17 Jun 2026 Muluembet (“Mulu”) Yohanes · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to ask post-discharge surgery patients about surgical-team discharge, worsening or red-flag advice View source Lack of an appropriate dedicated neurosurgery pathway for elective, non-trauma surgery View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Review predetermined-management-plan training to clarify how call handlers identify relevant post-operative advice and escalate complex cases.
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AI-generated summary
Muluembet (“Mulu”) Yohanes · 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
Muluembet Yohanes underwent surgery to remove a pituitary tumour and was discharged with advice that repeated vomiting required immediate medical attention. After developing vomiting, NHS 111 and Clinical Assessment Service calls resulted in home management advice, and she later suffered a seizure and cardiac arrest due to severe hyponatraemia before dying from hypoxic brain injury. The principal concerns were the absence of a dedicated neurosurgery pathway and the failure to ask about post-surgical discharge or red-flag advice during the calls.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ask post-discharge surgery patients about surgical-team discharge, worsening or red-flag advice
Wider context from the report “3. Pathways does not include a question for post-discharge surgery patients about whether they have been given discharge, worsening or red flag advice by their surgical team .
” Source location Muluembet (“Mulu”) Yohanes · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an appropriate dedicated neurosurgery pathway for elective, non-trauma surgery
Wider context from the report “2. I am concerned that without a dedicated pathway for “neurosurgery”, it is left to call handlers to choose the most appropriate pathway . To me, “head injury” is not reflective of elective, non-trauma surgery .
” Source location Muluembet (“Mulu”) Yohanes · Prevention of Future Deaths report
Open source report
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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 Review predetermined-management-plan training to clarify how call handlers identify relevant post-operative advice and escalate complex cases.
Verbatim wording from the response “Instead, to address risks that may arise from such situations, and to cover the issue as in this case, where a patient has had recent treatment or been given specific advice in advance, NHS Pathways also has a clear route for callers who have what is referred to as ‘Predetermined management plans.’ All health advisors must complete training associated with this within their mandatory core module training. This includes scenarios of when this route applies including: ‘Recent hospital discharge; Medical devices fitted e.g. pacemaker; chronic, terminal, rare or serious illnesses; Patient with other special needs’.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A specific neurosurgery pathway or key point is unnecessary because symptom-based triage and predetermined management plans address relevant risks.
Verbatim wording from the response “However, a specific situation such as previous neurosurgery would not generally be added as a key point, and so the NHS Pathways team do not consider that this specific change should be made. The triage system uses a symptom-based approach rather than having separate specific routes for every possible medical procedure or medical condition, as it would not be practical or possible to add a question on every single possible scenario. This means that within the triage assessment different questions will be presented to establish symptoms of concern, and as noted above, serious and potentially life-threatening symptoms are assessed first to ensure rapid escalation, such as reaching an ambulance outcome or involving a clinician. The assessment then progresses to less urgent symptoms to identify the most appropriate level of care. The tool is not diagnostic.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A dedicated post-discharge advice question is unnecessary because predetermined management plans and existing surgical-procedure questions address relevant callers.
Verbatim wording from the response “The ‘Predetermined management plans’ route described above does provide a route for those who have been given specific post-operative advice or a plan in the event of certain criteria. In view of this case, this route and the associated training is also being re-examined to ensure that it is considered by call handlers in cases where a caller does not specifically mention their recent surgery, or in case the potential relevance of this is not obvious, to ensure that the call is identified as complex and passed to a clinician for review.” Source location Response from NHS England
Open published response
11 May 2026 Oliver Charles Major Shelley · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Oliver Charles Major Shelley · 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
Oliver Charles Major Shelley became seriously unwell on 22 July 2024 with symptoms including a non-blanching rash, vomiting and reduced consciousness. After no ambulance was dispatched, his parents took him to hospital, where he was treated for meningococcal septicaemia but died approximately 7.5 hours after arrival. The report identified concerns about the lack of a sepsis algorithm for emergency medical advisors and the training and description of those advisors’ role.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
Wider context from the report “1. The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls
At 14:51 hours on 22nd July 2024, Oliver’s parents called 999 indicating their concern that Oliver was suffering from meningitis as he was suffering from a non-blanching rash, vomiting and reduced level of consciousness. The EMA began a triage using NHS Pathways algorithm but as they were unable to prioritise any of the listed symptoms, they requested operational support at 14:57 hours, to ask if there was a meningitis pathway within the system. This call was concluded at 15:51 with the EMA indicating to Oliver’s parents that a call back was scheduled within 20 minutes.
