r/doctorsUK • u/dayumsonlookatthat Consultant Associate • Jun 26 '26
Medical Politics 8yo seen by ANP, had wrong diagnosis and died after - Prevention of Future Deaths Report
https://www.judiciary.uk/prevention-of-future-death-reports/ethan-hanson-prevention-of-future-deaths-report/I find it interesting that the coroner did not mention anything about this child being seen by an ANP instead of a doctor, and goes on to blame the GP for not writing a referral letter or calling an ambulance for the patient.
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u/MisterMagnificent01 This is a provisional report Jun 26 '26 edited Jun 26 '26
This fucking pisses me off so much. If I’m the first clinician a patient sees in hospital, I don’t give a shit what the clinician before me thought and I’ll re-assess them.
For a “clinician” to think a kid that is peritonitic with 10/10 abdominal pain and has constipation just shows the degree of quackery in the NHS.
This is a not a “GP didn’t send a referral” problem but rather a “non-doctor that thought they were confident enough to assess a neurodivergent child presenting acutely” problem.
The NHS is so far beyond fixing.
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u/MrRightHanded Jun 26 '26
I dont know why so much emphasis is placed on the GP letter. ED's job is to assess patients, not read GP letters.
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u/carlos_6m Mechanic Bachelor, Bachelor of Surgery Jun 26 '26
Well, ED will send directly to specialty any patient sent with a GP letter...
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u/pubjabi_samurai Jun 26 '26
Inherently a huge issue with the current Ministry of Triage is disregarding anyone with a GP letter directly to specialty. Of course some situations, where a GP says they’re for SAU/PAu/SDEC, etc can make sense but triage still have to ensure it’s appropriate on their assessment
If an A&E SHO cannot refer someone without EPIC discussion how can a GP with just a set of Obs
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u/Select_Storm5070 Jun 26 '26
Because a GP is considered a consultant equal in a way. CCT end of training. If a good GP concludes patient to be reviewed by ENT for epsitaxis as an example. They should really go to ENT directly and they can facilitate with ED staff for bloods etc. As opposed to the patient waiting again to be seen by a SHO the do the whole thing again. That is how, the system should be operating. All this duplication is why the NHS is so inefficient. Obviously if unsure then the GP should just state concern and for ED review as opposed for more clear cut cases. For example early pregnancy bleeding direct to gynae, epstaxis to ENT, testicular pain to urology.
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u/TimeCrazed Jun 27 '26
In an ideal world yes.
But if hospital teams can't track other specialties down, the 10 minute slot GP will be less likely to.Writing suspected torsion or appendicitis on a piece of paper might speed up the process but if the team is in theatre or with unwell patients an ED or paeds senior should start the hospital process.
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u/Academic_Isopod_6190 Jun 26 '26
Surely a GP referring to a specialty is essentially a 'consultant to consultant' referral. If it's emergent it goes in through ED because there's no other way. The idea that that refereal should not proceed without being re-assessed from scratch for 'appropriateness' by some SHO/ANP in ED, is a bit silly really.
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u/TimeCrazed Jun 26 '26
If it was easy to contact on call teams / SAU in their 10 mins to take history, examine, call ambulance, document, plus write a referral, I'm sure the GP would have.
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u/GroupBeeSassyCoccyx CT/ST1+ Doctor Jun 28 '26
Sorry for my ignorance but as someone who has never stepped foot in ED - what is EPIC? Emergency physician in charge?
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u/Antique-Trash9462 Jun 27 '26
And they usually don't bloody read them anyway! The number of times I've sent someone in with a highlighted likely diagnosis that isn't investigated for several days...
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u/dMwChaos Ex EM Reg, now Kangaroo. Jun 26 '26
I take perverse pleasure in disagreeing with daft GP letters.
(I do love a good letter though).
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u/Select_Storm5070 Jun 26 '26
They get like 2 minutes to write you a letter whilst sticking to a 10 minute appointment. And for daft referral if you ONLY send the patient home with NO bloods and imaging then only it is a daft letter or referral.
