PFD report

Francesca Margaux Sio · Prevention of Future Deaths report

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Issued 15 Nov 2019•South London

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

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 raised1

  1. Failure to separate adult and child patients in urgent care centres
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.1

  1. Action

    Provide a dedicated paediatric waiting room separate from adult patients.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Adult and child populations are not mixed in the urgent care centre, as children have a dedicated waiting room.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 separate adult and child patients in urgent care centres

Wider context from the report

“Three days before she died, Francesca attended the urgent care centre in the grounds of Princess Royal University Hospital run by Greenbrook Healthcare. She waited nearly 4 hours to be assessed by a doctor and was then referred appropriately to the paediatric accident emergency department in the hospital. I heard unchallenged expert evidence during the hearing that mixing adult and child patients in urgent care centres risked children quietly deteriorating unnoticed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 a dedicated paediatric waiting room separate from adult patients.

Verbatim wording from the response

“To ensure that children are managed safely in the UCC and do not deteriorate unnoticed the following systems are in place:”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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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

Adult and child populations are not mixed in the urgent care centre, as children have a dedicated waiting room.

Verbatim wording from the response

“• A concern that mixing child and adult populations in a UCC creates a risk that children will quietly deteriorate unnoticed”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 1 · response
Published 28 December 2019

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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 assessment, monitoring, training, escalation and transfer systems are considered effective to reduce the risk of children deteriorating unnoticed.

Verbatim wording from the response

“To ensure that children are managed safely in the UCC and do not deteriorate unnoticed the following systems are in place:”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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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 triage, supervised children’s waiting area, contractual monitoring and CQC assurance are relied on to address risks while services remain commissioned.

Verbatim wording from the response

“Greenbrook Healthcare is an established urgent care provider managing 11 urgent care centres across London and has been commissioned by BCCG to provide community and primary care facilities to the local population against a contractual service specification which meets with NHS England requirements. In line with NHS England guidance, the urgent care centre is led by a general practitioner and in this case, is co-located within the Emergency Department (ED) at the Princess Royal University Hospital (PRUH). The types of patients that present to an urgent care centre are not in need of ‘emergency’ treatment but are those that can be seen and treated by a general practitioner. All patients presenting to the PRUH ED are triaged and signposted to the service most relevant to their presenting complaint.”

Source location

2019-0390-Response-by-NHS-Bromley-CCG
Page 1 · response
Published 28 December 2019

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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.10

  1. 1

    Require all UCC clinicians to complete online training on recognising seriously ill children.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  2. 2

    Audit streaming consultations monthly for recorded observations and appropriate direct streaming of high-risk cases to the Emergency Department, with governance oversight.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  3. 3

    Prioritise urgent paediatric cases for timely consultation and recheck observations when prolonged waits trigger escalation.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  4. 4

    Train streaming nurses through a competency programme covering paediatric assessment.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  5. 5

    Visually monitor waiting rooms every 10 minutes and reassess patients showing signs of deterioration.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  6. 6

    Assess every child within 15 minutes, record clinical observations, and direct children with concerning findings to the paediatric Emergency Department.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  7. 7

    Display waiting-room signage instructing patients and carers to report worsening symptoms to the streaming nurse.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  8. 8

    Maintain clinician-developed pathways for transferring patients to the Emergency Department when deterioration or specialist investigation requires it, with monthly joint governance monitoring.

    Stated by Bromley Clinical Commissioning Group and Greenbrook HealthcareStated completedThe respondent said that this action was complete when they made their response on 28 December 2019.
  9. 9

    Give due consideration to the concerns raised in the Prevention of Future Deaths report during re-procurement.

    Stated by NHS Bromley Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 28 December 2019.
  10. 10

    Review options for re-procuring urgent care services at both sites from 1 September 2020.

    Stated by NHS Bromley Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2019.

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 all UCC clinicians to complete online training on recognising seriously ill children.

