Madhumita Mandal
8 Dec 2015 · Coroner Selena Lynch · London (South)
The coroner's concerns
1. inadequate patient assessment by non‑medical staff
“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 [name redacted] 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.”
2. ambulance service misuse due to assessment bias
“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.”
3. delayed medical assessment resulting in critical condition
“Mrs [name redacted] 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 [name redacted] was seen by any qualified healthcare professional, by which time her condition was Critical”