Mandy Dickerson

Atrumed Healthcare   
C/o Luton Urgent GP Clinic  
LU4 0DZ 
UK 
– 
Reference Number: ATR03 
Date: 30th May 2022 

Her Majesty’s Assistant Coroner for Bedfordshire and Luton 

Dr Sean Cummings  

The Court House  

Woburn Street 

Ampthill  

Bedfordshire 

MK45 2HX 

30 May 2022 

Dear Sir 

The inquest touching upon the death of Mandy Jane Dickerson 

Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 

Coroner (Investigations) Regulations 2013, dated 3 April 2022 and following the inquest 

touching the death of Mandy Jane Dickerson who sadly passed away on 30 April 2020. 

I would like to take the opportunity on behalf of Atrumed Ltd to offer my sincere condolences 

to Mrs Dickerson’s family and friends for their loss. 

London Office  
Atrumed Ltd, International House, 
142 Cromwell Road, Kensington, SW7 4EF 

Luton Office 
Urgent GP Clinic, Luton and Dunstable  
Hospital, Lewsey Road, Luton, LU4 0DZ 

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 Matters of Concern in respect of Atrumed Ltd 

“1. 

In my view there was considerable reluctance on the part of Atrumed Ltd, led by CEO 

, to engage properly with my investigation. This resulted in the issue of 

a Schedule 5 Notice to 

, to attend a special court session, so that I did 

secure  his  attention  and  to  impress  on  him  the  significance  of  a  Coroner's 

investigation and that his cooperation was not optional, in large part to ensure future 

learning. 

2. 

The computer system in use at the Urgent GP Care Centre was prone at the time 

(April  2020)  to  glitches  which  rendered  the  use  of  the  "Sepsis  template"  to  be 

"advised" rather than mandatory. Sometimes it would display and other times not. It 

is my view that had the Sepsis template been fully operational and mandatory then 

the signs of sepsis shown by Mandy Dickerson would have likely altered the clinical 

decision making and resulted in prompt treatment for sepsis with probable survival. 

3. 

There was fundamental confusion with regard to the management of patients, out of 

hours,  who  the  treating  UGPC  clinician  felt  should  be  assessed  by  a  relevant 

speciality,  in  this  case  medical,  and  where  the  relevant  speciality  felt  assessment 

was  unnecessary.  It  was  understood  by  Mr 

  and  by  the  treating  UGPC 

nurse that once the speciality registrar had made a decision then that decision was 

final and the only option was to discharge the patient, unless they were in extremis, 

when a 222 call could be made for emergency assistance from the nearby hospital. 

I was told that if the patient was returned to the ED, then the streaming nurse would 

simply refer them back. 

London Office  
Atrumed Ltd, International House, 
142 Cromwell Road, Kensington, SW7 4EF 

Luton Office 
Urgent GP Clinic, Luton and Dunstable  
Hospital, Lewsey Road, Luton, LU4 0DZ 

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 4. 

That view was flatly contradicted by Dr 

, Consultant in Emergency Medicine at 

the Luton and Dunstable University Hospital and Deputy Medical Director. He told 

me it was entirely open to the UGPC staff to refer to ED if there was difficulty. He did 

not accept that the ED would refuse to see patients referred back, saying it happened 

all the time. 

5. 

There was in my view a failure to record and then to convey key information to the 

medical registrar who consequently may have given advice which was ill-informed. 

The nurse practitioner told me, in oral evidence and in a statement provided at the 

eleventh  hour  the  night  before  the  Inquest,  that  the  measurements  had  been 

performed  but  simply  not  recorded.  However,  the  remainder  of  the  note  was 

particularly  and  contemporaneously  detailed  with  these  critical  observations  being 

conspicuous by their absence. I found that the observations had not been made. In 

addition,  no  record  was  made  of  the  name  of  the  medical  registrar  making  

investigation of this element  difficult.” 