A call back was not undertaken until 1 hr and 41 minutes later and in the absence of a response a further unsuccessful call was made 2 hrs and 18 minutes later before Secamb closed the referral. In the meantime, Oliver’s parents made the decision to convey Oliver to hospital arriving there at around 15:55 hours. On attendance it was recognised that Oliver was gravely unwell and despite maximal supportive management sadly died from overwhelming meningococcal septicaemia 7.5 hours after his arrival.
In their investigation, Secamb acknowledged that the EMA’s management of the 999 call was not compliant and have taken the opportunity to offer ongoing training. However, it was also recognised EMA’s found it challenging to triage individuals when multiple signs and symptoms were present in relation to a possible sepsis diagnosis and that having a dedicated sepsis algorithm would assist them in being able to provide an appropriate response to callers and to ensure appropriate management . This has important implications for prioritising ambulance disposition, which may also include the ability of a paramedic to attend at the earliest opportunity to give antibiotics.
” Source location Oliver Charles Major Shelley · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A separate sepsis algorithm pathway is unnecessary because sepsis screening is embedded across multiple symptom-based NHS Pathways.
Verbatim wording from the response “It is noted that the health advisor sought advice from a Senior Non-Clinician as they wanted to know if there was a specific Pathway for meningitis before then passing the case to the clinical queue for inability to prioritise a main symptom. It is important to highlight that as NHS Pathways is a non-diagnostic clinical assessment tool 'Meningitis' (or any other condition) would not present as a pathway option, however, questions regarding septicaemia and meningitis are covered in a variety of symptom-based pathways and when answered positively result in an ambulance dispatch. In essence, rather than one ‘sepsis algorithm’ pathway, NHS Pathways has embedded a ‘sepsis’ algorithm into a wide range of symptom-based pathways where sepsis could” Source location Response from NHS England
Open published response
30 Apr 2026 Dr Kenneth Wilson CULLY · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Insufficient questioning to identify uncontrolled bleeding View source
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Dr Kenneth Wilson CULLY · 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
Dr Kenneth Wilson CULLY died after a catastrophic, uncontrollable bleed from the foot while taking blood-thinning medication. The report identified a concern that the ambulance service’s newer NHS Pathway system may lack sufficient questions to recognise the seriousness of an uncontrolled bleed, potentially leading to incorrect categorisation and delayed treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient questioning to identify uncontrolled bleeding
Wider context from the report “In the new NHS Pathway system there appeared to be an insufficiency in the questions to correctly identify the seriousness of an uncontrolled bleed (there is no question regarding whether the bleed is controlled or not ). This could lead to the categorisation of the call being incorrect and a delay in treating a catastrophic event needing immediate attention .
” Source location Dr Kenneth Wilson CULLY · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Pathways does identify serious and uncontrolled bleeding through questions about blood loss, bleeding characteristics and soaked dressings.
Verbatim wording from the response “• Immediate establishment of whether there is, or has been, any bleeding present, even if it has stopped at the time of the call;” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS Pathways triage arrangements are considered sufficient because identified uncontrolled bleeding produces the same Category 2 ambulance outcome as the other system.
