Recurring concern

Unreliable NHS 111 clinical triage algorithms and systems

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First reported 6 Aug 2015•Latest report 17 Jun 2026

Definition

What this concern includes

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

Not included

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

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

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England15

NHS Pathways9

South East Coast Ambulance Service NHS Foundation Trust6

Department of Health and Social Care4

Care Quality Commission3

Royal College of General Practitioners3

Asthma + Lung UK2

Appello Limited1

Association of Ambulance Chief Executives1

College of Policing1

DHU 111 (East Midlands) CIC1

Family of Alexander Davidson1

Integrated Care 241

Joint Royal Colleges Ambulance Liaison Committee1

Mitie1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

1 Jun2022
Hull and East Riding of Yorkshire
Concerns raised2
1. Failure to consider the timing of requests for advice in 111 dispositions
2. Failure to accommodate prior direct general practitioner review in 111 dispositions
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 4
1. Position
  NHS Digital develops and manages NHS 111 algorithms, so responsibility for their modification rests with NHS Digital.
  Stated by Royal College of Paediatrics and Child HealthRedirects responsibility
1. Position
  Dispositions should not be varied solely by time of day; assessing interference with usual activities is considered the safer objective approach.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  Investment to enable primary-care and out-of-hours record sharing would require action by NHS England, NHS Improvement and the Department of Health and Social Care.
  Stated by Royal College of General PractitionersRedirects responsibility
3. Position
  Automatic clinician transfer after prior healthcare review is not considered appropriate because it could delay assessment and compromise patient safety.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Esma GUZEL · 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

Esma Guzel, aged five, died on 10 May 2019 after developing vomiting and abdominal pain due to complications of a congenital diaphragmatic hernia. After a GP assessment and subsequent deterioration, the 111 service advised attendance at an out-of-hours GP service, where she arrived in cardiac arrest and could not be resuscitated. The principal concerns relate to questioning about vomitus, the 111 algorithm’s assessment and disposition, and referral to paediatric services.

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 to consider the timing of requests for advice in 111 dispositions
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Source location
Esma GUZEL · Prevention of Future Deaths report
Page 2 · concerns
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 to accommodate prior direct general practitioner review in 111 dispositions
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Source location
Esma GUZEL · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 Digital develops and manages NHS 111 algorithms, so responsibility for their modification rests with NHS Digital.

Verbatim wording from the response
“It was useful to hear about the change to the 111 algorithms as a result of learning from the circumstances surrounding Esma’s passing. The pathways used to inform 111 are currently developed and managed by NHS Digital to the NHS in England and to individual users, including but not limited to NHS Pathways and 111online.nhs.uk. The RCPCH are not required to and do not endorse these pathways but paediatricians represent the RCPCH to provide clinical advice and expertise to inform their shaping and to provide clinical expertise on ad hoc queries and patient safety concerns.”

Source location
Response from Royal College of Paediatrics and Child Health
Page 3 · response
Published 29 September 2022
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
Dispositions should not be varied solely by time of day; assessing interference with usual activities is considered the safer objective approach.

Verbatim wording from the response
“NHS Pathways is a comprehensive decision support system, which assesses symptoms presented at the time of a call and signposts to next level of care. Therefore, assessment of time of day is not routinely considered as it would not be clinically safe to change level of care signposted to be based upon time of day as a discriminator alone. However, the functional impairment question identifies when the presenting problem is interfering with normal daily activities and that would include sleeping. This is an assessment against the patient’s ‘usual activities’ so takes account of different patients having different baselines. In addition, NHS Pathways must consider differing daily routines encountered and ‘usual activities’ at different times of day may differ from person to person.”

Source location
Response from NHS Digital
Page 4 · response
Published 29 September 2022
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
Investment to enable primary-care and out-of-hours record sharing would require action by NHS England, NHS Improvement and the Department of Health and Social Care.