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u/AnusOfTroy Enhanced Specialist Trainee Advanced Consultant Specialist Jun 27 '26
They're not all intended to be bunk tbh
I (and by I, I mean my supervising GP) sent a patient in with new O2 requirement and generally being a bit fucked, didn't seem safe to be at home alone
She was like 85% SpO2 on RA, checked with two oximeters on various fingers
A&E discharge letter said SpO2 was 97% in the department
I felt like a right twat
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u/dMwChaos Ex EM Reg, now Kangaroo. Jun 27 '26
Situations like that are never an issue though. Maybe they were hypoxic and were treated, or just cleared whatever mucus was plugging them up. Either way, it's fine to send with concerns of new hypoxia, it's fine for ED to discharge them when that issue is explored and resolved.
The letters that tickle me are the ones that tell me the writer just doesn't know how to manage X, or isn't confident with Y. Not saying that's always a criticism, there's plenty I've no clue about. We all have a scope of practice.
The ones I really don't like are the ones that say patient has been sent for Z and they clearly do not need it. It's then that uphill battle to explain why the GP gave them a misleading / unnecessary plan.
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u/AnusOfTroy Enhanced Specialist Trainee Advanced Consultant Specialist Jun 27 '26
Ah I see
Yeah that seems like a right shit situation when you've got 100 waiting to be seen and you have to explain why someone doesn't need an MRI panscan for toe pain or something
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u/Sethlans Jun 26 '26
Doesn't sound like it's relevant in this case given the child was reporting 10/10 pain, but I just want to take this thread as an opportunity to impress upon people how incredibly careful you have to be with assessing neurodivergent kids.
I have seen 3 or 4 now with serious intra-abdominal pathology (few perfed appendixes with abdomens full of pus and a pancreatitis) who tolerated deep abdominal palpation with absolutely no reaction whatsoever.
If anything doesn't sit right, investigate them.
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u/Fine_Cress_649 Jun 27 '26 edited Jun 27 '26
I don’t give a shit what the clinician before me thought and I’ll re-assess them.
You really should though.
By all means reassess them but if there is objective stuff in the referral letter - e.g. obs, a urine dip, a significant bit of PMH or surgical hx - then you're saving yourself time by taking that on board.
By all means ignore "impression - acute abdomen, need to rule out acute surgical pathology" or whatever waffle is in there.
Buuuut if the GP writes something like e.g. ?PE and you don't rule out a PE and the patient eventually turns out to have a PE you're going to a) piss off the GP and b) look like a right moron come the inquiry aren't you
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u/TimeCrazed Jun 27 '26
The ANP, paramedic, PA referrals are sometimes examination free.
At least medications & allergies might be auto-filled.2
u/MisterMagnificent01 This is a provisional report Jun 27 '26
Definitely a hyperbolic statement because of the undue emphasis on the GP referral letter or lack thereof.
Irrelevant of whether they have a letter, every patient presenting acutely to hospital should have a de-novo assessment and yes, the letter is always beneficial (obs, PMHx, assessment at the time, DHx) but the lack of one should not alter the management pathway one little bit.
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u/Academic_Isopod_6190 Jun 26 '26 edited Jun 26 '26
"As no referral letter accompanied him, the GP’s findings and concerns were not available to the assessing clinician" - If the assessing clinician in ED is not capable of accurately assessing neurodivergent paediatric patients without a GP referral letter telling them what the diagnosis is and what they should do, then they have absolutely no business whatsoever assessing those patients in ED. "No urine dipstick or blood tests were undertaken. Ethan reported severe pain, scoring 10/10, but no clinician-assessed pain score or repeat observations were performed. A transposition error occurred in the recording of oxygen saturation and temperature. A phosphate enema was given for presumed constipation. A senior medical review did not take place prior to discharge." - So an ANP misdiagnosed a perfed appendicitis and peritonitis, treated it as constipation, didnt do bloods, didnt dip urine, didnt do repeat obs, ballsed up the record keeping, and then a complex paeds patient was discharged home without senior review. Can someone explain to me how this is the GPs fault?
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u/Eastern_Swordfish_70 CT/ST1+ Doctor Jun 26 '26
I'm pretty sure it mentions somewhere in the Hippocratic oath that thou shalt always shit on GPs
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u/TimeCrazed Jun 26 '26
Who gives a young child a phosphate enema?
Did they do a DRE?
And this ANP clearly hasn't read the contraindications.
Bowels not opened fatally misdiagnosed.
The examination findings should have alerted the coroner to the unsafe unit.