Verbatim wording from the response “From the information provided regarding Dr Cully, I would wish to convey to you that the serious nature of such bleeding would have been dealt with at least as well as in the other system. And whilst the exact wording between the two systems differs, NHS Pathways does identify volumes of blood lost, nature of bleeding and picks up signs of catastrophic bleeding such as pooling or soaking through dressings, rather than asking a clinical judgement to be made by the caller as to whether bleeding is uncontrollable or dangerous. When uncontrolled bleeding is identified, as is most likely in a case presenting with the same or similar symptoms, the recommended disposition in line with up-to-date national clinical guidance is for a Category 2 ambulance for Major Blood Loss.” Source location Response from NHS England
Open published response
27 Apr 2026 Christine Joan Clegg · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Christine Joan Clegg · 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
Christine Joan Clegg died at Hull Royal Infirmary after an unwitnessed fall at her care home, in which she sustained a traumatic brain injury and later deteriorated. The report raises concern that inaccurate information given to NHS 111 led to a minor-wounds pathway being followed instead of the head-injury pathway, resulting in basic first-aid advice without clinical input. It also concerns the availability of the minor-wounds script for injuries above the neck, which may lead to a non-clinical outcome for head injuries.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck
Wider context from the report “(1) The NHS 111 script for scratches grazes or minor wounds is available for head injuries but can lead to a non clinical outcome and basic first aid advice being given. The fact is, however, either a scratch, graze or nick above the neck indicates that either has been a head injury of some degree or other and so the script which should correctly be followed is the head injury pathway. If injuries above the neck were excluded from the scratches grazes and nicks pathway then the possibility of basic first aid advice being given is eliminated as all head injury answered result in clinician advice being sought.
” Source location Christine Joan Clegg · Prevention of Future Deaths report
Open source report
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1
Failure of NHS Pathways triage wording to be readily understood by callers in distress View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.
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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 triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” Source location Roman Louie BARR · Prevention of Future Deaths report
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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 Review ambulance triage outcome mapping and evidence, recommending changes to triage questions for implementation across providers.
Verbatim wording from the response “Within NHS England, the mapping of triage outcomes to response categories is undertaken and reviewed regularly by an expert group which makes recommendations to the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) for implementation across all NHS ambulance service providers.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update NHS Pathways wording and supporting information to improve recognition of clinical shock across different skin tones.
Verbatim wording from the response “The question of concern “is the patient a deathly colour”, is the question used to identify symptoms of clinical shock within the CDSS. It has been been utilised in triage prior to 2005. Questions within the system often have supporting information that helps the health advisor probe when necessary, as this one does. All supporting information utilises common style and design but, as with all content, can be subject to iterative review based upon feedback from providers. For example, if a provider identifies a question that health advisors are finding difficult to answer then they can raise this as a clinical enquiry to NHS Pathways for review.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add and maintain mandatory training on recognising skin-colour changes and using probing questions for patients with different skin colours.
Verbatim wording from the response “In September 2021, a unit was added to NHS Pathways Core Module 1 mandatory training materials to give health advisors and clinicians more detailed guidance on identifying skin colour changes in patients with different skin colours. This training includes guidance on how to use the existing supporting information to form probing questions to help the caller understand what is being asked, and where on the body to best check for any change in skin colour. The module includes an interactive PowerPoint session explaining the challenges faced by those of non-white skin colours, as well as practice case studies and scenarios to help put this information into practice. It has formed a part of NHS Pathways Core Module 1 training since it’s initial inclusion in 2021.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will address the report’s other concerns in a separate response.
Verbatim wording from the response “The report raises concerns over the continued pressure caused by prolonged ambulance handover times at local hospitals which reduced emergency capacity to respond in the community, risk of patient’s family transporting Roman to hospital themselves and clarity of NHS Pathways triage wording. NHS England will reply separately on other concerns in your report.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nationally approved triage systems, clinical support, oversight and regular script review provide the framework for consistent, safe 999 call handling.
Verbatim wording from the response “NHS Ambulance Services in England must process 999 calls through a nationally approved clinical triage system. NHS England currently approves two systems in England for primary 999 assessments: NHS Pathways and Medical Priority Dispatch System (MPDS). This ensures that there is a degree of consistency and standardisation in 999 call handling.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Pathways and ambulance-service concerns fall outside the Royal College of General Practitioners’ remit.
