First reported 31 May 2019•Latest report 3 Sep 2025
Definition
What this concern includes
Includes failures in algorithms or algorithm-governed triage processes used to assess unwell patients where the system inadequately accounts for reported symptoms or emergency indicators, fails to identify serious deterioration, provides insufficient direction for clinical escalation, or encourages unsafe reliance without appropriate clinical input.
Not included
Excludes failures in clinical assessment or treatment after the algorithm has appropriately identified the need for clinical input.
Excludes generic staffing, training, communication or service-capacity deficiencies unless they directly impair the algorithmic triage process.
Excludes named triage systems with a more specific established parent, such as NHS 111, MPDS, Manchester Triage System or ambulance call triage, when the assertion is confined to that system.
Excludes ordinary algorithm use where the algorithm reliably supports clinical judgement and no unsafe triage condition is identified.
Reports
7
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2019–2025
First to latest report issue date
Stated actions
8
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care4
Barts Health NHS Trust1
Care Quality Commission1
East of England Ambulance Service NHS Trust1
NHS England1
North East Ambulance Service NHS Foundation Trust1
South Central Ambulance Service NHS Foundation Trust1
Welsh Ambulance Services NHS Trust1
Welsh Government1
NHS trust5
Ministerial department4
Devolved government1
Executive non-departmental public body1
Health and social care service regulator1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Manchester South
Concerns raised1
Lack of an algorithm for office call handlers to triage clients who appear unwell and determine a course of action
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing CQC regulation and reasonable initial guidance are considered sufficient; further action is not considered likely to prevent a similar incident.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Department of Health and Social Care may be better placed to address concerns about call-handler triage algorithms.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Oxfordshire
Concerns raised2
Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems
Total reliance on an algorithm that does not direct early clinical input
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The review concluded that the NHS Pathways algorithm functioned as intended in this case and required no changes.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS England, not the Trust, is responsible for altering the NHS Pathways algorithms.
Stated by South Central Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local services manage the availability of services matched to the NHS Pathways recommended outcome.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.
Stated by South Central Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Over-reliance on the NEWS algorithm in clinical assessment
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gwent
Concerns raised1
Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
Stated by Eluned MorganRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of the ambulance call algorithm to direct exploration of concerning symptom responses
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Newcastle upon Tyne
Concerns raised1
Insufficient triage by algorithm when inadequate weight is given to reported symptoms and indicators of a medical emergency
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Lack of a neurological-deficit triage algorithm
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Work with the IAED to improve triage standards and identify protocol gaps requiring clinical support.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Action
Meet the IAED, draft and submit a proposal for a neurological-deficit pathway in 999-call triage.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Send the neurological-deficit pathway proposal to NASMeD for consideration and support.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The absence of a neurological-deficit protocol did not negatively affect the care provided or response assigned.
Stated by EEASTDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The IAED owns and designs the triage system, so protocol changes require its consideration and approval.
Stated by EEASTRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Pin
Get email alerts
Request correction
Includes failures in algorithms or algorithm-governed triage processes used to assess unwell patients where the system inadequately accounts for reported symptoms or emergency indicators, fails to identify serious deterioration, provides insufficient direction for clinical escalation, or encourages unsafe reliance without appropriate clinical input.