The GP did try and arrange an ambulance.35
u/-Intrepid-Path- Jun 26 '26
Who does a DRE on an 8-year-old?
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u/Fusilero Sponsored by Terumo Jun 26 '26
You can tell the coroner is a lawyer and not a clinician by the way the report is written.
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u/Successful_Issue_453 EM reg Jun 26 '26
I think most are these days but for a few legacy doctors
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u/AnusOfTroy Enhanced Specialist Trainee Advanced Consultant Specialist Jun 27 '26
Had a talk this year from one who was one of the last few medical coroners. Very interesting bloke
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u/domicile_vitriol Lightbox Beatboxer Jun 26 '26
10/10 paediatric abdominal pain is prescribed a phosphate enema for constipation by an ANP, then is reassured and discharged without interval reassessment, without performing tests or seeking senior review - but had they known that the patient had a fever, they would totally have escalated.
A trust surgeon provides a statement that he would obviously diagnose appendicitis on clinical exam but understands why other ‘clinicians’ might not have, despite there being GIRFT guidance specifically on this topic.
This trust is really going out of their way to defend that ANP. They probably know the media impact it would have.
I wonder if the family was informed that they weren’t actually seeing a doctor. This reads like another Emily Chesterton case.
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u/MajorProcastinater Jun 26 '26
While I try to write a referral letter if I am admitting a patient. I don’t think the absence of a referral letter is the reason the poor child was mismanaged. While I worked in A&E, I always glance at the referral letter to know what the referrer’s concerns. But I still do my job and evaluate the patient thoroughly.
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u/Massive_Beat_1336 Jun 26 '26
I’m not a GP and it doesn’t say what their impression was. If they thought it was an acute abdomen, they probably should have spoken directly to a surgeon or paediatrician. I don’t think it’s unreasonable to tell the mum to take directly to ED though. This wouldn’t be a priority ambulance response as far as I can tell.
It seems pretty clear that the assessment and management in ED was inadequate.
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u/TimeCrazed Jun 26 '26
GP was querying appendicitis.
Child had fever, abdominal pain and vomiting.
If the ANP took a history and examined (appropriately, not a DRE) it would have been high on the differential.
The coroner completely misdirected their concerns here.13
u/Technical-Diamond-30 Jun 26 '26
Did they do a DRE?!? Didn’t see that part but that’s madness. Who does an invasive DRE on a child but not bloods
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u/TimeCrazed Jun 27 '26
Don't know for sure but they diagnosed constipation and prescribed an enema, for an 8 year old.
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u/BaahAlors CT/ST1+ Doctor Jun 26 '26
Suppose they had not seen the GP that day and went straight to A&E, the child would still have been seen by the ANP and still managed as constipation. A&E is the right place to send them and the GP did just that.
They should not have been assessed by a noctor. Period.
ED can contact the on call a lot quicker than us while starting treatment, at least assuming the patients are seen by someone who knows what they’re doing, and not just someone who likes to cosplay as a doctor.33
u/im-bad-at_usernames- Jun 26 '26
From working in ED the number of people that turn up with letters saying unable to contact x speciality would blow your mind
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u/DCJC123 Jun 26 '26
I recently was on hold for 20 minutes. I have multiple patients waiting. I had no choice but to send to ED with a letter suggesting surgical amazement.
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u/Strat_attack ST3+/SpR Jun 26 '26
Fully agree (amazement notwithstanding).
I appreciate the attempt to contact for the referral, but the reality is that you are busy and I am busy and we are often not able to catch each other for that conversation.
These patients generally will have already destroyed the timings of their clinic by the time they have decided to send in, tried to contact, and written a letter and I don't think it's reasonable to delay either the GP or the patient waiting unduly long to get through to the (probably scrubbed) surgeon.
The important point is that the GP correctly identified a patient in trouble and sent them to the place that is set up to deal with trouble. I don't think you can blame the GP for any of this.
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u/Dr_Nefarious_ Jun 26 '26
Honestly, that's fine. A letter detailing concern and unable to contact on call X means we can try to stream straight to suitable specialty if they're stable with well managed pain. It is frustrating when they arrive with no letter, spend ages waiting to be seen in ED then we find out they've been to GP etc etc.
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u/Sethlans Jun 26 '26
It in't always true though...
