Kasey Beech

Xavier Mooyaart  
Assistant Coroner 
Inner South London 
Southwark Coroner’s Court 
1 Tennis Street 
London  
SE1 1YD 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

19 December 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Kasey Beech who died on 
13 October 2021.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  29 
August 2024 concerning the death of Kasey Beech on 13 October 2021. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to  Kasey’s family and loved ones. NHS England are keen to 
assure the family and the Coroner that the concerns raised about Kasey’s care have 
been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay  may  have  caused  to  Kasey’s  family  or friends.  I  realise  that 
responses to Coroner’s Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

The matters of concern as presented in your Report include the use of the STREAMing 
model / guidance to assess and exclude a cardiac cause of chest pain in new non-
injury  ambulatory  patients.  In  particular,  you  raised  that  the  prioritisation  of  current 
cardiac sounding chest pain and the streaming to the Medway on Call Care (MedOCC) 
or an equivalent service may be to the detriment of other patients who are nonetheless 
at risk of sudden deterioration, creating a risk of future deaths in both cardiac and non-
cardiac patients. 

NHS  England  have  engaged  with  colleagues  at  Medway  Maritime  Hospital  to 
understand  how  the  STREAMing  model  upon  which  their  Urgent  Treatment  Centre 
(UTC) operates  and I can  confirm  that  NHS England  does not  endorse  a  particular 
STREAMing model nationally. 

The training and experience of the initial assessor at an UTC is critical to patient safety 
and the Royal College of Nursing (RCN) and the Faculty of Emergency Nursing (FEN) 
have specific training and competencies for clinical staff working in initial assessment 
roles. 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
  
 Models of initial assessment currently in use prioritise a patient with chest pain as an 
acuity  2  patient  who  should  be  seen  urgently,  with  a  general  aim  (based  on 
international consensus) that this should be within 10 minutes.  

NHS England is currently developing a new initial assessment model in collaboration 
with  the  Royal  College  of  Emergency  Medicine  (RCEM),  the  RCN,  the  FEN,  the 
Emergency Nurse Consultant Group, and lay (patient) representation. This new model 
has  been  successfully  introduced  in  more  than  20  sites  across  England  and  is 
specifically focused on improving patient safety. This new model has been successful 
in bringing down the time to initial assessment to below 15 minutes in sites where it 
has been implemented.  

The  Emergency  Care  Data  Set,  introduced  in  2017,  discouraged  the  concepts  of 
'cardiac  chest  pain'  and  'non-cardiac  chest  pain'  for  the  reasons  identified  in  your 
Report. Instead, all chest pain was coded solely as 'chest pain'.  

In response to your specific concerns relating to the care of Kasey, I have consulted 
with NHS England’s National Clinical Director for Heart Disease. They advise that it is 
recognised that pain can often fluctuate over time but that the lack of ongoing pain in 
someone with other features suggesting a low risk profile is clinically reassuring, and 
the  streaming  /  direction  of  Kasey  to  the  MedOCC  was  appropriate  in  the 
circumstances. 

As  noted  in  your  Report,  pain  can  also  be  masked  by  analgesia,  especially  if 
intravenous  or  intramuscular  opiates  have  been  administered  prior  to  assessment. 
This is a key reason why other features such as the general condition of the patient 
and any breathlessness must be assessed. These assessments are included in the 
STREAMing pathway. 

Following  their  review,  I  am  advised  by  the  National  Clinical  Director  that  the 
STREAMing pathway in use by Medway Maritime Hospital does not have an undue 
prioritisation  of  chest  pain  (particularly  cardiac-sounding  chest  pain).  As  indicated 
above, the general condition of the patient, any signs of breathlessness, their ability to 
talk in sentences and their ability to walk unaided are all assessed. In this tragic case, 
the initial assessments all pointed towards a low-risk situation for which direction to 
the MedOCC was appropriate. A low risk initial assessment does not completely rule 
out the possibility of future deterioration but usually indicates the lack of a need for 
immediate treatment.  