Verbatim wording from the response
“Sharing of data/ clinical notes between primary care and the out-of-hours service There are some out-of-hours services who are able to see the whole GP record. It does not appear in this case it was possible from the Regulation 28 report. If both the out-of-hours service and the GP surgery use the same electronic notes system it is possible, with patient consent, to share all of the GP record. However, in many areas, the GP record is not visible to the out-of-hours service as both use different digital platforms. The RCGP would welcome investment in primary care (both GP and out-of-hours services) infrastructure, to enable best practice of sharing of all notes, subject to patient consent, to be rolled out across the NHS to benefit patient care. However, we recognise this will require significant investment form NHS England and NHS Improvement and the Department of Health and Social Care.”

Source location
Response from Royal College General Practitioners
Page 2 · response
Published 29 September 2022
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
Automatic clinician transfer after prior healthcare review is not considered appropriate because it could delay assessment and compromise patient safety.

Verbatim wording from the response
“NHS Pathways assesses symptoms at the time of the call. If all patients who had a previous encounter with a healthcare provider were automatically transferred to a clinician this would prevent the initial NHS Pathways assessment occurring which has the potential to prevent a timely generation of an urgent disposition such as an ambulance dispatch. It is also not possible to interrogate previous encounters as part of the NHS Pathways assessment such to only transfer some to a clinician, as this would require reliance on caller’s recollection and knowledge, and health advisors to use discretion, neither of which is clinically safe or appropriate for telephone triage by non-clinical staff.”

Source location
Response from NHS Digital
Page 3 · response
Published 29 September 2022
Open published response
7 Mar2022
Surrey
Concerns raised1
1. NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
This report raised 13 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 1
1. Action
  Incorporate feedback about fluctuating consciousness into the ongoing NHS Pathways review and governance cycle.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  Existing training and triage functions adequately address changing or fluctuating consciousness during calls.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Josephine Celia BARKER · 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

Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.

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
NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
Wider context from the report
“8. There is a concern over the NHS Pathways tool’s ability to deal with fluctuating consciousness. This is because there is only an assessment on conscious or on unconscious so moving between the two states triggers the call handler to move into the conscious or unconscious pathway respectively but is not able to take into account fully that consciousness level is impaired or mixed. This is considered as a huge challenge to any call handler even a clinician as it then is not established if the patient is conscious or unconscious and it forces the call handler to restart triage with each change. I was told that this can ”
Source location
Josephine Celia BARKER · Prevention of Future Deaths report
Page 8 · 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
Incorporate feedback about fluctuating consciousness into the ongoing NHS Pathways review and governance cycle.

Verbatim wording from the response
“NHS Pathways have not been advised that this principle is a challenging one for health advisors to date but will take this feedback into account in our ongoing review and governance cycle.”

Source location
Response from NHS Improvement
Page 3 · response
Published 16 March 2022
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
Existing training and triage functions adequately address changing or fluctuating consciousness during calls.

Verbatim wording from the response
“Health advisors are supported with training materials and undergo core learning. NHS Pathways provides a number of training materials which support health advisors relating to the identification of consciousness, unconsciousness or reduced consciousness. This includes a ‘Hot Topics on Levels of Consciousness and Checking Breathing and Consciousness’. Assessing consciousness is also heavily featured throughout the Pre-Module Learning for Core Module 1 (with a dedicated section on Levels of Consciousness, there is a video to support this). This material includes the following statement: “If you were presented with a patient who couldn’t be woken or was very difficult to wake (unconscious or semi-conscious), you would need to select”

Source location
Response from NHS Improvement
Page 2 · response
Published 16 March 2022
Open published response
4 Oct2021
West Sussex
Concerns raised3
1. Failure of 111 call handlers to correctly complete the algorithm
2. Failure to recognise complex 111 cases requiring transfer to a more senior member of the service
3. Failure of the 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Issue focused complex-case learning to all 111 call-handling staff.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
2. Action
  Add complex-call handling to core mentoring competencies for new Health Advisors and Emergency Medical Advisors.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
3. Action
  Develop training materials and lead provider sessions supporting Health Advisors to identify and manage complex calls.
  Stated by NHS EnglandStated completed
1. Action
  Include learning-disability call handling in the next quarterly core-skills training for Health Advisors and Emergency Medical Advisors.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated planned
2. Action
  Release additional learning content on learning disabilities and telephone communication within mandatory training for NHS 111 and 999 staff.
  Stated by NHS EnglandStated completed
Respondent positions 3
1. Position
  South East Coast Ambulance Service is responsible for responding to concerns about non-compliant 111 calls and escalation failures.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Existing NHS Pathways complex-call and Early Exit functions provide appropriate support for callers with learning or developmental needs.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  Responsibility for NHS Pathways accommodating patients with underlying disabilities rests with NHS Digital.
  Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibility
AI-generated summary

