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Patient died after being diverted to GP 'streaming' service in A&E

Concerns about safety have been raised about GP streaming services in A&E departments following the death of a patient.

David Birtwistle went to Bristol Royal Infirmary’s A&E suffering from breathlessness last November after being referred by the NHS 111 helpline.

He was discharged but was forced to return by ambulance six days later, when his symptoms became worse. He was diverted to a pilot GP ‘streaming’ project, run by BrisDoc Healthcare Services and designed to relieve pressure on A&E.

However, the coroner said that because he was diverted checks that could have saved him were not carried out and he died of a pulmonary embolism.

The coroner’s report, which was sent to University Bristol NHS Trust, BrisDoc and NHS England, said that 'during the course of the inquest the evidence revealed matters giving rise to concern'.

It ruled that a 'national review of serious incidents and near misses in similar "front door" services should happen as a matter of some urgency in order to identify common themes that can inform future service design'.

The report said: ‘Mr Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death.

'This meant that further tests, which could have led to an earlier diagnosis of his condition, were not done.’

The coroner said that ‘streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians' and 'this should include at least a basic set of physiological measurements’. 

The report further said future front door projects should consider the recommendations of the recent Royal College of Emergency Medicine (RCEM) report, ‘Initial Assessment of ED (Emergency Department) patients’.

A spokesperson for NHS Bristol CCG said: ‘This tragic incident has affected everyone who cared for him. The pilot project was immediately halted and thorough internal investigations were carried out. We also commissioned a thorough independent review.

'All of the learning following this tragic incident is now being acted upon in planning next steps for urgent and emergency care, in line with national guidance.’

NHS England has pledged to commit to providing a ‘comprehensive front door clinical streaming service in every hospital’ so that A&E departments are free to care for the sickest patients.

Meanwhile NHS England denied press reports that it had commissioned a new national review of schemes to divert patients away from A&E departments amid safety fears. 

An NHS England spokesperson told Pulse that its medical director had responded to the coroner to inform him that there was already a National Institute for Health Research (NIHR)-funded research project into the GP streaming scheme, which has been running for about 18 months.

NHS England said this was ‘a research project by the NIHR as part of their everyday work’. It was not linked to Mr Birtwistle’s death, which came after the setting up of that project, the spokesperson stressed. 

The research project, which NHS England said was 'not a review' is being led by Cardiff University, which said it was looking into the scheme becuase it was 'unclear in terms of its impact on service provision, patient experience and the effectiveness and safety of clinical care delivery'.

Professor Adrian Edwards, director, PRIME Centre at Cardiff University, is leading a study on ‘Evaluating effectiveness, safety, patient experience and system implications of different models of using GPs in or alongside Emergency Departments. (GPs in EDs)’.

The research proposal says: ‘Finding better ways to assess and treat patients coming to EDs could have a major impact on the experience and care of the millions of people attending EDs and on all NHS services by providing evidence of how best to manage resources.’

The researchers will select three sites for each of the three main model types (GPs working geographically adjacent to EDs; GPs serving in a triage and screening capacity; and GPs fully integrated into ED service provision) and three that do not use GPs in or close to the service.

New GPC chair Dr Richard Vautrey told Pulse: ‘I think it’s very difficult because when the patient presents in general practice or indeed A&E it’s important that a proper assessment is done.

'But medicine isn’t an exact science and there’s always a risk that things may be inadvertently missed even with the best clinical assessment. Symptoms can change and it’s important that you put in place good safety-netting advice and guidance so that if situations do change or the condition doesn’t develop in the way that they would anticipate the patients need to be seen again.' 

Dr Vautrey added: ‘I think it’s important that A&Es do identify the right clinician to see the right patient because it’s the best way of ensuring patients get the quickest treatment. I think there’s always been some form of initial triage and assessment – it’s just that you need to ensure that that’s done by people with the necessary skills and competence.’

NHS Providers, the representative body for trusts, warned in July that it will not be able to sustain the new 'GP streaming' services in A&E beyond next winter unless the Government puts more cash into the scheme

In response to the latest safety concerns, NHS Providers’ director of policy and strategy, Saffron Cordery, said it would support a review of these schemes in a bid to fully understand the impact on patients. 

‘In many cases they have been proven to be an important part of helping trusts manage demand for A&E services,’ said Ms Cordery. ‘They are designed to ensure treatment is quick, convenient and safe, based on assessment by a doctor or senior nurse.

Ms Cordery added: ‘They are not about turning people away from A&E but making informed choices about the most appropriate care for patients. 

‘The Government has indicated its support for these schemes and has set aside £100m of capital funding to help trusts restructure their emergency departments, however we need to ensure we have the right resources available to actually deliver these services, this includes being able to employ the GPs that would be needed in A&E units.’

Readers' comments (8)

  • Bob Hodges

    A tragic case, but surely a GP can identify and investigate a suspected PE?

    I work in ED streaming and I have access to pulse oximeter, ECG and D-Dimer testing.

    This is essentially an anecdote that doesn't really shed light on the pros and cons of the GP Streaming model.

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  • Any healthcare setting can miss a PE.

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  • if I consider SOB to be a PE then I refer to secondary care for them to do a bucket load of tests and carry the risk.
    No way would I be a streaming GP

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  • This type of work is higher risk..why would any sensible GP want to do it.

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  • I find myself offended by the implicit acceptance in this that GPs can't deal with PEs. Having working in aGP unit attached to ED, we have DVTs / PEs routinely triaged to us, and took them through to final disposition, usually without admission unless necessary, and including CTPA. It's a very elusive condition and can be missed by ED just as easily. What's important is to have someone used to dealing with it, not who that person is.

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  • The problem lies with A&E not being able to cope with workload and re-directing true emergencies even RTAs for assessment to the GP service next door. GPs working in these services are at high risk because they are after all GPs and not Emergency Medicine specialists - they could miss things putting themselves and the patients. Answer to this is - A&E should deal with emergencies and patients being re-directed should have had at least an initial assessment to exclude life threatening issues before being sent to the GP. But then , would that be necessary - maybe worthwhile telling them to book with their own GP and teach them A&E or coughs and colds are not emergencies. A third issue may arise - no GP appointments available for 2 weeks - so we are back to where we started ie - give appropriate funding support to GPs and not try to bring Practices down by squeezing them financially or burdening with work overload. Quite a playfield for NHSE and CCGs to wield their clout.

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  • Unfortunately primary care and secondary care always have and always will be unable to diagnose all PE cases.

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  • Kings College Hospital A&E have deployed GPS for years. This tragedy could have occurred anywhere. HHSE seems to be rediscovering "the wheel"with yet another Study!

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