Recurring concern

Unreliable NHS 111 clinical triage algorithms and systems

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First reported 6 Aug 2015•Latest report 17 Jun 2026

Definition

What this concern includes

Includes failures of NHS 111 or NHS Pathways clinical triage algorithms and their dedicated safety controls, including algorithm design, disability accommodation, recognition of complex cases, escalation to senior clinical advice and correction of identified algorithm deficiencies.

Not included

Excludes generic telephone communication, staffing or training deficiencies unless they directly impair the NHS 111 clinical triage algorithm or its dedicated safety controls.
Excludes ambulance dispatch, response-capacity and hospital handover failures occurring after the NHS 111 triage process has operated adequately.
Excludes clinical assessment or treatment failures unrelated to NHS 111 or NHS Pathways triage algorithms.
Excludes general healthcare accessibility concerns where no NHS 111 algorithm or triage-system deficiency is identified.

Reports: 21
Individual concerns: 30
Date range: 2015–2026
Stated actions: 40

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England15

NHS Pathways9

South East Coast Ambulance Service NHS Foundation Trust6

Department of Health and Social Care4

Care Quality Commission3

Royal College of General Practitioners3

Asthma + Lung UK2

Appello Limited1

Association of Ambulance Chief Executives1

College of Policing1

DHU 111 (East Midlands) CIC1

Family of Alexander Davidson1

Integrated Care 241

Joint Royal Colleges Ambulance Liaison Committee1

Mitie1

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.

6 Aug2015
Buckinghamshire
Concerns raised1
1. Failure of NHS Pathways toddler/child pathways to identify very sick children
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Amend the system to advise regularly checking unwell children overnight.
  Stated by NHS PathwaysStated completed
2. Action
  Enhance training materials to support safer identification and management of paediatric sepsis.
  Stated by NHS PathwaysStated completed
3. Action
  Continue reviewing clinical content and system architecture for safe identification of paediatric sepsis.
  Stated by NHS PathwaysStated in progress
Respondent positions 2
1. Position
  Responsibility for the NHS Pathways system rests with HSCIC, which has provided the relevant response.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  There are no grounds or sufficient evidence that the toddler and child pathways fail to identify very sick children.
  Stated by NHS PathwaysDisputes the concern
AI-generated summary

Robert Gordon John Hogg · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Robert Gordon John Hogg was taken to hospital with cold and temperature symptoms and was assessed and sent home. He later became lethargic and unresponsive in the urgent care centre waiting room, and his death was confirmed on 21 April 2014. An investigation identified concern that NHS Pathways toddler/child pathways were not necessarily identifying very sick children, and this was described as a continuing risk at the inquest.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of NHS Pathways toddler/child pathways to identify very sick children
Wider context from the report
“(2) The third area of concern stated specifically “NHS Pathways toddler/child Pathways are not necessarily highlighting/picking up very sick children. This is not the first event relating to incidents involving toddlers/children and this has been highlighted through our own Pathways Lead to NHS Pathways for investigation” (3) The evidence given by ████████ during the Inquest was that no changes have been made to the toddler/child pathways, and that the third area of concern identified in the Investigation Report is a continuing risk. ”
Source location
Robert Gordon John Hogg · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend the system to advise regularly checking unwell children overnight.

Verbatim wording from the response
“However as a learning system, and as a consequence of this document, NHS Pathways did amend the system, and is continuing to review the clinical content and architecture in regards to safe identification of cases of paediatric sepsis.”

Source location
2015-0313-Response-by-NHS-Pathways
Page 2 · response
Published 6 August 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Enhance training materials to support safer identification and management of paediatric sepsis.

Verbatim wording from the response
“However as a learning system, and as a consequence of this document, NHS Pathways did amend the system, and is continuing to review the clinical content and architecture in regards to safe identification of cases of paediatric sepsis.”

Source location
2015-0313-Response-by-NHS-Pathways
Page 2 · response
Published 6 August 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue reviewing clinical content and system architecture for safe identification of paediatric sepsis.

Verbatim wording from the response
“However as a learning system, and as a consequence of this document, NHS Pathways did amend the system, and is continuing to review the clinical content and architecture in regards to safe identification of cases of paediatric sepsis.”

Source location
2015-0313-Response-by-NHS-Pathways
Page 2 · response
Published 6 August 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for the NHS Pathways system rests with HSCIC, which has provided the relevant response.

Verbatim wording from the response
“The Health and Social Care Information Centre (HSCIC) is the national provider of information, data and IT systems for commissioners, analysts and clinicians in health and social care. HSCIC is an executive non-departmental public body and is responsible for the NHS Pathways system. NHS Pathways has provided a response which I am enclosing.”

Source location
2015-0313-Response-by-Department-of-Health
Page 2 · response
Published 6 August 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
There are no grounds or sufficient evidence that the toddler and child pathways fail to identify very sick children.

Verbatim wording from the response
“1. NHS Pathways toddler/child pathways are not necessarily highlighting/picking up very sick children.”

Source location
2015-0313-Response-by-NHS-Pathways
Page 3 · response
Published 6 August 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of NHS Pathways toddler/child pathways to identify very sick children

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 3

Respondent positions 2