Virgin Care Wandle LLP

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First report 8 Dec 2015•Latest report 8 Dec 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
7

Described in responses

Concerns and recipient responses

Statements from Virgin Care Wandle LLP linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South London

    AI-generated summary

    Madhumita Mandal · 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

    Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.

    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 Virgin Care Wandle LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess emergency department patients consistently regardless of mode of transport

    Wider context from the report

    “Mrs Mandal’s death also raises questions about the use of ambulance services. A difference in assessment of patients based upon their mode of transport to the emergency department may encourage patients to err on the side of calling an ambulance. ”
    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 Virgin Care Wandle LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient qualification for assessment of urgent care patients

    Wider context from the report

    “Mrs Mandal was taken to Croydon University Hospital by her husband. Virgin Care was contracted by the Croydon Clinical Commissioning Group to provide urgent care services, and to stream adult patients arriving at the emergency department. A streaming model was followed by a receptionist who had no medical training and who performed no medical observations. This led to a delay of about an hour before Mrs Mandal was seen by any qualified healthcare professional, by which time her condition was critical. The streaming model had been approved and commissioned in the contract as recommended by an NHS body called the Emergency Care Intensive Support Team. The system at Croydon has changed since Mrs Mandal’s death but concerns remain about the level of qualification for assessment of patients, and there may be lessons for other Trusts who contract out the provision of urgent care. ”
    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

    Train receptionists to apply the streaming process and escalate uncertain or concerning patient presentations to a clinician.

    Verbatim wording from the response

    “Receptionists were instructed to speak to a clinician if they were unsure about a patient's condition or if they had any concerns about a patient. Receptionists were trained to carry out the streaming process and a record of this is attached at Appendix 3 (One to One Training), which has been redacted appropriately to maintain confidentiality. The receptionist who booked in Mrs Mandal had received such training in October 2012.”

    Source location

    MMandal-Response1
    Page 2 · response
    Published 8 December 2015

    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

    Strengthen the triage process by assigning General Practitioners rather than nurses to carry out Manchester Triage System assessments.

    Verbatim wording from the response

    “When the services commenced in April 2012, the UCC was required, under the contract and conditions of the commission, to assess patients using a process based on the Manchester Triage System (MTS). Due to the nature of patient flows within the services, the MTS process resulted in delays to treatment for both the UCC and the CUH ED. Delays were resulting in four hour breaches in the ED and prolonged waits in patients being seen by a clinician in both services, which was an agreed significant patient safety cause for concern by both services. At busy times clinical staff were taken from treatment duties to assist with the MTS. This meant there were fewer clinicians treating people which in turn added to delays. The UCC had already identified triage as a bottleneck and had strengthened the process by replacing nurses with General Practitioners (GP) to carry out the MTS.”

    Source location

    MMandal-Response1
    Page 3 · response
    Published 8 December 2015

    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

    Use interim clinical streaming by an ED nurse to assess patients entering the department while the UCC and ED redevelopment proceeds.

    Verbatim wording from the response

    “From November 2015, interim changes have taken place to the way patients are directed to the UCC or ED while the redevelopment of UCC and ED is underway. This means that the ED is now providing ‘clinical streaming’, i.e. one nurse viewing all patients as they enter the department to determine presenting condition. This is not a triage system. This decision was made by the CCG, CUH and Virgin Care as the two departments are no longer co-located. Virgin Care is working closely with both the CCG and CUH to ensure patient safety is maintained during the redevelopment. It is anticipated that the redevelopment will last until March 2017 at the earliest.”

    Source location

    MMandal-Response1
    Page 2 · response
    Published 8 December 2015

    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

Data last updated 7 September 2026