Dear Mr Landau Re: Regulation 28: Prevention of Future Deaths: Francesca Sio, dec: Bromley Clinical Commissioning Group (BCCG) is in receipt of a Regulation 28, Prevention of Future Deaths report which you issued under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, issued as a result of unchallenged evidence provided during the Inquest of Francesca Sio in relation to deterioration of children whilst waiting to be seen_ It is with great sadness that Francesca's illness progressed so rapidly resulting in her death and my condolences are with the family at this sad and difficult time as adjust to life without her. Greenbrook Healthcare is an established urgent care provider managing 11 urgent care centres across London and has been commissioned by BCCG to provide community and primary care facilities to the local population against a contractual service specification which meets with NHS England requirements. In line with NHS England guidance, the urgent care centre is led by general practitioner and in this case, is co-located within the Emergency Department (ED) at the Princess Royal University Hospital (PRUH): The types of patients that present to an urgent care centre are not in need of 'emergency' treatment but are those who that can be seen and treated by a general practitioner. All patients presenting to the PRUH ED are triaged and signposted to the service most relevant to their presenting complaint: The urgent care centre has a dedicated waiting area for children that is supervised by nursing staff who whilst are not paediatric specific staff members, do have appropriate training in the care and management of children. BCCG seeks assurance of compliance against the contractual commitments via regular formal contractual meetings with Greenbrook where performance reports, contractual reviews, key performance indicators are presented and scrutinised: Bromley CCG also reviews all serious incident reports and monitors the implementation of action plans at contract meetings with Greenbrook Healthcare Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan they very

In addition, to local monitoring of performance against their contractual commitments, the service was inspected by the Care Quality Commission (CQC) to ensure compliance against their Key Lines of Enquiry (KLoEs) which consist of five domains; Safe, Effective, Caring, Responsive and Well-Led. Greenbrook Healthcare was last inspected by the CQC on 13 December 2017 . Each of the domains was rated as 'Good' . The findings of the CQC provide another level of assurance to the CCG. Bromley CCG has contracts in place for the provision of two Urgent Care Centres (UCCs) providing treatment for Bromley residents with minor injury & illness at Beckenham Beacon Hospital and the Princess Royal University Hospital (PRUH) both of which expire on 31st August 2020. The CCG is in the process of reviewing the options for re-procuring services at both sites from Ist September 2020 in line with the mandate from NHS England. As part of the re-procurement; the CCG will ensure that it gives due consideration to the concerns you have raised by the prevention of future deaths and welcome the opportunity to improve services in Bromley:

Dear Mr Landau I write in response to the Regulation 28, Prevention of Future Deaths report which you issued to Bromley Clinical Commissioning Group and Greenbrook Healthcare as a result of unchallenged evidence provided during the inquest of Francesca Sio. I would like to share my condolences with the family of Francesca during this very difficult time. Bromley CCG and Greenbrook Healthcare have prioritised their investigation into the issues raised in your report, we are responding jointly to the concern you raised which is:
• A concern that mixing child and adult populations in a UCC creates a risk that children will quietly deteriorate unnoticed We note the acknowledgment in your inquest conclusion that the above concern did not affect the outcome for Francesca in any way, as she was appropriately referred into the Emergency Department and there was no evidence to suggest her condition deteriorated whilst she was in the UCC. We are sorry that we did not have representation in the inquest at the time when the paediatric expert witness gave her evidence. As a result, we could not provide immediate assurance to you that the potential risk, highlighted by Dr Bohin, is fully mitigated against within the UCC. Greenbrook Healthcare are an established urgent care provider managing 11 UCCs across London; working closely with Bromley CCG the service is continually scrutinised to ensure patient safety, of both adults and children, is paramount. The service we offer is in line with the national specification for UCCs (from NHS England) in which both children and adults with minor illness and minor injuries should be managed within a primary care led UCC.