Hannah Elizabeth ROYLE · 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

Hannah Elizabeth ROYLE, a 16-year-old girl with severe learning disability, developed diarrhoea and vomiting before suffering a cardiorespiratory arrest on the way to hospital. She was diagnosed with a massive gastric volvulus and later sustained an irreversible hypoxic brain injury; she was declared brainstem dead on 1 July 2020. The report raised concerns about inadequate 111 triage, insufficient accommodation of disabilities, the clinical advisor’s assessment, public understanding of the service, misleading terminology, and the abdominal pain pathway.

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 111 call handlers to correctly complete the algorithm
Wider context from the report
“1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case. 2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm. ”
Source location
Hannah Elizabeth ROYLE · Prevention of Future Deaths report
Page 2 · concerns
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 to recognise complex 111 cases requiring transfer to a more senior member of the service
Wider context from the report
“1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case. 2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm. ”
Source location
Hannah Elizabeth ROYLE · Prevention of Future Deaths report
Page 2 · concerns
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 the 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise
Wider context from the report
“1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case. 2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm. ”
Source location
Hannah Elizabeth ROYLE · Prevention of Future Deaths report
Page 2 · 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
Issue focused complex-case learning to all 111 call-handling staff.

Verbatim wording from the response
“Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken:”

Source location
2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
Page 1 · response
Published 13 October 2021
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
Add complex-call handling to core mentoring competencies for new Health Advisors and Emergency Medical Advisors.

Verbatim wording from the response
“3. Health Advisors and Emergency Medical Advisors have a period of mentoring following their initial training and also if any concerns are recognised during routine or requested audits. In order to pass the mentoring process, they have to demonstrate that they have passed all key competencies. This is achieved by a mentor witnessing the mentee undertake all of the required elements from within the mentoring pack to the required standard. The mentor will then sign off on the individual elements once competency is achieved. The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.”

Source location
2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
Page 2 · response
Published 13 October 2021
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
Develop training materials and lead provider sessions supporting Health Advisors to identify and manage complex calls.

Verbatim wording from the response
“A key element of healthcare delivery is recognising when one is at the limit of one’s knowledge or understanding and escalating the matter appropriately. An important safety feature within NHS Pathways is the identification of a ‘complex call’. A complex call is defined as ‘any call which isn’t straightforward and where the Health Advisers determines that they are working at or beyond the limits of their knowledge’. In addition to this broad definition of a ‘complex call’, the following situations would also be classed as ‘complex’:”

Source location
2021-0327-Response-from-NHS-Digital_Published
Page 2 · response
Published 13 October 2021
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
Include learning-disability call handling in the next quarterly core-skills training for Health Advisors and Emergency Medical Advisors.

Verbatim wording from the response
“2. Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability. A copy of the relevant part of the key skills course content is attached.”

Source location
2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
Page 2 · response
Published 13 October 2021
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
Release additional learning content on learning disabilities and telephone communication within mandatory training for NHS 111 and 999 staff.

Verbatim wording from the response
“At the time of Miss Royle’s inquest The NHS Pathways Training Team were in the process of developing additional learning content for all users of the system. This has subsequently been released and the content of this new material focuses on:”

Source location
2021-0327-Response-from-NHS-Digital_Published
Page 3 · response
Published 13 October 2021
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
South East Coast Ambulance Service is responsible for responding to concerns about non-compliant 111 calls and escalation failures.

Verbatim wording from the response
“correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case”

Source location
2021-0327-Response-from-NHS-Digital_Published
Page 2 · response
Published 13 October 2021
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
Existing NHS Pathways complex-call and Early Exit functions provide appropriate support for callers with learning or developmental needs.

