PFD report

Gianni Khan · Prevention of Future Deaths report

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Issued 9 May 2014•Bedfordshire and Luton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of full triage before streaming
    Part of recurring concern: Unreliable emergency-department triage
  2. Failure to refer suspected head injuries to the A&E team
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Review the streaming process and all adult and child streaming protocols, including exclusion criteria and consideration of triage before streaming.

    Stated by NHS Luton Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  2. Action

    Exclude children with head injuries, children conveyed by ambulance, and babies aged six months or under from the streaming protocol.

    Stated by NHS Luton Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of full triage before streaming

Wider context from the report

“That when Gianni was taken to the A&E Department at the Hospital and reported that he had suffered a head injury he was “streamed” to be seen in the GP Clinic rather than see a Doctor in the Emergency Department. The Consultant from the Department told me, during the course of his evidence, that it would be ‘good practice’ for all suspected head injuries to be referred to the A&E Team. I was also told that the Hospital have always requested a full triage before streaming and the Clinical Commissioning Group refused to allow for such a triage. ”

Is this part of a recurring concern?

Yes — Unreliable emergency-department triage.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to refer suspected head injuries to the A&E team

Wider context from the report

“That when Gianni was taken to the A&E Department at the Hospital and reported that he had suffered a head injury he was “streamed” to be seen in the GP Clinic rather than see a Doctor in the Emergency Department. The Consultant from the Department told me, during the course of his evidence, that it would be ‘good practice’ for all suspected head injuries to be referred to the A&E Team. I was also told that the Hospital have always requested a full triage before streaming and the Clinical Commissioning Group refused to allow for such a triage. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries.

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

Review the streaming process and all adult and child streaming protocols, including exclusion criteria and consideration of triage before streaming.

Verbatim wording from the response

“The Urgent Care Strategic Implementation Group will undertake a comprehensive review of the streaming process for both adults and children.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 3 · response
Published 9 May 2014

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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

Exclude children with head injuries, children conveyed by ambulance, and babies aged six months or under from the streaming protocol.

Verbatim wording from the response

“In order to mitigate the risk, following the inquest on 28 April 2014 and our Serious Incident Overview Report, Luton Clinical Commissioning Group, the Luton and Dunstable University Hospital and the Urgent GP Clinic agreed to exclude the following patient groups from the streaming protocol with immediate effect:”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 2 · response
Published 9 May 2014

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. 1

    Share the Serious Incident Overview Report with involved providers and ensure dissemination to frontline staff for review, discussion, and learning.

    Stated by NHS Luton Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  2. 2

    Enhance monitoring of the Urgent GP Clinic through regular monthly Joint Service Review meetings.

    Stated by NHS Luton Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.
  3. 3

    Work with relevant provider organisations to ensure recommendations are risk-assessed, actioned, and implemented through quality-governance processes.

    Stated by NHS Luton Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  4. 4

    Review the child head-injury clinical assessment tool against NICE CG176 and introduce version control for pathways and procedural documents.

    Stated by NHS Luton Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  5. 5

    Undertake a longer-term review of emergency and urgent-care commissioning arrangements and reflect its findings in 2015/16 commissioning arrangements.

    Stated by NHS Luton Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  6. 6

    Continue improving assurance that Local Healthcare Solutions delivers its service against national risk-management standards.

    Stated by NHS Luton Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  7. 7

    Monitor provider actions and ensure their completion through the developed action plan and existing quality-governance processes.

    Stated by NHS Luton Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  8. 8

    Assess the risk of streaming children with head injuries to the Urgent GP Clinic using the CCG risk matrix.

    Stated by NHS Luton Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.
  9. 9

    Review and oversee clinical governance meetings between the hospital and Urgent GP Clinic to support integrated quality monitoring.

    Stated by NHS Luton Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Provider organisations are responsible for implementing specified clinical and organisational actions, while the commissioning group monitors completion and provides assurance.

    Stated by NHS Luton Clinical Commissioning GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 the Serious Incident Overview Report with involved providers and ensure dissemination to frontline staff for review, discussion, and learning.