Response 

1.  I  am  sorry  that  you  formed  the  view  that  there  was  reluctance  on  the  part  of  either 

Atrumed Ltd and / or myself to engage with your investigation. I can assure you that 

this was not the case. As you are aware, Atrumed Ltd is closely aligned with Luton and 

Dunstable Hospital (run by Bedfordshire Hospitals NHS Foundation Trust – “the Trust”) 

in terms of the provision of the Urgent GP Care Centre. I have not previously  been 

involved in inquest proceedings and I was initially under the impression that the Trust 

would  co  -  ordinate  with  your  office  on  both  its  own  and  our  behalf  .  Immediately  I 

became  aware  that  you  required  assistance  and  information  from  Atrumed  Ltd 

specifically, I provided it to you.   

London Office  
Atrumed Ltd, International House, 
142 Cromwell Road, Kensington, SW7 4EF 

Luton Office 
Urgent GP Clinic, Luton and Dunstable  
Hospital, Lewsey Road, Luton, LU4 0DZ 

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 2.  The sepsis template and how it operates is part of the System One software. System 

One is a nationally used software and the function of its templates is outside the control 

of Atrumed Ltd. However, Atrumed Ltd has recently (1) changed the software module 

to an Urgent Care Module and (2) added a Sepsis Screening tool as a bolt on. This 

means that if a patient’s observations are abnormal such that there is a risk of sepsis, 

this will be flagged up on the system. It is Atrumed’s local policy (attached) that this 

tool is to be used by its clinical practitioners.  

3.  This paragraph addresses both paragraphs 3 and 4 of your concerns. Following the 

inquest and in conjunction with one another, Atrumed Ltd and the Trust reviewed the 

protocol that was in place for referrals between the hospital and the Urgent GP Care 

Centre and have revised it.  The protocol now makes clear that the Urgent GP Care 

Centre can refer any patient back to the hospital for further assessment, whether or 

not  it  has  the  agreement  of  a  speciality  doctor.  As  a  result,  there  is  no  longer  any 

confusion between the Urgent GP Care Centre and the Trust in this regard. Protocol 

attached. The protocol has been shared with all clinicians and is available in all the 

consultation rooms and provided at induction.  

4.  As to paragraph 5 of your concerns, it is of course for each individual practitioner (in 

accordance  with  their  relevant  regulatory  body  and  their  professional  obligations)  to 

ensure  that  they  record  the  key  information  about  a  patient  and  the  patient’s 

presentation  and that  they  accurately  report  the  same  to  any  other  practitioner  that 

they may contact in respect of a patient. It is now, however, part of Atrumed’s policy 

that  practitioners  must  record  (in  a  patient’s  records)    the  name  and    times  of  any 

specialty  clinicians  that  they  speak  to  (please  see  attached)  We  carry  out  monthly 

audits of the records to ensure that this is happening and any issues that are identified 

are discussed with the Trust out our joint clinical governance meetings.  

London Office  
Atrumed Ltd, International House, 
142 Cromwell Road, Kensington, SW7 4EF 

Luton Office 
Urgent GP Clinic, Luton and Dunstable  
Hospital, Lewsey Road, Luton, LU4 0DZ 

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 I  hope  that  the  above  information  provides  you  with  the  reassurance  that  action  has  been 

taken  by  Atrumed  Ltd  in  respect  of  the  concerns  that  you  raised  during  the  course  of  the 

inquest and in your Regulation 28 report.  

Atrumed Ltd is committed to ensuring the high-quality provision of urgent GP care services 

and we will ensure that the lessons learnt as a result of this inquest continue to be implemented 

and monitored across our service. 

Yours sincerely,  

Chief Executive Officer  

London Office  
Atrumed Ltd, International House, 
142 Cromwell Road, Kensington, SW7 4EF 

Luton Office 
Urgent GP Clinic, Luton and Dunstable  
Hospital, Lewsey Road, Luton, LU4 0D  

A list of directors is available at the registered office. Atrumed Limited is a company registered in England & Wales. Company No: 10636369

ri!1:~1 

Bedfordshire Hospitals 
NHS Foundation Trust 

Luton & Dunstable University Hospital 
Lewsey Road 
Luton 
Bedfordshire 
LU4 ODZ 

25 May 2022 

Dr Sean  Cummings 
The Bedfordshire and Luton Coroner 
Service 
The Court House 
Woburn Street 
Ampthill 
MK45 2HK 

Dear Dr Cummings 

Re:  Mandy Dickerson - Regulation 28 Report to Prevent Future Deaths 

I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued on 3rd  April 
2022, following the Inquest into the death of Mandy Dickerson which concluded on 1st December 
2021. 