Verbatim wording from the response
“As set out in my witness statement to HM Assistant Coroner dated 22 July 2021, NHS Pathways is a comprehensive decision support system, which assesses symptoms presented at the time of a call and signposts to next level of care. Therefore medical history (including disabilities) is not routinely enquired about as it could delay assessment of life-threatening symptoms, and it would not be clinically safe for non-clinical Health Advisors to assess the impact of a patient’s medical history. It would also not be safe or appropriate to apply blanket rules based on the presence of learning disabilities. However, where a certain medical history is relevant to a specific clinical problem, then NHS Pathways will present relevant questions to be asked. For example, within the chest pain pathway, the caller is asked if they have ever been diagnosed with a heart condition.”

Source location
2021-0327-Response-from-NHS-Digital_Published
Page 2 · response
Published 13 October 2021
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 NHS Pathways accommodating patients with underlying disabilities rests with NHS Digital.

Verbatim wording from the response
“It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.”

Source location
2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
Page 2 · response
Published 13 October 2021
Open published response
9 Dec2019
West Sussex
Concerns raised1
1. Early exit from NHS Pathways Module 0 for third-party calls
This report raised 7 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.
AI-generated summary

John Michael WELLS · 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

John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.

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
Early exit from NHS Pathways Module 0 for third-party calls
Wider context from the report
“(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision. From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller. ”
Source location
John Michael WELLS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
11 Jun2019
Plymouth, Torbay and South Devon
Concerns raised3
1. Lack of NHS Pathways questioning about cold hands and feet in children aged over five
2. Failure of NHS Pathways questions to allow meaningful assessment of pain in children
3. Inappropriately high NHS Pathways threshold for questioning about green vomit in children over five
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 4
1. Action
  Complete the formal evaluation of the cold-hands-and-feet question before considering extension to children aged five to sixteen.
  Stated by NHS EnglandStated in progress
2. Action
  Implement and deploy a green-vomit question for children aged five to sixteen in Release 14, with emergency-department referral when positive.
  Stated by NHS EnglandStated completed
3. Action
  Broaden green-vomit questioning and emergency-treatment-centre referral scenarios for children over five in Release 17.
  Stated by NHS EnglandStated completed
1. Action
  Analyse outcome and deployment data to evaluate the green-vomit and critical-illness changes and identify overlooked cases or further safety enhancements.
  Stated by NHS EnglandStated completed
Respondent positions 3
1. Position
  Cold hands and feet were not included for older children because evidence indicated they were an unreliable discriminator of critical illness in remote assessment.
  Stated by NHS EnglandDisputes the concern
1. Position
  Functional-capacity questions were considered the most meaningful available method for assessing children's pain remotely.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  The pathway was not deficient regarding green vomit because other critical symptoms were already assessed and the existing threshold had clinical support.
  Stated by NHS EnglandDisputes the concern
AI-generated summary

Sebastian · 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

Sebastian was a six-year-old boy who became ill on 10 October 2015 and deteriorated over the following weekend. He suffered a cardiac arrest and was confirmed deceased at Derriford Hospital on 12 October 2015. The concerns included limitations in NHS Pathways questions and support arrangements that may have hindered recognition and escalation of an acutely unwell child, as well as the absence of a failsafe mechanism for repeated enquiries about the same complaint.

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
Lack of NHS Pathways questioning about cold hands and feet in children aged over five
Wider context from the report
“Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician. Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician. ”
Source location
Sebastian · Prevention of Future Deaths report
Page 1 · concerns
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 questions to allow meaningful assessment of pain in children
Wider context from the report
“Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician. Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician. ”
Source location
Sebastian · Prevention of Future Deaths report
Page 1 · concerns
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
Inappropriately high NHS Pathways threshold for questioning about green vomit in children over five
Wider context from the report
“Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician. Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician. ”
Source location
Sebastian · 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
Complete the formal evaluation of the cold-hands-and-feet question before considering extension to children aged five to sixteen.

Verbatim wording from the response
“The question about cold hands and/or feet with the amended disposition was finalised and included in Release 14 in all illness pathways for the under 5 years age group. Widescale deployment of release 14 to all providers of NHS111 and all ambulance services in England that use the NHS Pathways system was 2nd October 2017, with services then having an 8 week period to update their staff and deploy in their systems. This question is undergoing a formal evaluation of impact for the under 5 years age group before extension to the 5-16 years age group. However, other markers to identify critical illness are included across the clinical content.”