Verbatim wording from the response “Suggestions for concerns regarding the NHS Pathways and Ambulance services are beyond the remit of the Royal College of General Practitioners.” Source location Response from Royal College for GP's
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4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1
Failure of NHS Pathways triage wording to be readily understood by callers in distress View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
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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 triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” Source location Roman Louie BARR · Prevention of Future Deaths report
Open source report
Concerns raised 2
Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways View source Failure of NHS Pathways to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
View source
NHS England
Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
View source
NHS England
Continue refining and aligning the MPDS and NHS Pathways triage systems.
View source
NHS England
Continue monitoring triage categorisation and strengthening clinical oversight.
View source See 1 more action
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Theo Gordon Tuikubulau · 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
Theo Gordon Tuikubulau, a three-year-old boy, died on 8 July 2022 from sepsis arising from an invasive Group A streptococcal infection. The report identified variation between the MPDS and NHS Pathways triage systems in assessing respiratory distress and cyanosis in children under five, resulting in different ambulance response categories for similar symptoms. The report stated that this two-tiered system continued to exist while work to review and align the systems had not yet occurred.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
Wider context from the report “The difference in assessment and triage of calls under these two systems appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally). It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to prevent future deaths was engaged in this case. However, I was conscious that I did not hear evidence directly from those responsible for the NHS Pathways or MPDS systems during the inquest.
I therefore requested further information from both of the organisations responsible for NHS Pathways and MPDS about why there appears to be a two tier system in Devon (and potentially nationally) which would result in a different ambulance categorisation (category 1 under MPDS and category 2 under NHS Pathways) when a caller describes breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both, for further information about what is being done to address those differences in call assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls triaged via the MPDS system and confirmed that these calls had been properly assigned a category 1 response time. They were unable to comment on the calls triaged by NHS Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED)… NHS England does not manage or oversee the MPDS and we are therefore unable to provide comment on their system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is developed and maintained by the Transformation Directorate at NHS England, and is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and acuity (severity and urgency of the symptoms/condition) of the patient based on the identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest pain). If, during the call, the patient’s condition changed (either improves or worsens), then there is an exception that the call handler will re-triage with the new information which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC) Teams, it is clear that there is variation between the two triage systems with regards to respiratory distress in children under 5 , specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS triage. However, the presence of cyanosis is not interrogated within NHS Pathways and as such this symptom/sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways, instead resulting in the generation of a Respiratory Distress disposition that is mapped to a Category 2 response."
I was advised within the letter that NHS England will work with the clinical coding groups and NHS Pathways to review this to ensure that the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate, for which I am grateful. However, as this has not yet occurred and the two tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter.
” Source location Theo Gordon Tuikubulau · Prevention of Future Deaths report
Open source report × 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 to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition
Wider context from the report “The difference in assessment and triage of calls under these two systems appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally). It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to prevent future deaths was engaged in this case. However, I was conscious that I did not hear evidence directly from those responsible for the NHS Pathways or MPDS systems during the inquest.
I therefore requested further information from both of the organisations responsible for NHS Pathways and MPDS about why there appears to be a two tier system in Devon (and potentially nationally) which would result in a different ambulance categorisation (category 1 under MPDS and category 2 under NHS Pathways) when a caller describes breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both, for further information about what is being done to address those differences in call assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls triaged via the MPDS system and confirmed that these calls had been properly assigned a category 1 response time. They were unable to comment on the calls triaged by NHS Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED)… NHS England does not manage or oversee the MPDS and we are therefore unable to provide comment on their system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is developed and maintained by the Transformation Directorate at NHS England, and is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and acuity (severity and urgency of the symptoms/condition) of the patient based on the identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest pain). If, during the call, the patient’s condition changed (either improves or worsens), then there is an exception that the call handler will re-triage with the new information which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC) Teams, it is clear that there is variation between the two triage systems with regards to respiratory distress in children under 5, specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS triage. However, the presence of cyanosis is not interrogated within NHS Pathways and as such this symptom/sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways , instead resulting in the generation of a Respiratory Distress disposition that is mapped to a Category 2 response. "
I was advised within the letter that NHS England will work with the clinical coding groups and NHS Pathways to review this to ensure that the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate, for which I am grateful. However, as this has not yet occurred and the two tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter.