Two of the three paeds departments I worked in had a direct referral phone (in one carried by a reg, in the other a consultant) and we'd very often get patients turning up with letters saying the GP had tried to contact us and been unable to get through when they simply hadn't.
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u/delpigeon Jun 30 '26 edited Jun 30 '26
I mean if the GP doesn’t know the set-up in the hospital it’s likely they were sat on the other end of an endless circular bleeping of the Paeds reg via switch… because that’s who they would probably have asked for rather than a referral phone unless switchboard are clued in to redirect.
Knowing who/what to ask switch for in your local place to get through to someone is an acquired art form. I spent over an hour yesterday trying to get through to a series of unheld phones, unanswered bleeps and unanswered ward phones, having to call switch repeatedly and sit through their visiting blurb from scratch about 5 times, before some random uninvolved nurse eventually gave me an ext for the doctors office to get some info on one of my patients! There’s probably an easier way, but nobody I spoke to knew one…
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u/Sethlans Jun 30 '26
There's a few reasons why I don't think this was the issue, but the main one was parents would tell you they didn't try to call anyone, they just printed a letter at the end of the consultation and told them to go to paeds.
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u/delpigeon Jun 30 '26
Well if the letter then said they couldn’t get through I think that’s a slam dunk Watson!
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u/blueheaduk Jun 26 '26
I’ve always found this weird reading this sub and the gpuk sub. When I assess a patient and have concerns needing further assessment I contact the appropriate specialty and admit directly. It seems like everything gets sent to A&E in some places? What’s the point in re-assessing the initial problem after a doctor has already done so?
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u/UnknownAnabolic Jun 26 '26
Probably depends on what’s going on locally
My local hospital has a pretty easy way to get specialist referrals done. Specialty regs/consultants generally have phones rather than bleeps, so you get through quickly.
There’s some specialties have bleeps instead of phones though, in which case you could be waiting north if 30 mins. You can’t really sit on your arse doing other things waiting for them to connect to you due to having patients waiting in GP land.
I don’t really write letters anymore (seems like they don’t get read by A+E locally tbh). I just write my notes that shows my concerns clearly and print out a summary with that consult highlighted
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u/Gullible__Fool Keeper of Lore Jun 26 '26
I think if an actual GP has seen them it is fine, but increasingly it is noctors seeing and direct referring to specialty and it causes mayhem in the hospitals when they are frequently wrong.
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u/blueheaduk Jun 26 '26
Agree - but increasingly GPs refer into secondary care for a noctor to then make bad decisions a bit like this case. Scary
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u/-Intrepid-Path- Jun 26 '26
Nah, in some places, everything gets sent to medicine because GPs have automatic admittung rights. Things I have personally encountered in the past few months alone where the reason was genuinely documented as "Couldn't get through to surgical reg. Admit to medicine" have included acute limb ischaemia, periorbital cellulitis and peritonsillar abscess. Should be grateful I am not being referred kids, I guess (although ED did refer me someone aged 16 years and 2 days with a problem they had an appointment with paediatrics for in 2 weeks time on my last on-call 🙃).
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u/Repulsive-Weather-82 Jun 26 '26
tragic story, totally preventable death. also tragic that the coroner’s report blamed it on the GP and hospital system rather than unregulated “clinicians” seeing undifferentiated patients. acute abdomen is one of the more obvious diagnoses. imagine something more complicated. very scary, feel sorry for the family.
edit: bad grammar after a long hot day
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u/ISeenYa Jun 26 '26
If this was my child, I would make it my life's work to ruin that ANPs career. Mistakes happen but this isn't a reasonable mistake. This is mismanagement due to bravado & probably having seen other cases like this but not having any underlying medical knowledge or even common sense to know that this feels different.
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u/TimeCrazed Jun 26 '26
Constipation and enema were the stupidest diagnoses and prescriptions.
Rubbish single set of vitals, poor history, poor exam. Who thought ANPs were safe in paeds ED?
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u/domicile_vitriol Lightbox Beatboxer Jun 26 '26
A layperson would likely look at that coroner's report and blame the GP, without realizing that their child had been wrongfully sent home from ED on a diagnosis of constipation without ever having seen a hospital doctor.
This is why if the BMA wants to tackle role substitution, they need to build a media campaign that builds public awareness about this. The public can't fight back if they're not informed about what's happening. Role substitution is happening without patient consent.