I would like to begin  by extending my sincere condolences to the family of Ms Dickerson for their 
loss. I appreciate this will still be a very difficult time for the family. 

In response to evidence heard at the Inquest you raised some concerns in relation to the care and 
treatment provided by Bedfordshire Hospitals NHS Foundation Trust's ("the Trust"), specifically 
around the streaming process carried out on arrival at the Emergency Department. 

This letter sets out the Trust's formal response. 

Regulation 28 Concern 

Matters of concern were raised and are responded to as follows: 

1. 

"I heard detailed evidence of the "streaming" service where patients attending the ED  were 
directed to the UGPC on the basis of very little information gained from their presenting 
complaint and basic "eyeballing" of the patient. f understood that there is a difference 
between streaming to UGPC and triage for entry into the ED.  I also understood the impact of 
the pandemic on the provision of services. However, it was apparent that very little 
documentation of the process with regard to each patient is made, kept or conveyed." 

 
 
 Streaming has been implemented within primary care to assist on arrival at the Trust Emergency 
Department (ED) in deciding whether a patient will be seen in ED or in the Urgent GP Clinic (UGPC) 
which is run by Atrumed Healthcare. Streaming is undertaken by a designated nurse who is 
employed by the Trust. 

The role of the streaming service is to visually assess patients presenting at the ED to allow for a 
quick decision as to whether they can best be supported by urgent or acute care services. 

Streaming is an initial allocation assessment. The streaming nurse records a brief summary on a slip 
of paper of the 1 minute consultation that is carried out. This slip is handed to the ED  receptionist. 
Where the patient is streamed to UGPC, the receptionist enters details onto SystmOne, UGPC's 
patient management software. The clinical information on the slip of paper is also added to 
SystmOne. 

Since this Inquest, the Trust are now able to access SystmOne. It could previously only be accessed 
by UGPC and the patient's own GP. The streaming information is therefore now available for all to 
access and review. 

A fully documented hands-on initial assessment is then carried out by triage in ED or at UGPC, the 
streaming system does not replace this as the first substantive assessment. 

2. 

11

/  have referred in {3)  above [concerns raised to Atrumed Healthcare] to the situation with 
respect to the referrals to the speciality registrars out of hours.  I was provided with 
information about many different policies and procedures but I did not hear evidence as to 
any policy directing how a speciality registrar should respond to a request for assessment 
when even allowing for the missing important observations, enough information was 
conveyed to mandate (in 

 opinions) a medical assessment." 

On arrival at the Trust, Ms Dickerson was streamed to the UGPC by the streaming nurse. When she 
was seen in UGPC, the assessing clinician felt she required further acute assessment. Given the time 
of day, a referral was sent to the Speciality Registrar in accordance with the UGPC guidelines. Based 
on the information provided to him, the Specialty Registrar concluded no acute assessment was 
required and  Ms Dickerson was sent home. At the Inquest, you heard evidence that the option was 
always open to the UGPC clinician to refer a patient back to ED if they remained concerned. 
However, it became clear that UGPC clinicians did not consider this as  an option and considered the 
Speciality Registrar's opinion to be final. 

The Trust has worked with Atrumed Healthcare to update the 'Streaming Guidelines for the Urgent 
GP Clinic (UGPC)' (appendix 1) to ensure more clarity in the system for referral from UGPC to the 
Hospital. 

As was previously the case, where the UGPC clinician identifies that further acute assessment is 
required, they refer to the GP Liaison or the Specialty Registrar if out of hours, as in Ms Dickerson's 
case. The Specialty Registrar then uses their own judgement to consider the information provided 
and advise on the next steps for the patient's care, as they would with any patient they are asked to 
review. The plan for next steps is to be agreed with the UGPC clinician. 

