Recurring concern

Unreliable NHS 111 clinical triage algorithms and systems

First to latest report 6 Aug 2015 — 17 Jun 2026

Reports that mention this concern
21
Times this concern has been raised
30
Stated actions linked to this concern
40

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.

What is 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 and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Buckinghamshire

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026