In this case, Kasey deteriorated rapidly after leaving the MedOCC. It does not appear 
that modification of the STREAMing pathway would have been likely to have predicted 
that or altered the outcome of the initial assessment.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 

 
 
 
 
 Kasey, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

04  November 2024  

Xavier Mooyaart 
HM Area Coroner  
Coroner’s Court, 
London Inner South   
Southwark Coroners Court 
1 Tennis Street 
London  
SE1 1YD 

Sent via email: 

Our reference: 

Dear Mr Mooyaart 

Re: Regulation 28 Prevention of Future Deaths Report (of Kasey Beech)  

I write in response to your regulation 28 report dated 29 August 2024 regarding the 
very sad death of Kasey Beech. I would like to express my sincere condolences to 
Kasey’s family.   

The patient safety leads at NICE have carefully considered the content of  your 
report and understand that your request relates to the use of the clinical streaming 
model and the organisation of acute care within the NHS. 

Given that the matters of concern  relate to the prioritisation system (STREAMing) 
which was produced by NHS England, these are not areas that are within  NICE’s  
remit. We believe that the issues raised are best addressed by NHS England, and 
note that you have also sent your report to them for response.  

Although not directly mentioned in your report, you may be interested to learn that  
we are updating our guideline on Asthma: diagnosis, monitoring and chronic asthma 
management and this update is expected to publish on the 27 November. 

I am sorry that we cannot comment further on the matters raised, and would like to 
reiterate my condolences to Kasey’s family.  

Yours sincerely, 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Chief executive 

                                                                                                                                 Page | 2

Mr Xavier Mooyaart  
Assistant Coroner for Inner South London 
1 Tennis Street 
London  
SE1 1YD 

26th September 2024 

Dear Mr Mooyart, 

Further to your prevention of Future Deaths Notice following the conclusion of your inquest 
(8th November 2023) into the death of Kasey Beech who died on 13th October 2021, we would 
like to extend our sympathy and condolences to the family and friends of Ms Beech. 

We note the initial assessment took place in an Urgent Treatment Centre (UTC) rather than 
Emergency Department (ED); from the described circumstances of Ms Beech’s death, it is not 
clear whether the UTC was effectively ‘gatekeeping’ access to an emergency department or 
not.    Regarding  the  Simple  Triage  Rapid  Emergency  Assessment  Method  ‘STREAMing 
Model’a, we have not been able to find any specific details regarding what appears to be an 
initial assessment tool, and we do not believe that this is an assessment tool that is routinely 
used in emergency departments.   As a consequence, we are not able to provide any specific 
response to your concerns regarding the apparent prioritisation of cardiac sounding chest pain 
over other potentially life-threatening conditions. 

The  Royal  College  of  Emergency  Medicine  (RCEM)  has  issued  the  following  guidance 
regarding the initial assessment (triage) of patients [1] 

•  The front door of the Emergency Department should be managed by the ED and fall 

within its quality improvement and governance systems. 

•  Gatekeeping to the ED by non-Emergency Department services is not supported. 
•  Emergency Departments use simple or complex streaming [2], as part of their initial 
assessment  processes.  Both  processes  should  be  resourced  to  meet  variation  in 
demand and be delivered by trained clinical staff. 

The RCEM has collaborated with NHS England to standardise the definition and processes 
that might be used in the initial assessment of a patient attending the emergency department 
[2].  The RCEM continues to work with NHS England to promote the standardisation of initial 
assessment of patients presenting to emergency departments.  Our current work has involved 

a  Streaming  is  the  process  of  allocating  patients  to  different  physical  areas  /  services,  pathways  or 
processes, to improve efficiency and effectiveness. The main objective of streaming is to ensure that 
the patient is directed to the correct location / service and to the correct person to manage their clinical 
needs. Streaming should always be performed by a trained clinician. 

 
 
 
 
 
 
 
 
 an evidence-based review of the effectiveness of current triage systems as well as helping to 
design  a  new  initial  assessment  process  for  implementation  in  all  emergency  departments 
throughout England [3]. 

Yours sincerely, 

Chair, Quality in Emergency Care Committee 

References 

Initial  Assessment  of  Emergency  Department  Patients.  RCEM,  2017.  

1. 
https://rcem.ac.uk/wp-content/uploads/2021/10/SDDC_Intial_Assessment_Feb2017.pdf  
Accessed 16.09.2024 

2. Guidance for emergency departments: initial assessment.  NHS England, August 2022.  
https://www.england.nhs.uk/guidance-for-emergency-departments-initial-assessment/  
Accessed 16.09.2024 

3. Standardising Acuity Clinical Guide.  NHS England, in publication.