Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0379, written 25 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2025 |
|---|---|
| Reference | 2025-0379 |
| Deceased | Jordan Babb |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG Re: Regulation 28: REPORT TO PREVENT FUTURE DEATHS. Dated 25.07.25 Date: 18.09.25 Dear Mr Osborne, I write to acknowledge on behalf of Milton Keynes Urgent Care Services (MKUCS) to address the matters of concern raised during the inquest into the death of Mr Jordan Babby and detailed in your regulation 28 dated 25.07.25. I welcome the opportunity to provide this final, detailed response. This response highlights both our organisations Standard Operating Procedures (SOP) and our Clinical Governance framework, detailing how clinical concerns are addressed through robust systems, clear clinical pathways, and defined clinician responsibilities. Milton Keynes Urgent Treatment Centre (MKUTC), provided by MKUCS and commissioned by BLMK ICB, is committed to delivering safe, evidence-based, and high-quality clinical care. Our service operates 24/7, 365 days a year. The MKUTC provides a comprehensive range of urgent primary care services, including: • Walk-in, GP led, service available 24/7. • Directly bookable appointments via NHS 111. • Telephone advice (Health Care Professional line, South Central Ambulance Service (SCAS). • Out of hours home visits. • Support for nursing homes, community practitioners, and the local hospice. • Streaming of patients from the Emergency Department (ED). Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 06635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG Any patient in Milton Keynes—including temporary residents, overseas visitors, and refugees—may access the service. Exclusion criteria are defined within the Safe Delivery of Clinical Care in an Urgent Treatment Centre SOP, with clear pathways for referral to ED where required (see attachment). The SOP outlines operational procedures, clinical responsibilities, and escalation protocols to ensure patient safety at every stage of their healthcare journey. Each matter of concern outlined in the Report to Prevent Future Deaths will be presented and addressed below. 1. Failure to Escalate Abnormal Observations Robust systems currently in operation. All patients presenting at MKUTC undergo a standardised early warning assessment within 15 minutes of arrival: • NEWS2 for adults. • POPS for children. These tools are consistently applied by Health Care Assistants (HCAs) at initial assessment. Scores are reviewed by the senior triage clinician, who makes an early risk-stratification decision and determines whether patients are safely manageable in urgent care or require immediate transfer to ED. This framework provides an objective, auditable escalation process and ensures patients with acute or life-threatening presentations are identified rapidly. Our identification and escalation process is as follows: • Every patient is seen within 15 minutes of arrival. • HCAs record presenting complaint, past medical history, medications, and vital signs. • If an HCA has any concern, for example an increased early warning score, the triage clinician is alerted immediately. Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG • The triage clinician conducts visual assessment, reviews risk scores, and applies relevant clinical tools (e.g. sepsis screening, Ottawa rules, NICE head injury pathways). This structured operational procedure ensures early recognition of deterioration and escalation to senior clinicians without delay. MKUTC clinicians are trained and audited in applying evidence-based pathways. Clear delineation of responsibilities ensures accountability and safe, coordinated care from arrival to discharge. The standard operational procedure outlines guidance to all staff defining patients requiring Emergency Care. Patients that are identified with abnormal physiological observations and/or signs and symptoms that are not appropriate for UTC, such patients should be urgently clinically assessed and managed by the Emergency Department. High-risk patients are referred immediately for further investigation or intervention. Low- risk patients are managed in line with validated processes, ensuring consistent, evidence- based decision-making. 2. Lack of Structured Risk Assessment for Pulmonary Embolism MKUTC supports safe and consistent application of evidence-based clinical decision tools through Ardens templates integrated within SystmOne. These digital templates provide clinicians with immediate access to structured assessment pathways and risk stratification tools during consultations. One key example in this case is the Wells Score for Pulmonary Embolism (PE): • The template enables clinicians to apply the Wells PE criteria consistently in line with NICE NG158 guidance. Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG • The score assists in risk stratification, ensuring patients at high risk are urgently referred for imaging or secondary care assessment, while low-risk patients can be managed safely using validated pathways. • The integration into SystmOne reduces variation, provides an auditable record, and supports clinical accountability. Use of Wells PE in Primary Care Pulmonary embolism is a potentially life-threatening condition, but symptoms are often non-specific and presentations subtle. In a primary care/urgent treatment centre setting, timely recognition is crucial. The use of the Wells PE score within Ardens templates ensures: • Early identification of patients at risk of PE in the community setting. • Appropriate escalation to hospital for definitive investigation (e.g. D-dimer, imaging). • Safe reassurance and discharge of low-risk patients in line with best-practice protocols. Clinician Training and Ongoing Learning MKUTC clinicians have received information sharing on the use of Wells PE and related clinical decision tools. This training has included: • Practical use of Ardens templates within SystmOne. • Case-based discussions on application of Wells PE in urgent care. • Reinforcement of appropriate clinical context for use, in line with NICE guidance. • Audit and feedback mechanisms to ensure safe, consistent application across the clinical team. 3. Unclear Use of Misunderstanding of Clinical Decision Tools Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG Awareness of PERC (Pulmonary Embolism Rule-out Criteria) All MKUTC clinicians have been introduced to the Pulmonary Embolism Rule-out Criteria (PERC). While PERC can be valuable in secondary care settings, its application in primary care is more limited due to differences in patient population, availability of confirmatory investigations, and clinical context. As part of this objective, MKUCS have involved the BLMK ICB to share learning, understanding and awareness across the region. All BLMK GP Clinical leads were consulted with via the ICB to evaluate the appropriateness of this tool. The consensus is that the PERC tool is not appropriate for primary care settings. Comments received: • • • “Not heard of the PERC tool”. “PERC is absolutely not validated for use in primary care, and we tend to use Well's scoring when there is any clinical suspicion of PE/DVT”. “PERC is not a tool I recognise at all and have not seen it used anywhere in primary care. My understanding is that it is not validated for primary care, so not even sure we can use or roll it out. Not sure this is something we can promote unless there is clear national guidance on this”. • “I'm not familiar with this tool at all. The Well's Criteria for PE /DVT is more commonly used in my opinion .... it seems the scoring system has been recommended since 2020, but the committee recognise that it has mostly been used in ED's and commonly not used in practice there either.” Accordingly, MKUTC clinicians have been made aware of the tool and its principles, however it is applied with caution. We have suggested that PERC is not used as a standalone rule-out tool in primary care; rather, it supports clinical reasoning alongside Wells PE and formal risk Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG stratification. Training emphasises the limitations of PERC in urgent care settings and reinforces that high-risk patients should always be escalated to ED for further assessment. This balanced approach ensures clinicians are aware of available tools but apply them appropriately, avoiding over-reliance on criteria that may not be validated for use in our setting. 4. Risk of Repetition in Similar Settings Clinical incidents are reviewed through established governance structures, with learning embedded into training and updated protocols. • Our clinical governance meetings also include a representative from Healthwatch UK. • Regular audits are conducted on the use of NEWS2, POPS, risk assessments, and decision tools. • Key performance indicators (KPIs) are reported monthly, and quality outcomes are reviewed quarterly with the commissioner. • Individual clinician performance is audited and reviewed in personal development meetings. This governance structure ensures that lessons are not only learned but actively applied to improve patient care and reduce risk. MKUCS is committed to excellence in patient safety, and the strengths of our service include: • Validated early warning scoring systems (NEWS2, POPS). • Timely initial assessment (within 15 minutes of arrival). • Structured, evidence-based risk pathways for high-risk conditions. • Ongoing staff training, supervision, and audit for consistent application of clinical tools. Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG • Clear governance and escalation protocols, ensuring rapid transfer to ED when appropriate. • Continuous improvement, informed by incident review, audit, and patient safety monitoring. All clinicians have defined roles and responsibilities as follows: • HCAs: Perform initial observations, apply NEWS2/POPS, escalate concerns immediately. • Triage Clinicians: Undertake rapid visual assessment, risk stratification, and escalation decisions. • Clinical Nurses: Assess and treat common conditions, prescribing independently where qualified. • Advanced Nurse Practitioners (ANPs): Provide senior clinical support, supervise training, and undertake complex case management. • Doctors: Provide senior clinical decision-making, support to nursing teams, and undertake home visiting. • Administration team: Manage appointments, support clinical systems, and maintain governance processes. Conclusion Milton Keynes Urgent Treatment Centre delivers safe, evidence-based urgent care supported by a robust SOP, validated risk assessment tools, and a clearly defined governance framework. Our systems of early warning, rapid assessment, structured escalation, and continuous improvement provide assurance that patient safety remains our foremost priority. Through this integrated approach, the risks of missed or delayed escalation are actively mitigated, reflecting our unwavering commitment to clinical excellence and patient safety. Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822. M I L T O N K E Y N E S U R G E N T C A R E S E R V I C E S THE URGENT CARE CENTRE, MK HOSPITAL CAMPUS EAGLESTONE, MILTON KEYNES, MK6 5NG CEO & Clinical Lead | MBBS, BScSEM (Hons), MSc (SEM), MRCGP Milton Keynes Urgent Care Services Community Interest Company. A Company Limited by Shares. Registered in England. Number 6635822.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Milton Keynes Urgent Care Service 1 CORONER I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 18 September 2024 I commenced an investigation into the death of Jordan Michael BABB aged 31. The investigation concluded at the end of the inquest on 25 June 2025. The conclusion of the inquest was that: Narrative Conclusion The deceased died of a pulmonary embolism which was not recognised or treated despite presenting with abnormal clinical observations suggestive of this condition. The decision to discharge the deceased without further investigation or escalation of care contributed to his death. 4 CIRCUMSTANCES OF THE DEATH The deceased had been complaining of chest pain and had visited the Urgent Care Centre in Milton Keynes on Friday 13th September 2024. He was assessed and put on a nebuliser for his asthma. He was discharged with a follow up GP appointment. He was not investigated for a possible pulmonary embolism. On the 16th September 2024 he collapsed and despite . resuscitation died of a pulmonary embolism at 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Failure to Escalate Abnormal Observations 1. Despite the patient presenting with a significantly elevated heart rate, high respiratory rate, and reduced oxygen saturations — all indicative of physiological instability — there was no escalation to secondary care or referral to the emergency department. There appears to have been no formal threshold or protocol in place to ensure that abnormal observations of this nature trigger an urgent clinical response. 2. Although pulmonary embolism was a relevant clinical possibility, no structured risk Lack of Structured Risk Assessment for Pulmonary Embolism Regulation 28 – After Inquest Document Template Updated 30/07/2021 assessment tool (such as the Wells score) was used or documented, and there was no attempt to apply an evidence-based diagnostic pathway as recommended by NICE guidance (NG158). Unclear Use or Misunderstanding of Clinical Decision Tools 3. Evidence suggested uncertainty about the appropriate use of the Pulmonary Embolism Rule-out Criteria (PERC) in primary care settings, with potential misapplication outside of the specific context recommended by NICE (i.e., in low-risk patients only and following validated pre-test probability assessment). There appears to be a lack of clarity or training regarding the scope and limitations of such tools in the primary care context. Risk of Repetition in Similar Settings 4. The inquest heard no evidence that the walk-in centre has a specific protocol or decision- support mechanism in place for the recognition and escalation of potentially life-threatening conditions such as pulmonary embolism. There is a risk that similar failings could occur in future, particularly where patients present with non-specific symptoms and abnormal vital signs. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th September 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Mr Jordan Michael BABB I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 25/07/2025 Tom OSBORNE Regulation 28 – After Inquest Document Template Updated 30/07/2021 Senior Coroner for Milton Keynes Regulation 28 – After Inquest Document Template Updated 30/07/2021
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