UK Inquiry Tracker

Vanessa Ferkova

PFD Report Historic (No Identified Response) Ref: 2023-0414

Date of Report 26 January 2018

Coroner Richard Brittain

Coroner Area Inner North London

Response Deadline ✓ from report 23 March 2018

Child Death (from 2015)

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The walk-in centre's triage process was judged adequate by the CQC despite lacking vital clinical observations, unlike secondary care, creating an unacceptable safety risk for unscreened patients.

View full coroner's concerns

I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need…’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen. I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool. Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place; a situation which is seemingly accepted by the regulator. I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged.

Sent To

Care Quality Commission
Coventry and Rugby Clinical Commissioning Group
Urgent Care NHS England
Virgin care Coventry LLP

Response Status

Linked responses 0 of 4

56-Day Deadline 23 Mar 2018

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

Vanessa Ferkova died, aged 2, on 16 January 2017 from meningococcus septicaemia. The inquest into her death concluded on 26 January 2018; I recorded a narrative conclusion (see attached).

Circumstances of the Death

Miss Ferkova had a non-significant medical history. She presented to Coventry GP Walk-in Centre at 2pm on 16 January 2017 with her parents, having suffered from fever and vomiting that morning. A receptionist took down details of her illness and recorded that Vanessa looked ‘pale’. The information recorded did not meet the ‘red or yellow flag’ conditions which would have prompted prioritisation of her care. Her parents stated that Vanessa vomited in the waiting room which would have prompted prioritisation but they were not aware of this ‘flag’ and did not report this incident. Vanessa also developed a rash whilst waiting to be seen which, if ‘non-blanching’ would have also prioritised Vanessa assessment. Her parents’ evidence was that the development of a rash was raised to the receptionist, although this was not her recollection of events. As such, there was no clinical assessment until Vanessa was seen by a nurse shortly after 4pm. At that time she was recognised to be very unwell and likely suffering from meningococcal septicaemia. She was given antibiotics and and an ambulance was called. In the ambulance, at shortly after 4.30pm, Vanessa went into cardiac arrest. Unsuccessful resuscitation attempts were made, including on arrival at hospital shortly after her arrest, and she died at 5.11pm. I heard evidence from the treating hospital paediatrician that it was likely Vanessa was suffering from compensated shock on her arrival at the walk-in centre and that, had observations been undertaken at this stage, this would have been recognised, treated and Vanessa would have survived. The paediatrician set out that recording clinical observations was a ‘vital patient safety tool’ in the secondary care setting. I heard from the walk-in centre provider that, unlike in the secondary care setting, they are not commissioned to undertake clinical triage and that nor is there a timeframe within which patients are required to be initially assessed.