” Source location Theo Gordon Tuikubulau · Prevention of Future Deaths report
Open source report
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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 Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Verbatim wording from the response “Your Report raises the concern that the triage and categorisation of ineffective breathing and respiratory distress is still not consistent across the two triage systems; NHS Pathways and the Medical Priority Dispatch System (MPDS). NHS England had informed you that a review would be undertaken of this, to ensure that the two triage systems are consistent and remain clinically appropriate. As you have not been informed that the review has occurred, this remains a concern.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
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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 refining and aligning the MPDS and NHS Pathways triage systems.
Verbatim wording from the response “NHS England welcomes the feedback from HM Coroner and will continue to refine and align both systems, monitor categorisation, and strengthen clinical oversight. I hope that this further response sufficiently addresses the outstanding concern raised within your Report.” Source location Response from NHS England
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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 monitoring triage categorisation and strengthening clinical oversight.
Verbatim wording from the response “There has been a significant increase in clinical support within 999 Emergency Operations Centres, providing enhanced oversight for patients who may not initially receive a Category 1 triage outcome, but who may benefit from clinical reassessment and potential ambulance re-categorisation. This includes patients at the extremes of age and those presenting with symptoms such as severe breathing difficulty.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Verbatim wording from the response “The information above confirms that another child presenting as Theo did would result in a category 1 response being reached, when triaged appropriately using either MPDS or NHS Pathways.” Source location Response from NHS England (2)
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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 The two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
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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 No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
Concerns raised 1
Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Implement a national urgent clinical review process for suicide-related Category 3 calls, supported by dedicated NHS Pathways disposition coding.
View source
NHS England
Publish and reissue national operational guidance for assessing lethality and toxicity in overdose and suicidal ideation calls.
View source
NHS England
Provide substantial training information on assessing patients with mental health conditions.
View source
NHS England
Keep NHS Pathways clinical content under review as new evidence or guidance emerges.
View source See 1 more action
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AI-generated summary
James Paul Michael Masheter · 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
James Paul Michael Masheter died by hanging at his home on 1 April 2024, after experiencing a significant mental health crisis and making calls for ambulance assistance. The report raises concerns that existing NHS Pathways mental health triage may not properly risk-assess serious crises involving a risk to life, and that categorisation as category 3 contributed to significant delays in ambulance attendance. Incorrect information about the expected waiting time was also provided to his friend, who believed the ambulance was arriving imminently and left him.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises
Wider context from the report “1. The NHS Pathways system is used for triage. This asks standard questions to ascertain the seriousness of the situation including whether the patient is awake and breathing and so on. The triage pathway includes some options for mental health situations but these are limited. Evidence was heard in the inquest that the North West Ambulance Service (NWAS) had liaised with NHS Pathways with a view to exploring how mental health calls are triaged. NHS Pathways declined to make any changes to mental health triage but offered advice to NWAS in how to triage mental health situations.
2. The evidence heard at the inquest was that notwithstanding the seriousness of the situation in which Mr Masheter presented, his appropriate categorisation was category 3. This led to significant delays in an ambulance attending. It is not clear to me whether it is possible for serious mental health crisis situations which present a risk to life are capable of being properly risk assessed on the basis of the NHS Pathways mental health triage which exists at present.
” Source location James Paul Michael Masheter · Prevention of Future Deaths report
Open source report
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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 Implement a national urgent clinical review process for suicide-related Category 3 calls, supported by dedicated NHS Pathways disposition coding.
Verbatim wording from the response “NHS England has led a number of national discussions regarding the management of suicidal calls. The NHS Pathways system has been adjusted to accommodate changes and the introduction of a national process. In this process, ambulance and NHS 111 providers facilitate an urgent clinical review for cases flagged as ‘Risk of Suicide’, which is further described below. These changes acknowledge that risks relating to suicidal intent are complex and may be multifactorial. Although non-clinical health advisers receive significant, structured training to use the NHS Pathways system, this system is organised to triage cases for further clinical input or assessment in most cases.” Source location Response from NHS England
Open published response
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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 Publish and reissue national operational guidance for assessing lethality and toxicity in overdose and suicidal ideation calls.