 
 
 T  e update to this policy emphasises that the UGPC clinician and the Speciality registrar must be in 
agreement that the proposed action is acceptable and clinically appropriate. It then adds a written 
step that if agreement cannot be reached, the UGPC clinician must record this in the notes before 
immediately sending the patient to ED. Although this step is new in the sense that it has been newly 
written into the policy, this option for UGPC clinicians to refer to ED has always been available in 
practice. The policy has been updated to give a clear written pathway for clinicians to refer to. 

This  addition is to be known as 'Mandy's Rule'. It clarifies that UGPC clinicians should act and seek 
the further assessment when they feel it is required, regardless of the view of the speciality 
registrar. When recording the lack of agreement in preparation to send the patient to the ED, 
Mandy's Rule can  be quoted and the patient must then be accepted by ED. This will ensure that 
UGPC clinicians feel confident in referring patients to ED so that no patient misses out on further 
assessment where a clinician believes this to be necessary. 

The  updated policy is joined by an addendum (appendix 2) setting out this rule in detail. It is made 
clear that a patient must not be sent home where the clinician feels they need immediate hospital 
attention. 

In all cases where a patient is referred to ED under this rule, an investigation will be carried and 
cases will be discussed at the regular UGPC/ED Joint Clinical Governance meetings to ensure learning 
and  the continuous improvement of this system. 

We  have reached out to the family regarding the naming of this rule after Ms Dickerson, who 
responded on 23rd  May 2020 giving their permission to name the rule after her. 

I hope that this response provides assurance to Ms Dickerson's family and yourself that the Trust has 
taken the learning from the Inquest very seriously. The Trust continues to improve its policies and 
put in place measures to ensure safe and effective services. 

Yours sincerely 

Chief Executive Officer 

 
 
 
 AT RU MED® 
HEALTHCARE 

t.!/:b1
Bedfordshire Hospitals 
NHS Foundation Trust 

j  Appendix 1 

\ 

L&D Streaming 
Guidelines 
2021-2022 

For Urgent GP Clinic 
(UGPC) 

December 2021  Version  3 

 Agreed By 

 (CD Luton ED) 
 (Tier 5  ED Clinician) 

 (Matron Luton ED) 

 (Band 7 sister) 

 (Band 7 charge nurse) 

 (CEO Atrumed Healthcare) 

 (GP rep from Atrumed Healthcare) 

 (MD from Atrumed Healthcare) 
 (GM Acute & Emergency Medicine) 

 (Head of Nursing Acute & Emergency Medicine) 

I Date Agreed 

I December 2021 

I Date of Review 

I July 2022 

IMaster Saved 

I Bedfordshire Hospttals 

L&D Streaming Guidelines 2021 /22 for UGPC Version 2 

Page 2 of 15 

 Guidelines for Streaming 

These are guidelines and allowance is given for streaming nurses to be able to exercise their clinical 
judgement.  Attendees can be streamed to services that may not be in line with the pathways if the 
streaming nurse's opinion is that the patient can be better supported in the alternative service onsite.  The 
decision will need to be supported by the reason for referring to that service. 

1. 

Aims and Objectives 

1.1 Aim 

The aim  of streaming is to visually assess the patient who presents at the Emergency Department (ED) and 
to make a quick decision as to where the patient can  be best supported by urgent or acute care services and 
to stream them to that appropriate service. 

The aim is to provide a high quality, clinically effective and cost effective service that meets the urgent 
primary medical care needs of patients in Luton. 

The aim of this service is to provide a facility to deliver face to face urgent consultation to those patients 
presenting at ED with urgent primary care specific conditions regardless of their status. The service will also 
aim to deliver appropriate education at the end of the consultation to ensure that they are aware of the 
alternative urgent care services including the 111 service. By integrating the approach and working with 
patients and stakeholders, the aim is to reduce the walk-in attendances at Luton & Dunstable Hospital 
Emergency Department for primary care conditions. 

Ongoing care following streaming is a two-way process and patients can be quickly referred between the 
Urgent GP Clinic (UGPC) and the L&D Assessment Teams if the UGPC clinician assessment identifies different 
patient needs for immediately necessary same day treatment. 