Source location
2019-0193-Response-by-NHS-Digital
Page 4 · response
Published 23 August 2019
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
Implement and deploy a green-vomit question for children aged five to sixteen in Release 14, with emergency-department referral when positive.

Verbatim wording from the response
“Upon further consideration of this issue an additional question about the presence of green vomit in children aged 5 - 16 was implemented in Release 14. A positive response results in callers being referred to the emergency department within 1 hour. Widescale deployment of Release 14 to all providers of NHS111 and all ambulance services in England that use the NHS Pathways system was 2nd October 2017, with services then having an 8-week period to update their staff and deploy in their systems.”

Source location
2019-0193-Response-by-NHS-Digital
Page 5 · response
Published 23 August 2019
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
Broaden green-vomit questioning and emergency-treatment-centre referral scenarios for children over five in Release 17.

Verbatim wording from the response
“As referrals to the ED are much lower than expected following the inclusion of the additional questions in Releases 14 and 15, it was identified that there was an opportunity to further enhance the interrogation of green vomit to support non-clinical call handlers without over referring children to the ED and impacting on services unnecessarily.”

Source location
2019-0193-Response-by-NHS-Digital
Page 6 · response
Published 23 August 2019
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
Analyse outcome and deployment data to evaluate the green-vomit and critical-illness changes and identify overlooked cases or further safety enhancements.

Verbatim wording from the response
“Since the additional question relating to green vomit was added to the child abdominal pain pathway in Release 14, we have analysed the data available to ensure that no cases of children presenting with green vomit had been overlooked. This work identified a very low proportion of potentially critically ill children identified through an NHS Pathways triage on the basis of these changes subsequently attended the emergency department or were admitted to a hospital ward.”

Source location
2019-0193-Response-by-NHS-Digital
Page 6 · response
Published 23 August 2019
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
Cold hands and feet were not included for older children because evidence indicated they were an unreliable discriminator of critical illness in remote assessment.

Verbatim wording from the response
“Historically, a question about whether a child has cold hands and/or feet has not been included within NHS Pathways. This was a deliberate decision not to include it after consideration of the available evidence of its accuracy as a discriminator of severe illness in a remote assessment setting. According to the National Institute for Health and Care Excellence (NICE) guideline for sepsis NG51, published in July 2016, cold hands and/or feet in the context of an unwell child is a moderate to high risk factor or an ‘amber flag’ considered during diagnosis in an unwell child with possible sepsis.”

Source location
2019-0193-Response-by-NHS-Digital
Page 3 · response
Published 23 August 2019
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
Functional-capacity questions were considered the most meaningful available method for assessing children's pain remotely.

Verbatim wording from the response
“A telephone assessment of pain in any age group is challenging as pain can be binary in nature. It is acknowledged that asking how bad the pain is will likely generate a very subjective description. Therefore, the system call handlers could undertake a ‘functional capacity’ assessment by way of the question presented.”

Source location
2019-0193-Response-by-NHS-Digital
Page 9 · response
Published 23 August 2019
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
The pathway was not deficient regarding green vomit because other critical symptoms were already assessed and the existing threshold had clinical support.

Verbatim wording from the response
“The question regarding the production of green vomit was not included in the abdominal pain pathway used for the over 5 years age group at the time of Sebastian's illness.”

Source location
2019-0193-Response-by-NHS-Digital
Page 5 · response
Published 23 August 2019
Open published response
2 May2019
Nottinghamshire
Concerns raised2
1. Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
2. Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the vomiting question to address callers’ unfamiliarity with the term “coffee-grounds”.
  Stated by NHS EnglandStated completed
2. Action
  Add “soil” to the supporting information for the question about vomiting blood.
  Stated by NHS EnglandStated completed
3. Action
  Review the gastrointestinal pathways, including diarrhoea and vomiting, clinical evidence on haematemesis, and whether user research could improve triage questions.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  Communication training, monthly audits, adaptable questioning and clinician transfer routes provide sufficient support for young or vulnerable callers.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  The coffee-ground description is clinically specific and supported by explanatory text; removing it could cause inappropriate over-referral.
  Stated by NHS EnglandDisputes the concern
AI-generated summary

Alexander James Davidson · 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

Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.