Verbatim wording from the response “In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled ‘Category 3/999 Overdose and Suicidal Ideation Calls: Initial Assessment of Lethality/Toxicity Principles Document’. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes to ensure suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above.” Source location Response from NHS England
Open published response
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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 Provide substantial training information on assessing patients with mental health conditions.
Verbatim wording from the response “NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions and has offered to advise North West Ambulance Service (NWAS) on how to triage mental health situations. Regional clinical quality colleagues for the North West have also been made aware of your Report for the appropriate assurance purposes.” Source location Response from NHS England
Open published response
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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 Keep NHS Pathways clinical content under review as new evidence or guidance emerges.
Verbatim wording from the response “Given the significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content) this will remain under review as and when new evidence or guidance emerges.” Source location Response from NHS England
Open published response
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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 NHS England is not considering further NHS Pathways system changes because national reviews, discussions and mandated changes have already addressed suicide-risk management.
Verbatim wording from the response “Given the significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content) this will remain under review as and when new evidence or guidance emerges.” Source location Response from NHS England
Open published response
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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 The NHS Pathways triage system elicited the correct information and triggered the nationally approved ambulance response in this case.
Verbatim wording from the response “In this particular case, it appears from the Report that the NHS Pathways triage system did elicit the correct information which triggered the correct nationally approved ambulance response.” Source location Response from NHS England
Open published response
Concerns raised 1
Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England South East Coast Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
South East Coast Ambulance Service NHS Foundation Trust
Apply overdose safeguards including timely clinical review, automatic escalation when delayed, TOXBASE consultation, and assessment of ongoing suicidal ideation.
View source
South East Coast Ambulance Service NHS Foundation Trust
Develop an ambulance-service workstream exploring artificial intelligence to identify rare or uniquely risky 999 calls and support earlier clinical attention.
View source
NHS England
Publish a national operational procedure requiring clinical oversight and timely escalation for Category 3 overdose and suicidal-ideation calls.
View source
NHS England
Update overdose guidance to include Category 5 dispositions and require urgent remote clinical assessment pending appropriate ambulance response.
View source See 1 more action
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AI-generated summary
Joel Phillip COLK · 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
Joel Phillip Colk called 999 after ingesting at least 50g of a substance and was attended by an ambulance after the call was upgraded from category 3 to category 2. He was in cardiac arrest on attendance and died at home on 2 October 2023. The concerns include that NHS Pathways did not differentiate overdoses by substance, amount, timing or patient weight, and did not reflect the time-sensitive treatment required for this ingestion; ambulances also did not carry the antidote in the area described.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category. The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose. The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight. The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3 .
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” Source location Joel Phillip COLK · Prevention of Future Deaths report
Open source report
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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 Apply overdose safeguards including timely clinical review, automatic escalation when delayed, TOXBASE consultation, and assessment of ongoing suicidal ideation.
Verbatim wording from the response “When an absence of immediately life-threatening symptoms such as the above is being presented in intentional overdose, the lowest ambulance disposition that can be reached is a Category 3 emergency ambulance outcome. However this Category 3 outcome is supported by additional measures specific to overdose that have been in place within SECAmb since July 2019 and further amendments to local procedures following the publication of a operational guidance by NHS England and the Association of Ambulance Chief Executives (AACE) entitled, “Category 3 – 999 Overdoses and Suicidal Ideation Calls; Initial Assessment of Lethality / Toxicity Principles Document” in April 2021, subsequently being further updated in November 2023.” Source location Response from SECAmb
Open published response
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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 Develop an ambulance-service workstream exploring artificial intelligence to identify rare or uniquely risky 999 calls and support earlier clinical attention.
