failure of practice nurses to reliably access and check attending patients' past medical history View source Lack of receptionist guidelines or triggers for booking a doctor's appointment instead of a nurse practitioner appointment View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Review and reinforce clinicians’ checking of patients’ past clinical history at each appointment.
View source
Action
Discuss the under-one-year contact survey at a clinicians’ meeting to determine whether GP triage should apply.
View source
Action
Arrange for a paediatrician to deliver a module on referral for a sick child.
View source
Action
Arrange for all clinicians to complete the Department of Health’s “Spotting the Sick Child” e-learning tool.
View source
Action
Provide laminated copies of the NICE Traffic Light guidance in all nurses’ consulting rooms.
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AI-generated summary
YUKI NORMAN-KNIGHT · 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
Yuki was a very young child who had a persistent cough and was seen at a walk-in centre and twice by practice nurses, receiving diagnoses of chest infection and courses of antibiotics. She later became unresponsive while with her father and died despite resuscitation efforts. Concerns related to checking her past medical history, guidance for practice nurses to refer children to a doctor, and appointment systems for securing a doctor’s assessment.
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. The report was sent to St Stephens Gate Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines or triggers for practice nurse referral to a doctor
Wider context from the report “(2) On the evidence given to the Inquest there appeared to be no guidelines or triggers for when a practice nurse should refer a patient to be seen by a doctor . I am therefore concerned that the systems at St Stephens Gate Medical Practice for such a referral, especially in the case of a very young child or baby may need to be reviewed .
” 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 St Stephens Gate Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure of practice nurses to reliably access and check attending patients' past medical history
Wider context from the report “(1) Evidence given at Inquest from the Timber Hill walk in centre was that a record of a patient's attendance, if not registered at that practice, would be sent either electronically or by fax to the surgery where the patient was registered. In their evidence to the Inquest the practice nurses who saw Yuki at St Stephens Gate Medical practice could not recall if they had access to this information . I am therefore concerned that the systems for practice nurses checking an attending patient's past medical history, especially where the patient is a very young child or baby may need review .
” 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 St Stephens Gate Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of receptionist guidelines or triggers for booking a doctor's appointment instead of a nurse practitioner appointment
Wider context from the report “(3) The evidence given to the Inquest was that when a caller telephoned the St Stephens Gate Medical Practice for an appointment the receptionist would ask the caller if they were happy with a nurse practitioner appointment. If the caller said they wanted a doctor then a doctor's appointment would be given. There appeared to be no guidelines for the receptionist or trigger for a doctor's appointment to be made in the absence of any specific request by the caller . I am therefore concerned that the systems for making appointments at the St Stephens Gate Medical Practice may need reviewing in particular whether there should be guidelines and/or triggers for a doctor's appointment as opposed to nurse practitioner when the appointment is for a very young child or baby .
” 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 Review and reinforce clinicians’ checking of patients’ past clinical history at each appointment.
Verbatim wording from the response “In other words, our ability to see the consultation details at another venue is reliant on the patient's consent. However, in the instance where consent has been given, we confirm that the information can be seen and that all nursing staff check records accordingly. Whilst this would be standard procedure in any case, we have reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment.” Source location 2013-0321-Response-by-St-Stephens-Gate
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 Discuss the under-one-year contact survey at a clinicians’ meeting to determine whether GP triage should apply.
Verbatim wording from the response “We have also undertaken a survey of contacts by parents/guardians of patients under one year that we have had, over a period of one month. We will then discuss the issue at a clinicians’ meeting to establish whether all under-one year olds should be triaged by a GP.” Source location 2013-0321-Response-by-St-Stephens-Gate
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 Arrange for a paediatrician to deliver a module on referral for a sick child.
Verbatim wording from the response “2. St Stephens Gate Medical Practice assures the Coroner that any Nurse Practitioner or Practice Nurse will have the support of a duty doctor at all times. Moreover, the Practice is arranging for a” Source location 2013-0321-Response-by-St-Stephens-Gate
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 Arrange for all clinicians to complete the Department of Health’s “Spotting the Sick Child” e-learning tool.
Verbatim wording from the response “paediatrician to attend here and present a module on ‘Referral for a Sick Child’; and also for all clinicians to undertake: ‘Spotting The Sick Child’, an e-learning tool commissioned by the Department of Health.” Source location 2013-0321-Response-by-St-Stephens-Gate
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 Provide laminated copies of the NICE Traffic Light guidance in all nurses’ consulting rooms.
Verbatim wording from the response “In recognition of this NICE guidance, in the event of any doubt a nurse would refer to or at the very least discuss a case of concern with a GP. We use the NICE ‘Traffic Light System for Identifying Risk of Serious Illness (new 2013)’, and are arranging for laminated copies of the Traffic Light guidance to be present on desks in all nurses’ consulting rooms.” Source location 2013-0321-Response-by-St-Stephens-Gate
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 Consultation details from other organisations cannot be viewed when patients withhold consent or make events private.
Verbatim wording from the response “However: we would not be able to see the detail of the consultation if SystmOne showed:” Source location 2013-0321-Response-by-St-Stephens-Gate
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations