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
Distinct published reports
Individual concerns
30
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
40
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.
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
Executive non-departmental public body15
Sub-organisation9
NHS trust8
Ministerial department4
Health and social care service regulator3
Health professional body3
Registered charity2
Type not available2
Community interest company1
Company1
Healthcare site1
Health professional committee1
Health-sector membership body1
Independent healthcare provider1
National policing body1
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.
Inner North London
Concerns raised2
Failure to ask post-discharge surgery patients about surgical-team discharge, worsening or red-flag advice
Lack of an appropriate dedicated neurosurgery pathway for elective, non-trauma surgery
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
Review predetermined-management-plan training to clarify how call handlers identify relevant post-operative advice and escalate complex cases.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A specific neurosurgery pathway or key point is unnecessary because symptom-based triage and predetermined management plans address relevant risks.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
A dedicated post-discharge advice question is unnecessary because predetermined management plans and existing surgical-procedure questions address relevant callers.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A separate sepsis algorithm pathway is unnecessary because sepsis screening is embedded across multiple symptom-based NHS Pathways.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Riding and Hull
Concerns raised1
Insufficient questioning to identify uncontrolled bleeding
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
NHS Pathways does identify serious and uncontrolled bleeding through questions about blood loss, bleeding characteristics and soaked dressings.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing NHS Pathways triage arrangements are considered sufficient because identified uncontrolled bleeding produces the same Category 2 ambulance outcome as the other system.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Riding and Hull
Concerns raised1
Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck
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.
Coventry
Concerns raised1
Failure of NHS Pathways triage wording to be readily understood by callers in distress
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.
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
Review ambulance triage outcome mapping and evidence, recommending changes to triage questions for implementation across providers.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.
Action
Update NHS Pathways wording and supporting information to improve recognition of clinical shock across different skin tones.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Add and maintain mandatory training on recognising skin-colour changes and using probing questions for patients with different skin colours.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NHS England will address the report’s other concerns in a separate response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Nationally approved triage systems, clinical support, oversight and regular script review provide the framework for consistent, safe 999 call handling.
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
NHS Pathways and ambulance-service concerns fall outside the Royal College of General Practitioners’ remit.
Stated by Royal College of General PractitionersOutside remitThe respondent said that this matter was outside its role or authority.
Coventry
Concerns raised1
Failure of NHS Pathways triage wording to be readily understood by callers in distress
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.
Devon, Plymouth and Torbay
Concerns raised2
Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
Failure of NHS Pathways to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition
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
Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Continue refining and aligning the MPDS and NHS Pathways triage systems.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Action
Continue monitoring triage categorisation and strengthening clinical oversight.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Lancashire and Blackburn with Darwen
Concerns raised1
Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises
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
Implement a national urgent clinical review process for suicide-related Category 3 calls, supported by dedicated NHS Pathways disposition coding.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Publish and reissue national operational guidance for assessing lethality and toxicity in overdose and suicidal ideation calls.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Provide substantial training information on assessing patients with mental health conditions.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Keep NHS Pathways clinical content under review as new evidence or guidance emerges.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England is not considering further NHS Pathways system changes because national reviews, discussions and mandated changes have already addressed suicide-risk management.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The NHS Pathways triage system elicited the correct information and triggered the nationally approved ambulance response in this case.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex, Brighton and Hove
Concerns raised1
Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions
This report raised 2 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.4
Action
Apply overdose safeguards including timely clinical review, automatic escalation when delayed, TOXBASE consultation, and assessment of ongoing suicidal ideation.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 November 2024.
Action
Develop an ambulance-service workstream exploring artificial intelligence to identify rare or uniquely risky 999 calls and support earlier clinical attention.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2024.
Action
Publish a national operational procedure requiring clinical oversight and timely escalation for Category 3 overdose and suicidal-ideation calls.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 November 2024.
Action
Update overdose guidance to include Category 5 dispositions and require urgent remote clinical assessment pending appropriate ambulance response.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing overdose procedures provide additional clinical review, TOXBASE assessment and automatic escalation, supporting Category 3 ambulance dispositions.
Stated by South East Coast Ambulance Service NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Central and South East Kent
Concerns raised1
Failure of NHS Pathways triage to take account of callers with learning disabilities
This report raised 2 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.2
Action
Train health advisors and clinicians to engage appropriately with people with learning disabilities.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Monitor NHS Pathways staff competency against the competency framework.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing NHS Pathways training, competency monitoring and adaptive triage, including clinician takeover, are considered sufficient for callers with learning disabilities.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