Registered office: Greenbrook Healthcare (Hounslow) Limited, Cardinal Square West, 10 Nottingham Road, Derby DE1 3QT. Company no.: 06025335 Greenbrook Healthcare Building 3, Hyde Park Hayes 13 Millington Road Hayes, Middlesex UB3 4AZ

The UCC lies adjacent to the Emergency Department at Princess Royal University Hospital, walk in patients are assessed by a senior UCC streaming nurse and those with more serious conditions are navigated directly to the Emergency Department. Walk in patients with more minor presentations are managed within the UCC. There are clear pathways to transfer patients from the UCC into the Emergency Department at any time should their conditions deteriorate, or they require more specialist investigations. The pathways for transfers have been jointly developed by senior UCC and PRUH Emergency Department Clinicians and are monitored via the shared ED/UCC monthly clinical governance meeting. To ensure that children are managed safely in the UCC and do not deteriorate unnoticed the following systems are in place:
• The UCC at Princess Royal University Hospital has a dedicated paediatric waiting room, child and adult populations do not sit in a shared waiting area (see attached photo).
• All children have a nurse assessment within 15 minutes of arrival which includes a set of clinical observations (pulse, temperature, oxygen saturations). Children with abnormal or concerning observations on arrival are directed straight to the paediatric Emergency Department and are not kept waiting or managed within the UCC.
• The UCC nurses making the streaming decision have all undergone Greenbrook’s streaming competency training program which includes specific training on assessing children.
• All UCC clinicians, GPs and Nurse practitioners, complete the on-line training module “spotting the sick child”.
• Greenbrook have a rolling monthly audit of streaming consultations to ensure all cases have clinical observations recorded and high-risk cases have been streamed directly to ED. The results of the audits are monitored through the monthly clinical governance meeting (this is a joint meeting with ED and paediatric ED).
• Children managed within the UCC are, by definition, lower risk cases- typically those usually managed in a GP practice. The children streamed into the UCC are classed as urgent or routine, all urgent cases will be prioritised for full consultation, usually within an hour, which reduces the risk of deterioration in the waiting room.
• Our average waiting times for a full consultation for children, after the initial clinical assessment, are between 1- 1.5 hours, occasionally our waiting times become longer, in such situations our escalation process is initiated, the shift lead nurse re-checks clinical observations on children (and adults) who have been waiting a prolonged time.

Registered office: Greenbrook Healthcare (Hounslow) Limited, Cardinal Square West, 10 Nottingham Road, Derby DE1 3QT. Company no.: 06025335 Greenbrook Healthcare Building 3, Hyde Park Hayes 13 Millington Road Hayes, Middlesex UB3 4AZ

• It is the role of the streaming nurse and shift lead nurse to visibly monitor the waiting room. The streaming room lies adjacent to the waiting area and has direct visibility of the adult and child waiting rooms. The senior nurses visualise patients in the waiting room every 10 minutes and re-assess patients who are showing signs of deterioration (e.g. increasing pain/distress, drowsiness).
• In addition to waiting room supervision by the nurse practitioners, there is clear signage in the waiting room (see attached photos) asking patients or their carer to speak with the streaming nurse if they feel their symptoms are worsening. As an organisation we are keen to continually learn and improve our service. Greenbrook Healthcare worked in partnership with the paediatric team at Kings College Hospital NHS Trust in the Serious Incident investigation into the death of Francesca Sio. The investigating paediatricians were satisfied with the process for transferring Francesca and they did not raise any concerns about the UCC’s ability to monitor and identify deteriorating children. More broadly, the UCC has robust clinical governance processes in place which identify incidents of concern and ensures actions are taken to reduce risk of recurrence. In the 6 years that Greenbrook have managed the PRUH UCC there here have been no serious incidents relating to the deterioration of a child in the UCC waiting room. Bromley CCG have oversight of the governance processes. We hope the above gives you assurance that adult and child populations are not mixed in the UCC and there are effective systems in place to reduce the risk of a child deteriorating unnoticed within the UCC. We are not complacent, and we continually review our processes; we will be cognizant of your report when developing and reviewing our paediatric pathways to ensure the current high standards are continually maintained.