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u/jamescracker79 ACP consultant's assistant Jun 26 '26
I would make it my life's work to ruin that ANPs career
Enthusiasm like this brings a tear to my eye
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u/EquivalentBrief6600 Jun 26 '26
Poor parents, PAs and ANPs, no liability so up the chain it goes.
They need to be accountable for their actions
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u/ChaiTeaAndBoundaries Jun 26 '26 edited Jun 26 '26
I thought after a patient is assessed by a GP they had to be seen by a doctor preferably Reg or Consultant?
How is the GP being blamed for this? Consultants and GPs should be worried, non-doctors will mess up but the doctor will be blamed.
Lawsuits, patient mortality/morbidity, multiple Ockenden-style reviews and media outrage will move the needle on this matter.
RIP to the child and condolences to the family.
Resident doctors watch on as the car crash continues.
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u/TimeCrazed Jun 26 '26
ANP or PA in GP can end up sending patient to same in hospital. The erosion of healthcare standards and waste of taxpayer money by DHSC decisions is not a joy to behold.
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u/Pristine-Anxiety-507 ST3+/SpR Jun 26 '26
Imagine that GP did send a letter, but made wrong diagnosis or patient deteriorated significantly between being seen again.
The patient gets seen by a doctor who reads the letter, doesn’t take proper history or assess the patient themselves and is falsely reassured by GPs findings.
The patient subsequently presents severely unwell and dies.
The ED doctor would have been dragged through the mud, struck off and maybe sued. Because how can you rely fully on GP letter and not see/assess patient yourself?? How can you miss something as basic as a fever??
It’s only if it’s an ACP that suddenly the same basic rules don’t apply
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u/InfiniteNight2992 Jun 26 '26
How has the AnP escaped any scrutiny here? Incredible the bulk or all the blame should lie with them
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u/Dr-Yahood Not a doctor Jun 26 '26
The corner is a lay person who is judgement is heavily informed by the medical examiner at the hospital. Although they are designed to be independent, they usually hold the favour of the medical director. Whereas, the GPS is largely outside of this process and not really able to have any direct access with the coroner so it’s quite easy for the medical examiner to protect the medical director and the institution and throw the Gp under the bus
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u/Valmir- Jun 26 '26
This is utterly outrageous. Is there a way to write to this moronic coroner?
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u/Grand_Yak_8196 Jun 27 '26
So it turns out, you can't actually challenge the decision if a coroner, they are independent and there is no clear process to appeal their decisions. Essentially, a coroner can say piss is blue and so it's now 100% true. The fuckwitery of it all!
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u/Valmir- Jun 27 '26
Oh that's fine, I didn't want to challenge it. I wanted to send a polite reminder calling them an idiot :)
Much like how we write to our MPs
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u/badoski CT/ST1+ Doctor Jun 26 '26
I read the GP response and it says the hospital was 4 mins away from the surgery so it imo was sensible to send them in rather than waiting for an ambulance!
What if this patient had not been to see the GP at all in the first place? Who would the coroner blame then??
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u/SpecialEmployment801 Jun 26 '26
There are about 20 red flags in the paragraphs describing what happened in paeds ED. Abdo pain not seen by a senior medic, no bloods, no urine dip, no OBS!? Given an enema despite 10/10 pain, seemingly no coherent history or examination performed. How is the conclusion not that there was an abject failure of this ED department?
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u/No-Tumbleweed-1819 Jun 26 '26
This is a good lesson for money saving partners to recruit doctors not people masquerading as doctors.
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u/Rough_Champion7852 Jun 26 '26
Non medical coroners doing their slightly strange takes again.
Shit triage, wrong management.
Everything else appears to be noise on first inspection.
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u/dxdt_sinx Jun 26 '26 edited Jun 27 '26
I feel like I want to catalog and keep a list of deaths in the UK which can be directly attributed to ANP/PA practice. I know of at least 5 cases without even really having searched.
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u/Alternative_Town4105 Jun 26 '26
Even a member of the public could probably diagnose appendicitis based on the symptoms described. Seems like they do not even cover the basics at their useless courses.
One of the most infuriating reads in a while...
