A coroner has raised concerns about GP patient queries being dealt with at remote ‘call centres’ and about the lack of clear triage guidance for care navigators, following the death of a toddler.
Assistant Coroner for Manchester West Michael Permberton published his ‘prevention of future deaths report’ after an inquest for Hailey Thompson, a 22-month-old toddler who died of sepsis at the end of 2022.
His investigation gave rise to concerns about how Ashton Medical Practice – which is run by the large private GP provider SSP Health – handled Hailey’s mother’s request following an apparent allergic reaction to antibiotics.
From the evidence given by the practice manager, a concern arose that ‘a care navigator may not have a clear pathway on whom to refer a task or action to’.
Mr Pemberton also expressed concern about the lack of policies ‘that apply to assist care navigators/ call handlers at a centre which is not located within the doctor surgery’.
Hailey had first attended the GP surgery on 7 December 2022 and was prescribed antibiotics to treat bacterial tonsillitis, but this medication was stopped three days later after she developed a rash.
Her mother believed this to be an allergic reaction and sought advice from the GP surgery, at which point a care navigator referred the appointment to a pharmacist working with the practice.
However, the inquest heard that the pharmacist ‘was not competent to deal with a paediatric medication enquiry’ and so sent a message back to the practice advising this.
The coroner was clear that although this was a ‘missed opportunity’ for the medication concern to be reviewed in general practice, it ‘did not contribute to her death’.
Hailey remained unwell and was diagnosed the following week with a viral upper respiratory infection at both her GP surgery and the local A&E department.
She was found unresponsive in her home on 19 December 2022, and the cause of death was found to be sepsis arising from strep A infection in the lungs, which caused pneumonia.
Despite making clear that the interaction regarding Hailey’s reaction to the antibiotics ‘was not causative’, the coroner warned there ‘is a risk that an urgent need for appropriate clinical referral may not occur’ given the practice’s current care navigation processes.
The report said: ‘A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
‘No evidence was provided to explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice.’
Coroner’s matters of concern
- The pharmacist to whom [the medical query] was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist.
- On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
- A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
- No evidence was provided to:
- explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice;
- whether a list of clinician competencies and whom to refer tasks to was held;
- Care Navigator training;
- algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
- These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
- Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case.
- The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
Source: Courts and Tribunals Judiciary
The report was sent to both Ashton Medical Practice and SSP Health for a response by 30 May 2025.
SSP Health CEO Andy Scaife said the coroner’s concerns relate to ‘common practices’ which will apply to a majority of English surgeries rather than Ashton Medical Practice specifically.
He said: ‘We are deeply saddened at the death of one of our patients. Our thoughts and heartfelt condolences are with Hailey’s family and loved ones during this difficult time.
‘We have received the report from the Coroner but cannot comment, in detail, at this time as we are in the process of preparing our response.
‘We note that the concerns raised by the Coroner relate to common practices which are in place across the vast majority of doctors surgeries in the country and are not specific to the surgery in this case.
‘We also note that the Coroner specifically states that the concerns raised did not contribute to this very sad death.
‘As is appropriate, we are currently conducting a thorough internal review to understand the exact circumstance, which will include a review of the factual accuracy of certain aspects of the report. Once completed, our response will be shared with the Coroner.’
In 2023, former health secretary Steve Barclay announced a major expansion of the role of receptions to become expert ‘care navigators’, as part of the GP recovery plan.
This included a new National Care Navigation Training programme for up to 6,500 staff, who can direct patients to the right service by having a ‘good understanding of local services and the expanded range of practice roles’.
NHS England has said ‘effective care navigation’ is a ‘key enabler of a modern general practice access model’.
GPs are trained to be expert Care Navigators.
Even PAs are not trained to do that to the same level.
Care navigation didn’t work and that is inherent when medical care is substituted by ‘navigation’.
Fail-safes for follow-up complications is a central GP role and prevents many tragedies like this.
To improve patient care it’s essential that GP training places are rapidly expanded (no significant increase since 2016), and that the false belief in underskilled staff painting by numbers is tackled. Failure demand is currently a massive problem in and of itself.
Does this item refer to ‘Ashton Medical Centre’ , Wigan Road, Aston-in-Makerfield, Wigan which is run by large private provider, SSP Health; ( there appears to be several surgeries, practices, named ‘Ashton’ online and the one called ‘Ashton Medical Practice’ may actually be in a different part of the UK, and not the one concerned in this item). How are Private Health providers held accountable? Who are the doctors, workers at the ‘Ashton Medical Centre’, (if this is, indeed, the practice referred to) or are their names anonymous? Is there a recent CQC report or just not obliged for each individual practice? What exactly is going on with the NHS, Wes Streeting MP, and Care Navigators? The Coroner obviously wants ‘Prevention of future deaths’ and he has matters of concern which seems to put things mildly in a way; however Ashton Medical ‘Centre’ (if this is the correct name?) and SSP Health have some serious and very, very important questions to answer by 30 May, which have inevitable huge consequences especially for these Private Provider practices nationally and those who assume they are suitable providers, ICBs and the ‘broken NHS’, Wes Streeting MP and Keir Starmer PM (who seems to waft this way and that), and not forgetting 14 years mal-government by Conservatives.
Chat GPT is better than all. The “Care Navigation Model” called 111 is worse than coroner’s concern.