Verbatim wording from the response

“• Share the Serious Incident Overview Report with the 3 healthcare providers involved in the incident and ensure it is disseminated to all front line staff for review and discussion at team meetings to inform learning.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 4 · response
Published 9 May 2014

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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

Enhance monitoring of the Urgent GP Clinic through regular monthly Joint Service Review meetings.

Verbatim wording from the response

“Additionally, Luton Clinical Commissioning Group has enhanced its monitoring of the Urgent GP Clinic by ensuring regular monthly performance (Joint Service Review) meetings.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 3 · response
Published 9 May 2014

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

Work with relevant provider organisations to ensure recommendations are risk-assessed, actioned, and implemented through quality-governance processes.

Verbatim wording from the response

“Luton Clinical Commissioning group will work with the relevant provider organisations to ensure all recommendations are risk assessed, actioned and implemented in line with our quality governance processes and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013: Action to Prevent Future Deaths.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 5 · response
Published 9 May 2014

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

Review the child head-injury clinical assessment tool against NICE CG176 and introduce version control for pathways and procedural documents.

Verbatim wording from the response

“Our report on the investigations into this case identified inconsistencies in use of the locally developed Clinical Assessment Tool for Head Injuries in Children. The tool was developed by Luton Clinical Commissioning Groups Children’s Strategic Implementation Group and forms one of seven Paediatric Urgent Care Pathways (head injury; fever; bronchiolitis; gastroenteritis; asthma; seizures; abdominal pain). These Urgent Care Pathways are based on NICE² guidance, are submitted to NICE’s shared learning collection and previously have been positively quality assured and published on the NICE website. They are scrutinised annually against any change in guidance and seek quality assurance as needed from NICE.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 3 · response
Published 9 May 2014

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

Undertake a longer-term review of emergency and urgent-care commissioning arrangements and reflect its findings in 2015/16 commissioning arrangements.

Verbatim wording from the response

“A key priority for Luton Clinical Commissioning Group will be a thorough review of emergency and urgent care commissioning arrangements in line with the findings of this investigation and Keogh³ (2013) through a longer-term piece of work. This will be reflected in commissioning arrangements for 2015/16.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 5 · response
Published 9 May 2014

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

Continue improving assurance that Local Healthcare Solutions delivers its service against national risk-management standards.

Verbatim wording from the response

“• Continue to improve on processes to gain assurance that Local Healthcare Solutions delivers their service against national risk management standards.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 4 · response
Published 9 May 2014

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

Monitor provider actions and ensure their completion through the developed action plan and existing quality-governance processes.

Verbatim wording from the response

“For the providers, Luton Clinical Commissioning Group recommends, will monitor and ensure completion on the following:”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 4 · response
Published 9 May 2014

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

Assess the risk of streaming children with head injuries to the Urgent GP Clinic using the CCG risk matrix.

Verbatim wording from the response

“Action Taken Following Gianni’s death and the subsequent investigations by all health organisations involved, Luton Clinical Commissioning Group, carried out an assessment of the risk relating to children being streamed into the Urgent GP Clinic with head injuries. This was undertaken using the Clinical Commissioning Group’s risk matrix (provided for reference in Appendix A). This established that the likelihood of harm occurring to children being streamed to the Urgent GP Clinic was ‘unlikely’ (0.1-1%) however the consequence/impact of that harm could be ‘catastrophic’ (incident leading to death), which led to an assessed risk rating of ‘high’.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 2 · response
Published 9 May 2014

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

Review and oversee clinical governance meetings between the hospital and Urgent GP Clinic to support integrated quality monitoring.

Verbatim wording from the response

“• Review and oversee clinical governance meetings between the Luton and Dunstable university Hospital and the Urgent GP Clinic to ensure an integrated approach and robust monitoring of service quality.”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 4 · response
Published 9 May 2014

Open published response

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

Provider organisations are responsible for implementing specified clinical and organisational actions, while the commissioning group monitors completion and provides assurance.

Verbatim wording from the response

“For the providers, Luton Clinical Commissioning Group recommends, will monitor and ensure completion on the following:”

Source location

2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
Page 4 · response
Published 9 May 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026