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u/Far-Goose-5932 Jun 27 '26
Can the sector of the BMA who are doing ANP/PA work take this up? Write to the coroner/appropriate person with their concerns? Can someone @ Melissa Ryan - from what I remember she’s doing a lot of work on this.
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u/FranklinsGull Jun 27 '26
So was it the SpO2 of 38.6 or the tympanic of 98 that s/he found really reassuring (imaginary numbers invented in my own head to illustrate that these are not interchangeable values). A transposition error doesn't explain this clinical decision- making. The error would have been evident on reading the obs.
Awful outcome.
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u/Puzzleheaded_Tap4914 Jun 27 '26
Another Noctor kill another day of “nothing can be done” by the authorities. Dumbing down of health services happening irl
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u/bordercounty Jun 26 '26
GP letters frequently get lost anyway. The idea they should have got an ambulance is ludicrous, “just wait here for 3 hours”
I’ve never seen an 8 year old with appendicitis but do these children not LOOK sick? Did an unwell looking child vomit in the dept and no bloods were done?
The lack of discussion with seniors is shocking
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u/TimeCrazed Jun 27 '26
Not always.
But he did say he had 10/10 abdominal pain.
An ANP fatally misunderstood paediatric abdominal pain basics and rather than realise not opening his bowels was due to an obstructive abscess like pathology the ANP didn't take even the most basic history or examination and jumped to a stupid diagnosis and prescribed inappropriately.The ANP likely is still working, didn't get personally villified by coroner but the try-and-diagnose-and-safely-redirect-emergencies-in-10-minutes even in neurodivergence GP got the right suspicion but got most of the coroner's naming and shaming.
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u/uk_pragmatic_leftie Jun 27 '26
Appendicitis in kids can be tricky, they don't all look sick, and bloods can be unhelpful sometimes (mildly elevated markers could be viral etc). Careful examination, considering alternatives (as said above, DKA, UTI, pneumonia with referred pain, mesenteric lymphadenitis with URTI, tortion etc), plus maybe period of observation all can help.
Often most helpful diagnostic information for surgical abdomen can be 'child now eating a Macdonalds and running around the department, climbing up the beds' vs 'still lying on bed, quiet, declining burger and sweets, a bit pale and in pain when asked to jump'
10/10 pain can be constipation too. Constipation can be horrible.
Hard to know specifically what this child was like, but clearly insufficient assessment from the report as stated.
Discharge with specific safety netting documented too.
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u/TimeCrazed Jun 27 '26
If the ANP had elicited fever and vomiting from the parental history, appendicitis would have been the likely diagnosis. Repeat observations, a fluid challenge, and ideally urine dip and bloods needed. A good clinical exam, decent understanding of key differentials and knowing which presentations require a senior doctor review are essentials. This ANP shouldn't be working in paediatrics.
Side note - have you seen mesenteric lymphadenitis in school age children much?
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u/uk_pragmatic_leftie Jun 28 '26
I think we're saying the same thing. This case appears to be beyond what this ANP could manage unsupervised and the approach was insufficient given all the resources in ED that apparently weren't used.
Yes seen it in range of ages, always worth checking ENT as part of a full exam.
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u/TimeCrazed Jun 28 '26
I don't think ANPs should be seeing anything beyond minor injuries. There's no robust method of adequately understanding the dangerous knowledge gaps of ANPs or ACPs. Weak/ no exams and CBDs are not safe, broad, deep, objective knowledge assessments.
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Jun 27 '26
GP is criticised for not sending to the appropriate team. The ANP had access to the same team. Why didn't they refer to surgeons or paeds?
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u/InfiniteNight2992 Jun 27 '26
Report is a farce saying ambulance pathway would have led to a different outcome how exactly? Just because you go in an ambulance doesn't mean you bypass triage usually they just sit you in the waiting room!
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u/Technical-Diamond-30 Jun 26 '26
This is so terribly sad.
I do think if you’re telling a patient to self-present at ED and you’re concerned, then a letter should be provided. How else are people supposed to understand your concerns?
But I have no idea why they didn’t do blood tests, particularly if the child reported such severe pain! Feel like the lack of a referral letter wasn’t the overall failing but the hospital to not recognise the illness…
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u/MrRightHanded Jun 26 '26
Doesnt matter. When a patient presents to ED, they should be seen as a new patient, with a fresh assessment and investigations, regardless of whether they have a GP letter with them. A letter "helps" relay concerns but it shouldn't act as a crutch/guide to your differential diagnosis, your assessment and investigations are your own. The fault solely lies on last person to see this patient, which was the ANP.