1.2 Objectives 

•  To ensure ED attendees are seen by the most appropriate healthcare professional based on their 

presenting clinical need 

•  To improve patient experience when seeking emergency care services in Luton 

•  To minimise the amount of time spent waiting for assessment and treatment in ED for patients with 

urgent primary care type complaints/conditions 

•  To ease the pressure of increased expectation/demand on the L&D ED 

•  To ensure a robust process with local primary care clinicians supporting those patients who have 

attended the service 

The UGPC shall be aware of and work to all relevant guidance including new and emerging policy guidance, 
which relate to and link with  urgent and/or unscheduled care. 

L&D Streaming Guidelines 2021 /22 for UGPC Version 2 

Page 3 of 15 

 2.  The Service 

•  Attendees to the Emergency Department (ED) can be streamed to the UGPC between the hours of 

08.00 to 23.00.  7 days a week, 365 days a year. Outside of these hours attendees will be seen in  ED 

•  During streaming an appropriately trained Band 6 (or higher) nurse speaks to the attendee and, 

following the guidelines, makes a decision  as to whether the attendee can be supported by a GP/ 

urgent primary care clinician or whether they need services that are better supported in the 

Emergency Department 

•  The nurse speaks to the patient/ carer to ascertain the reason for attendance.  This interaction is not 

a triage, and the streaming nurse will make decisions as to where the attendee needs to be seen 

based on the information given at this time. The streaming nurse in this role should ensure the 

patient feels listened to, understood and if needs be, the rationale for the streaming decision is 

explained. Where a streaming decision is contentious and the patient/carer is dissatisfied, this should 

be de-escalated and confrontation avoided and a senior doctor or nurse asked to review the decision. 

• 

Ifthere are any queries or concerns about an attendee the ED Streaming Nurse can contact the UGPC 

reception via extension 2545. 

•  The UGPC service offers appropriate healthcare services to attendees of the ED who present with low 

acuity medical complaints/conditions that can be treated by a General Practitioner or urgent care 

clinician under the leadership of a General Practitioner.  Active communication is encouraged to 

deliver high quality of care to all attendees. 

• 

The UGPC service will access patient records subject to permission and will ensure accurate clinical 

records of all individual patient consultations are transferred in an  approved structured electronic 

format to General Practices the next working day following the patient's attendance. 

•  The UGPC will be able to evidence robust clinical leadership is in place. 

•  When the UGPC waiting area is full, attendees can still be booked in to the UGPC service but may be 

asked to wait in an alternative location ie ED waiting room, additional UGPC space.  The UGPC will 

then contact the ED Reception and ask for patients to be sent to the clinic once space becomes 

available in the waiting room. The Senior Manager on Call  (SMOC) may become involved if the 

number of patients waiting to be seen at the UGPC is impacting on the space available or capacity. 

•  Where waiting times are extended within the UGPC service and patients held in the ED waiting room, 

the streaming nurse should be encouraged to review their initial streaming decision if there is 

patient/carer concern and the ED pathway is now considered more appropriate. In this instance the 

patient should be registered to ED by reception and taken off the UGPC registration screen. 

•  Streaming Guidelines and  pathways are to be reviewed and audited annually by the Clinical 

Governance Group. However any concerns or changes can be raised and discussed at any time within 

the contract term. 

•  Any referrals made deemed to be inappropriate are to be recorded and discussed at the monthly 

clinical governance meetings with appropriate action taken at the time. 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 4 of 15 

 3.  Patient Criteria  (please refer to pathways) 

•  Attendees presenting that are appropriate to be seen by a GP or nurse practitioner can  be seen by 

the Urgent GP Clinic on site. 

•  The UGPC clinician is able to refer to specialities for same day urgent admission when appropriate, so 

if the attendee looks stable, they can be streamed to the UGPC. 

•  Unwell children can  be streamed to the UGPC in accordance with protocols/pathways in Diagram 2 .. 

The paediatric emergency department is for minor injuries and unstable/unwell children. 

•  The  UGPC service is able to glue/steristrip and dress wounds, as appropriate to the symptoms being 

presented. 

• 

If on closer examination a patient is assessed, by the UGPC, to require other same day hospital 

services or further same day acute assessment they can be referred on following "Diagram 6. 

Referring from UGPC to L&D Hospital", noting why the patient is being sent to L&D. 

