The system which was supposed to ensure he was treated on the basis of his clinical need actually provided a barrier to getting any treatment at all

Thomas Rogers died on a trolley, nine hours after he'd first arrived at Whipps Cross Hospital in East London.

The inquiry team blamed a total breakdown in the system used to assess patients in A & E.

But what went wrong at Whipps Cross they said could just as easily happen elsewhere.

The problem lies in the informal use of a system known as 'triage within triage' system which is used widely throughout the NHS.

Triage is the name given to the process of deciding whether you're sick enough to be seen immediately or whether you can be left waiting so that other cases can be prioritised.

It is usually carried out by a nurse who checks your symptoms and then decides whether you are a priority.

Traffic lights

At Whipps Cross they use a traffic lights system orange for the most urgent cases, yellow for those less urgent, green for the least.

The problem is that demand is often so great there are large numbers of people in the yellow category, so they in turn need to be prioritised again.

But this time the patient isn't necessarily examined again.

A nurse might approach a doctor and ask for a patient to be prioritised. Or the cards with patients' information may simply be reviewed and shuffled in the box for the queue to be seen by a doctor.

Now this system may have been used for years, but in the face of increasing demand for A & E facilities, the inquiry team found it was no longer appropriate.

Unless you have the proper systems and protocols in place, the danger is that on days when the department is overstretched, as it was at Whipps Cross in August, patients like Thomas Rogers who don't appear to be at risk keep being sent to the back of the queue.

Barrier

The system which was supposed to ensure he was treated on the basis of his clinical need actually provided a barrier to getting any treatment at all.

The inquiry team found that staff at Whipps Cross regretted what had happened to Mr Thomas but they viewed such incidents as inevitable in a system that just didn't work.

And it could be about to get worse.

Government targets for the maximum wait in A & E are to be reduced from 12 hours down to 4 hours.

Will that mean more shuffling of the cards in the appointment box as doctors are put under pressure to beat the clock?

And if it does mean that, and tighter controls on the quality of assessment aren't introduced, how will doctors ensure that cases like Thomas Rogers don't fall through the net once again?