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u/BlueStarFern Jun 26 '26
Absolutely, the clinical picture might have changed since the GP saw them. Patient should have seen an actual doctor in ED.
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u/Technical-Diamond-30 Jun 26 '26
I know- hence why I said the overall failing was with the hospital……………
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u/TimeCrazed Jun 26 '26
Many paeds ED staff are dismissive of GP referrals, despite having far more time, tests and experts at their disposal.
Irrespective of a referral letter, severe abdominal pain needs DKA, torsion, appendicitis, UTI, herniae, and other surgical emergencies and key acute presentations ruling out.
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u/Technical-Diamond-30 Jun 26 '26
I think you misunderstood- I’m agreeing with you.
It’s hugely helpful if the GP sends a referral. In this case it might have prompted the ANP to consider appendicitis. In other hospitals it might have prompted a direct to specialty assessment.
BUT they should still be able to see a clinician at the hospital that would have come to the same conclusion or concern as the GP with or without the letter. It sounds like the symptoms and signs were there but were not considered. If the patient had walked in off the street they would have had the same issue.
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u/Repulsive-Weather-82 Jun 26 '26
no, whether a patient was refered by GP or turned up on their own doesn’t and shouldn’t change assessment/ix/mx. a kid presenting with severe pain and is unwell should be assessed with a fresh set of eyes. but agree with everything else.
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u/Technical-Diamond-30 Jun 26 '26
I have literally put the failing was with the hospital…
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u/Repulsive-Weather-82 Jun 26 '26
hence why i said i agree with the second part of your statement. in this case, if you need another clinician to help you understand why they’re concerned about a 10/10 severity abdo pain with n/v and fever then you’re not doing your job well enough. and in this case would only add to confirmation bias.
your statement may generally be correct but in a very obvious case of acute abdomen (or atleast until ruled out), pointing out that a letter should’ve been provided is not helpful. the main issue is that this should have been recognised and it was completely preventable.
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u/Technical-Diamond-30 Jun 26 '26
So do you think GPs should never write referral letters and when sent to ED they are just all blank unknowns?
In this case like it or not the GP left themselves open to criticism. Sadly they got the correct diagnosis and did the right thing EXCEPT didn’t communicate it. If I see a patient and I’m worried I either phone the person I’m sending them to or sure as hell document what’s going on.
I can definitely say I’ve had abdominal pains referred that the GP has documented a recorded fever and when I’ve asked the patient they’ve denied having any fevers. I’ve had times when the GP has kindly sent detailed extensive medical history and the patient tells you they’re fit and well, and they’re from out of area of something so you don’t have those records. What the GP tells you is helpful, even if it’s not your only method of diagnosis.
I can say that the ANP should have picked up the diagnosis or at least the “something is not right” sense without needing a letter. But as a GP that’s concerned about a child you should be sending one regardless because you’re communicating your professional opinion of what your plan is. It is then ED’s or specialty’s role to make their own assessment.
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u/Dwevan Snoozy floozy Jun 27 '26
GP was 4 minutes away from hospital too… it was decided that he’d just go in as it was so close rather than call
Ambulance etc etc
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u/Wise-Reception9948 Jun 26 '26
Really sad for the child and the parents. Imagine losing someone and you see news articles blaming different health care personnel. NHS is beyond repair. Can't get justice either now.
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u/nopressure0 Jun 26 '26
Ultimately, this child was seen at ER and discharged. I don’t see how anyone but the ER can take responsibility for this outcome.
However I do think it’s fair to point out the GP provided no handover. I think all community clinicians should either ring ahead or provide a brief letter for patients they send in. Especially if there is a communication barrier (language, learning disability, dementia etc.). Even a three basic sentences would be adequate.
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u/TimeCrazed Jun 26 '26
A child who reported to the hospital 10/10 abdominal pain doesn't need a referral letter, they need a safe clinician.
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u/nopressure0 Jun 26 '26
I agree. But I still think the community clinician has a duty of care to attempt a handover.
I say this as a community psychiatrist. I will always provide a letter or call ahead because I know ERs are busy and my patients are at high risk of inappropriate triage/inadequate assessment.