Verbatim wording from the response

“• All UCC clinicians, GPs and Nurse practitioners, complete the on-line training module “spotting the sick child”.”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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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 streaming consultations monthly for recorded observations and appropriate direct streaming of high-risk cases to the Emergency Department, with governance oversight.

Verbatim wording from the response

“• Greenbrook have a rolling monthly audit of streaming consultations to ensure all cases have clinical observations recorded and high-risk cases have been streamed directly to ED. The results of the audits are monitored through the monthly clinical governance meeting (this is a joint meeting with ED and paediatric ED).”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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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

Prioritise urgent paediatric cases for timely consultation and recheck observations when prolonged waits trigger escalation.

Verbatim wording from the response

“• Children managed within the UCC are, by definition, lower risk cases- typically those usually managed in a GP practice. The children streamed into the UCC are classed as urgent or routine, all urgent cases will be prioritised for full consultation, usually within an hour, which reduces the risk of deterioration in the waiting room.”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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

Train streaming nurses through a competency programme covering paediatric assessment.

Verbatim wording from the response

“• The UCC nurses making the streaming decision have all undergone Greenbrook’s streaming competency training program which includes specific training on assessing children.”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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

Visually monitor waiting rooms every 10 minutes and reassess patients showing signs of deterioration.

Verbatim wording from the response

“• It is the role of the streaming nurse and shift lead nurse to visibly monitor the waiting room. The streaming room lies adjacent to the waiting area and has direct visibility of the adult and child waiting rooms. The senior nurses visualise patients in the waiting room every 10 minutes and re-assess patients who are showing signs of deterioration (e.g. increasing pain/distress, drowsiness).”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 3 · response
Published 28 December 2019

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 every child within 15 minutes, record clinical observations, and direct children with concerning findings to the paediatric Emergency Department.

Verbatim wording from the response

“To ensure that children are managed safely in the UCC and do not deteriorate unnoticed the following systems are in place:”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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

Display waiting-room signage instructing patients and carers to report worsening symptoms to the streaming nurse.

Verbatim wording from the response

“• In addition to waiting room supervision by the nurse practitioners, there is clear signage in the waiting room (see attached photos) asking patients or their carer to speak with the streaming nurse if they feel their symptoms are worsening.”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 3 · response
Published 28 December 2019

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

Maintain clinician-developed pathways for transferring patients to the Emergency Department when deterioration or specialist investigation requires it, with monthly joint governance monitoring.

Verbatim wording from the response

“The UCC lies adjacent to the Emergency Department at Princess Royal University Hospital, walk in patients are assessed by a senior UCC streaming nurse and those with more serious conditions are navigated directly to the Emergency Department. Walk in patients with more minor presentations are managed within the UCC. There are clear pathways to transfer patients from the UCC into the Emergency Department at any time should their conditions deteriorate, or they require more specialist investigations. The pathways for transfers have been jointly developed by senior UCC and PRUH Emergency Department Clinicians and are monitored via the shared ED/UCC monthly clinical governance meeting.”

Source location

2019-0390-Response-by-Greenbrook-Healthcare
Page 2 · response
Published 28 December 2019

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

Give due consideration to the concerns raised in the Prevention of Future Deaths report during re-procurement.

Verbatim wording from the response

“The CCG is in the process of reviewing the options for re-procuring services at both sites from 1st September 2020 in line with the mandate from NHS England. As part of the re-procurement, the CCG will ensure that it gives due consideration to the concerns you have raised by the prevention of future deaths and welcome the opportunity to improve services in Bromley.”

Source location

2019-0390-Response-by-NHS-Bromley-CCG
Page 2 · response
Published 28 December 2019

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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 options for re-procuring urgent care services at both sites from 1 September 2020.

Verbatim wording from the response

“Bromley CCG has contracts in place for the provision of two Urgent Care Centres (UCCs) providing treatment for Bromley residents with minor injury & illness at Beckenham Beacon Hospital and the Princess Royal University Hospital (PRUH) both of which expire on 31st August 2020.”

Source location

2019-0390-Response-by-NHS-Bromley-CCG
Page 2 · response
Published 28 December 2019

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