•  The service will treat minor illness, some minor injury and attendees that present with exacerbation 

of long term conditions including but not limited to the following: 

Allergic reactions (where airways are not compromised) 

Upper respiratory tract infection: coughs, sore throat, cold, flu (all ages) 

Fevers, headaches and dizziness (in accordance with unwell child pathway- Diagram 2 

Wounds requiring re-dressing (wounds requiring primary closure should be seen in Minors 
Burns for re-dressing only- caution if any signs of toxic shock or infection should be seen in 

Minors 

Soft tissue/muscular pain 

Back pain/ache non traumatic and walking (normal bowel and urine) 

Eye care, not foreign body or penetrating trauma or chemical splash 

Stomach and other alimentary problems 

Genito - urinary tract infection or problems 

Bites animal, insect or human not requiring complex wound closure or washout 

All childhood ailments 

Gynaecological issues 

Pregnancy complications <20 weeks (in  accordance with guidance in UGPC Specification) 

Asthma and COPD - all ages (not moderate/severe respiratory distress) 

Mental health - low mood/stress or anxiety (not suicidal) 

Diarrhoea and vomiting (all ages) 

Chest pain (as per protocol - Diagram 3) 

Low mechanism road traffic collision (ie car -v- car) 

Tetanus injection (which maybe provided by ED  and administered by UGPC) 

For children attending the Urgent GP Clinic it is mandated that national CP-1S requirements 
should be adhered to 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 5 of 15 

 4.  Patients not to be seen at the Urgent GP Clinic 

•  Attendees seen in the UGPC or ED within the previous 72 hours for the any problem 

•  Children with facial lacerations (This would potentially be classed as  a head injury). 

•  Burns affecting special areas (Genitals/Face/Palms/Soles of feet) 

•  Children under 6 months old 

•  Floppy, unresponsive or fitting children 

•  Attendees with moderate/severe respiratory distress (as  per the protocol Diagram 3) 

•  Any burns greater than the palm of the patients hand or that are circumferential are to be seen in ED. 

•  Suspected fractures 

•  No foreign body 

•  Patients requiring suture, perform x-ray  or blood analysis 

•  Any head injuries 

•  Pregnancy complications >20 weeks 

5.  Referring Patients back to L&D 

When the UGPC clinician examines the attendee it may become apparent that they have care needs that 
cannot be provided in the UGPC or may require further assessment.  If this is the case they can  refer the 
attendee to Medicine or Surgery through the GP Liaison Team (8am - 6.30pm), Paediatrics via Paediatric 
Assessment Unit (PAU) using Urgent Connect (8am to 6.30pm) or directly to specialities.  These cases will 
be noted for the clinical governance group and for data reporting to Luton Clinical Commissioning Group 
{LCCG). 

•  The GP Liaison Team will take the GP referral and  refer the patient to the most appropriate service 

for General Surgery patients (all ages) and medical patients (over the age of 17) only between the 

hours of 8am to 6.30pm Monday to Friday. GP liaison will make a recommendation as to whether to 

send the patient to SDEC,  ESU,  ED  or another accepting area for speciality referral. 

•  Referrals to PAU  are made direct through Urgent Connect Monday to Friday or via the Bleep 733 out 

of hours. 

•  Out of hours patients should be directly referred to the relevant speciality clinician.  See  Referring 

from UGPC to l&D Hospital pathway Diagram 6. 

•  Patients that have been assessed as  incorrectly streamed will be referred back to the Emergency 

Department streaming nurse and details logged with the receptionist for follow up at the UGPC L&D 

Clinical Governance meeting.  The referral will be supported by a telephone call to the ED Doctor in 

Charge to advise that the patient is being sent back and the reasons for the concerns. 

•  Patients that were inappropriately streamed {following further investigation from the GP) will be 

referred to the appropriate assessment team and  details logged for follow up at the UGPC l&D 

Clinical Governance meeting. 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 6 of 15 

 • 

If a patient is referred by the UGPC to a specialty team, but the referral is refused despite all 

reasonable steps to refer, the UGPC can  refer back to the Emergency Department. The UGPC will 

then datix the incident so that it can  be logged and reviewed and action taken appropriately. 