Verbatim wording from the response “As a Trust, we would like to use this case alongside others to support a workstream in early development that we are undertaking, regarding the potential for the use of new and emerging technologies, such as Artificial Intelligence to ‘ambiently listen’ to 999 calls. The aim is to enhance patient safety and reduce human cognitive burden, potentially highlighting certain calls to clinicians that have rare or unique risks earlier. We are in the early stages of understanding this technology and undertaking this work alongside four other NHS Ambulance Trusts as part of the Southern Ambulance Collaborative, and although we envisage if successful this having wider benefits to a range of presentations that 999 ambulance calls present, we have included ████████ overdose as an example within the proposed case for change.” Source location Response from SECAmb
Open published response
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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 Publish a national operational procedure requiring clinical oversight and timely escalation for Category 3 overdose and suicidal-ideation calls.
Verbatim wording from the response “In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled, “Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document”. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes, to ensure suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above. The guidance highlights the critical importance of clinical oversight and review (rather than, for example, a re-categorisation of calls to Category 1 on a case-by-case basis) and sets out that:” Source location Response from NHS England
Open published response
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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 Update overdose guidance to include Category 5 dispositions and require urgent remote clinical assessment pending appropriate ambulance response.
Verbatim wording from the response “Most recently, the overdose guidance was updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). This followed a review by ECPAG, NHS England and NASMeD, part of the AACE, to ensure it remained clinically fit for purpose. For those cases which do not automatically result in a Category 1 or 2 emergency ambulance response, an urgent remote clinical assessment will take place, pending which the case will be dealt with as a Category 3 emergency ambulance response. The objective of further remote clinical assessment” Source location Response from NHS England
Open published response
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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 Existing overdose procedures provide additional clinical review, TOXBASE assessment and automatic escalation, supporting Category 3 ambulance dispositions.
Verbatim wording from the response “When an absence of immediately life-threatening symptoms such as the above is being presented in intentional overdose, the lowest ambulance disposition that can be reached is a Category 3 emergency ambulance outcome. However this Category 3 outcome is supported by additional measures specific to overdose that have been in place within SECAmb since July 2019 and further amendments to local procedures following the publication of a operational guidance by NHS England and the Association of Ambulance Chief Executives (AACE) entitled, “Category 3 – 999 Overdoses and Suicidal Ideation Calls; Initial Assessment of Lethality / Toxicity Principles Document” in April 2021, subsequently being further updated in November 2023.” Source location Response from SECAmb
Open published response
Concerns raised 1
Failure of NHS Pathways triage to take account of callers with learning disabilities View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Daniel Robert Ludlam · 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
Daniel Robert Ludlam died at the scene on 30 December 2019 after an obstructed hiatus hernia caused gastrointestinal haemorrhage and hypovolemic shock. Concerns included that NHS Pathways triage did not specifically account for callers with learning disabilities, and that the absence of a suitable procedure could lead to incorrect triage or delays in sending paramedic support, particularly where no carer was available to assist communication.
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× 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 triage to take account of callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability . Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew.
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” Source location Daniel Robert Ludlam · Prevention of Future Deaths report
Open source report
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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 Train health advisors and clinicians to engage appropriately with people with learning disabilities.
Verbatim wording from the response “With reference to your first concern around the system not taking into specific account of patients who have not been able to understand the questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis.” Source location Response from Department of Health and Social Care
Open published response
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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 Monitor NHS Pathways staff competency against the competency framework.
Verbatim wording from the response “With reference to your first concern around the system not taking into specific account of patients who have not been able to understand the questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis.” Source location Response from Department of Health and Social Care
Open published response
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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 Existing NHS Pathways training, competency monitoring and adaptive triage, including clinician takeover, are considered sufficient for callers with learning disabilities.
Verbatim wording from the response “With reference to your first concern around the system not taking into specific account of patients who have not been able to understand the questions asked, I would like to assure you that all health advisors and clinicians are trained on engaging with people with learning disabilities and this forms part of core training. NHS Pathways staff are monitored against the competency framework so staff competency is checked on an ongoing basis.” Source location Response from Department of Health and Social Care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.