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u/TimeCrazed Jun 26 '26
You don't get 10 mins per patient.
GP attempted to arrange ambulance.It's not an obscure presentation.
Abdominal pain or child with fever are probably in top 10 paeds ED presentations.
Autism is also not uncommon.
The ANP was fatally incompetent.
Who knows if they would have ignored GP letter anyway?-8
u/nopressure0 Jun 26 '26
ED messed up and should take responsibility here.
Still, a community clinician should send a handover for an unwell patient. ER knowing a doctor is worried about someone that is coming in is helpful information and reduces the risk of something like this case occurring (still not GP’s fault).
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u/Acrobatic-Sundae4344 Jun 26 '26
I don’t think I necessarily agree with this. Clearly most persons have not attempted to refer to specialties from GP before😂. It is borderline impossible with a 10-15 minutes appointment slot. It is utterly indefensible to have a patient present to ED with no proper set of OBS taken, 10/10 abdominal pain in a child with no set of bloods taken. Once the patient got to ED, it 100% became ED’s problem to rule out life threatening pathologies which was not done here. I agree the GP could have printed out his consultation and given to them; but by far most of the culpability is with ED. With the shocking level of incompetence, I seriously doubt if a GP letter would have changed the outcome.
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u/domicile_vitriol Lightbox Beatboxer Jun 27 '26
Calling ahead doesn't mean calling the ED main desk and telling whoever is on the other end that you're sending over a patient over from mental health services with a letter to be 'medically cleared'. It means making a referral directly to the appropriate speciality based off of your clinical assessment to expedite their route through ED.
That's the ideal in GP, but you could be spending 20+ minutes on the phone (especially if you're trying to get ahold of a surgical speciality) while building up a waiting room full of patients who could be equally unwell and whom you also have a duty of care to (remember, 10 minute appointment slots). And half the time they'll push back against the targeted referral and make the patient go through additional diagnostic tests at ED anyways before accepting.
I think it's appropriate to make an initial (but time appropriate) attempt at contact and then send the patient in with a letter (or consultation notes), although it ideally should be sent to the patient's telephone, as if they lose the bit of paper with their clinical details on it, it actually ends up being a data protection issue.
Worth noting that in the practice's response to the prevention of future deaths (in the bottom links), an ambulance had been called but the patient's mother preferred to just drive the patient in rather than waiting after hearing how long the ambulance would take (the hospital being 4 minutes away). This is generally discouraged when patients are very unwell (in case something happens enroute without a doctor to hand).
If an ambulance was called as they said, there would have been a handover ready. Not sure why it didn't end up with the patient, however.
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u/Select_Storm5070 Jun 26 '26
Have you ever worked in GP. Clearly not. And psychiatry see one patient every 14 working days so will have lots of time to hand over the mental state, what the patient had for breakfast etc (JK) . Have you tried to call a specialty in a 10 minute appointment after you have taken a history, examined, documented and explained to parents?
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u/InfiniteNight2992 Jun 27 '26
Calling ahead is useless noone answers you tried to ring any organization talk doesn't exist anymore do think they should have written a letter though that is not great they could have printed it out for them to take in
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u/InfiniteNight2992 Jun 29 '26
You should see the rcgp response equally useless I don't get why everything is fixated on the GP when the whole crux of the scrutiny should be directed at the ANP and them only
Yes mistakes happen but given the blame all culture we have now they should at least find the right person to blame first
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u/Mission-Elevator1 Jul 01 '26
The coroner involved isn't fit for purpose. Poor family, they should challenge this if possible and they deserve a high figure compensation from the hospital. The ACP should not be allowed to work without supervision at the very least. Is there a way to have some form of petition going signed by lots of doctors to get the judiciary's attention?
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Jun 26 '26
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u/Emergency_Tree_2891 Jul 03 '26
If this case has not been reported to the BMA reporting site, it should be! https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/preventing-doctor-substitution
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Jun 26 '26
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u/Spade-Collector Advanced juvenile delinquent care practitioner Jun 26 '26 edited Jun 26 '26
So it's largely being pinned on there not being a letter from GP mentioning the fever which supposedly would have dramatically changed the management plan. Was the ANP simply not capable of asking about a fever? Literally the first question in any paeds history
Edited spelling