6.  Ambulance Patients 
• 

Patients who arrive by ambulance who meet the following inclusion criteria can be sent to the UGPC 

(Diagram 7) 

Independently mobile 
NEWS2 less than 3 (correlate with clinical context, e.g. COPD, Anxiety etc ... ) 
No red flag features (such as; chest pa in, visibly in severe pain) 
Has carer if required /No injury 

If the ambulance patient attends UGPC without the relevant signed paperwork, they will be sent back to ED. 

7.  Secondary streaming 

This involves patients being streamed to the UGPC after the triage process has occurred and the patient then 
meets the UGPC criteria now that more clinical information has been obtained. This process can only be 

activated; it is not in place all the time. 

There are 2 routes for activation: 
1)  ED consultant in charge asks the SMOC to speak to the UGPC due to capacity and/or volume of 

attendances 

2)  The UGPC informs the ED consultant in charge that they have capacity and can accept additional patients 

This is in place for both adults and paeds. 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 7 of 15 

 Diagram 1- Ambulatory Patient 

Look at the attendee 
(ensure children are specifically 
visualised) 

Can the patient talk in 
complete sentences without 
becoming out of breath? 

___D_o_ th_e_y_h..a_v_e...,c_h_es_t_p_a_in_? 

__ 

See chest 
pain protocol 
Diagram 3 

Can the patient walk? 
(excepting long term 
disability) 

No 

Is this an unscheduled return 
visit within 72 hours? 

Is this an injury or illness? 

Injury less than 4 weeks 

Send to ED for: 
x-ray,  suture, 
exploration required, 
or foreign body 

L&D Streaming Guidelines 2021 /22 for UGPC Version 2 

Page 8 of 15 

 Diagram  2 Unwell Child 

Initial visual review of the child and assessment by parent/carer 

Is the child in obvious 
respiratory distress, fitting or 
looks shocked? 

Is the child alert, responsive, 
good colour and appears well 

Has the child passed urine in 
the last 12 hours? 

YES 

No 

No 

Does the child have a non-
blanching petechial rash? 

YES 

NICE CG160 
Compliant 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 9 of 15 

 Diagram 3 -Ambulatory Chest Pain 

GP 

•  Traumatic chest pain with no history of new 

signifttant or danae,ous mechanism 

•  MIid/Moderate  exacerbations of Asthma or 

COPD, able to speak In full sentences and looks 
well clinically 

•  Chest pain sent to ED by a Nurse or 111 that 
doesn't feature in any RED criteria (Right) 

•  Pleurltic soundin1 chest pain  (but not likely PE} 

•  Clinically looks well 

•  Panic attack/Anxiety• No previous cardiac Hx 

•  Patients on anticoagulants - depends on cardiac sounding chest pain or not & in case of 

CONSIDERATIONS: 

trauma whether minor or dangerous mechanism; 

•  Use of other pathways (eg; SDEC); 

• 

In case of shortness of breath- previous intensive care admissions/frequency of inhaler 

use preceding hospital; 

•  Chest pain with history of aortic aneurysm; 

L 

•  >65 years with pleuritic, traumatic or epigastric pain can  be seen in UGP  if age is the 

single factor or clinically features the UGP criteria. 

 Diagram 4 - Nosebleed 

ED 
Attendees presenting with any of the below 
symptoms are to remain in the Emergency 
Department 

•  Active severe bleeding 

•  Bleeding not stopped in 20-30 minutes 

•  Trauma to nose/ face 

•  On anticoagulant therapy 

•  Has cancer of head, neck, ear, nose or throat 

•  Has bleeding or blood disorders 

•  Has advanced liver disease 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 11  of 15 

 Diagram 5 -Testicular Pain 

•  Nainjury 

•  Pain for > 48 hours 

•  Able to pass urine 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 12 of 15 

 Diagram  6 -
Referring from  UGPC to L&D  Hospital 

r 

UGPC Clinician identifies need for 
further acute assessment 

Is patient stable? 

