Kirsty Childs

1. 1. lack of standard initial questioning

   “There was no standard question asked at the beginning of the calls to identify whether the patient had previously contacted NHS Direct, or any other agency, with regard to the symptoms giving rise to the latest call.”

2. 2. non‑medical staff selecting medical questionnaires

   “Medical advisers in NHS Direct were not medically qualified, and emergency medical despatchers in West Yorkshire Ambulance service are not medically qualified. They were required to illicit details of the patient's symptoms, and proceed to identify the most significant symptom from the information gained to select the most appropriate questionnaire.”

3. 3. diagnosis without face‑to‑face assessment

   “Nurse [name redacted] within NHS Direct were reaching a diagnosis in [the deceased]'s case , without having the opportunity to undertake a face to face assessment, and there did not appear to be a lower threshold of recommending a face to face medical review”

4. 4. failure to review prior call information

   “Within NHS direct there was a complete consistency of treating each call separately, there was no attempt to review details of earlier calls made.”

5. 5. inability to access recorded advice

   “It was not possible at the inquest to review what details were recorded. | was concerned that details of earlier calls may not contain the conclusion and advice given to the patient.”

6. 6. override of questionnaire recommendation

   “The Nurse [name redacted] was able to override the recommendation of the questionnaire programme to downgrade the recommended advice outcome. This led to a tragic outcome in [the deceased]'s case.”

No published response was found on judiciary.uk.