Refer back to ED 
Contact Majors or 
Paeds nurse in 
charge as 
appropriate 

Contact GP Liaison 
Team (8am - 6.30pm) 
or PAU (9am - 5pm) 
via Urgent Connect for 
advice and referral 
(tel 01582 297311) 
or directly to 
specialities by bleep 
system or contact 
number outside these 
hours 

If no response or refusal to accept the patient by the 
specialty team, refer back to ED and UGPC to Datix 
incident for follow up 
Reasonable effort should be made by the GP to refer 
the patient as this is in their best interests.  This may 
mean bleeping alternative contacts or routing the call 
via switchboard. 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 13 of 15 

 Diagram 7 - Ambulance  Pathway 

Ambulance -ADULTS  Direct Stream to UGPC 

Ambulance Arrives 

Inclusion Criteria for UGPC Streaming 

Independently mobile 

• 
•  MEWS less than 2 (correlate with clinical context, e.g . 

COPD, Anxiety etc... ) 

•  No red flag features (chest pain, other  pain more than 

7/10) 

•  Has carer /No injury 

w 
Streaming Assessment can be made by any one of the 
following clinicians: 
•  Nurse in charge {NIC) 
•  Emergency Physician in Charge (EPIC) 
•  Sign Ambulance paper work {electronic/paper) by NIC 

Ambulance clinicians can flag patients who they feel would 
be suitable for UGPC in order to expedite offload. 

I, 

Ambulance Crew Role after streaming assessment: 
•  Reports to Reception 
•  Book in patient stating for UGPC Streamed Patient 
•  Give a copy of notes to patient to attend UGPC  and 

signed ECG  if available 
•  Hand PIN to Reception 

•  Signpost patient to UGPC 
•  Handover complete and to log back in to service 

L&D Streaming Guidelines 2021/22 for UGPC Version 2 

Page 14 of 15 

 Diagram 8 - COVID pathway 

Questions to ask: 
Have you had a lateral flow test? 
Have you had a PCR test? 
Contact with positive patient in last 7 days? 

CONSIDERATIONS: 

•  Refer  Patients to the  near Pharmacy for a  free  test (Dunstable  Road  near  NISSA)  if 

presenting with new Respiratory symptoms and not double vaccinated before booking 

in as National Guidelines states that everyone should know their status before going to 

public places (NHS,2022); 

•  Patients  on  Isolation  testing  negative  on the  5th  and  6th  day  are  no  longer COVID+ 

(NHS,2022); 

 To be Read in conjunction with Diagram 6 (page 13} of L&D Streaming Guidelines 2021-2022 for 

Urgent GP Clinic (UGPC), dated December 2021 

Appendix 2 

Mandy's Rule 

•  After streaming, patients seen and examined by clinicians at UGPC are who deemed to 

require onward referral to inpatient specialties at hospital should be discussed with the GP 

Liaison service or the relevant specialty registrar, following the agreed pathway in Diagram 

6. 

•  This conversation will result in an agreed plan which may involve the patient attending 

hospital immediately, being seen at a later time in SDEC or similar urgent clinic, or being sent 

home with appropriate advice from UGPC. 

• 

It is imperative that both the referring clinician (in the UGPC) and the GP Liaison/ Specialty 

registrar are in agreement that the proposed action is acceptable to both and is clinically 

appropriate.  Mutual agreement assures both clinicians that they are fully compliant with 

their duties under NMC and GMC guidance, and are not in breach of their Duty of Care. 

• 

If agreement cannot be reached, and the UGPC clinician feels that the patient needs to be 

seen without delay despite the specialty team not agreeing to this, the UGPC clinician 

must record this in the medical notes, and then send the patient to the Emergency 

Department. 
If the UGPC clinician feels that the patient needs immediate hospital attention they must in 

• 

no circumstances send the patient home.  They should primarily use the agreed and 

commissioned pathways to make a referral, and only use Mandy's Rule to send the patient 

• 

to ED if agreement cannot be reached despite this. 
It is stressed that this is not considered to be a normal situation, and every such case will be 
investigated to determine how and why it occurred.  learning will be taken from each case in 
order to improve the system and prevent any future occurrences.  All such cases will be 
discussed at the regular UGPC/ED Joint Clinical Governance Meetings. 

 MRCS FRCEM 
Consultant in Emergency Medicine 
Deputy Medical Director 
13th  May 2022