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 to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report
“(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms. ”
Source location
Alexander James Davidson · Prevention of Future Deaths report
Page 2 · concerns
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
Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report
“(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit. Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable. ”
Source location
Alexander James Davidson · Prevention of Future Deaths report
Page 2 · 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
Review the vomiting question to address callers’ unfamiliarity with the term “coffee-grounds”.

Verbatim wording from the response
“In 2018 NHS Pathways reviewed the question that asks about dark brown or black vomit in view of the concern that callers may not be familiar with the term ‘coffee-grounds’. Removing the 'coffee-grounds' description could result in over referral as dark/black fluid alone without texture ('bits') could be drinks (e.g. cola, coffee, Guinness) or other dietary intake that has been vomited. The reference to coffee-grounds is a texture that is reasonably specific to haematemesis and this is commonly used in health-related literature, whereas cola is not. NHS.uk also refer to coffee-ground appearance only.”

Source location
2019-0149-Response-by-NHS-Digital
Page 5 · response
Published 29 July 2019
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
Add “soil” to the supporting information for the question about vomiting blood.

Verbatim wording from the response
“In 2016 NHS Pathways added reference to ‘soil’ in the ‘supporting information’ of the question asking about vomiting blood.”

Source location
2019-0149-Response-by-NHS-Digital
Page 5 · response
Published 29 July 2019
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
Review the gastrointestinal pathways, including diarrhoea and vomiting, clinical evidence on haematemesis, and whether user research could improve triage questions.

Verbatim wording from the response
“NHS Pathways are, as part of routine review and governance procedures, conducting a review of the gastrointestinal suite of pathways (including the diarrhoea and vomiting pathways), with changes planned for Release 19 (which will be deployed May 2020). As part of this review, the clinical evidence related to haematemesis will be reviewed with consideration also given as to whether user research will be helpful in improving triage questions and the identification of haematemesis.”

Source location
2019-0149-Response-by-NHS-Digital
Page 5 · response
Published 29 July 2019
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
Communication training, monthly audits, adaptable questioning and clinician transfer routes provide sufficient support for young or vulnerable callers.

Verbatim wording from the response
“Call handlers are permitted to deviate from the exact wording presented by the system to a certain extent as each question has supplementary text called ‘supporting information’; the purpose of which is to guide the call handler to form additional probing questions or alternative ways of phrasing a question if a patient/caller might not understand what’s being asked.”

Source location
2019-0149-Response-by-NHS-Digital
Page 3 · response
Published 29 July 2019
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
The coffee-ground description is clinically specific and supported by explanatory text; removing it could cause inappropriate over-referral.

Verbatim wording from the response
“The question (see example below) currently asks whether there has been ‘dark brown or black vomit, like coffee-grounds’.”

Source location
2019-0149-Response-by-NHS-Digital
Page 4 · response
Published 29 July 2019
Open published response
21 Feb2019
Surrey
Concerns raised1
1. Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
This report raised 16 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.
AI-generated summary

Terrence Arthur Albert Smith · 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

Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.

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 ambulance call-triage tools to support recognition and appropriate response to ED/ABD
Wider context from the report
“The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly. I was told that it is intended that version 17 will do so but this is not yet in use. My concern is that, unless and until it is in use, there will continue to be a failure by call handlers to recognise ED/ABD and respond appropriately. ”
Source location
Terrence Arthur Albert Smith · Prevention of Future Deaths report
Page 6 · concerns
Open source report
18 Dec2018
Avon
Concerns raised1
1. Lack of NHS Pathways questions about recent surgical or interventional procedures for patients reporting severe abdominal pain
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review abdominal pain pathways with Royal College subject-matter experts, including whether to add recent-procedure questions to the severe-pain section.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  For severe abdominal pain, urgent primary-care referral and symptom-based questions are considered sufficient without asking about recent procedures.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Mrs. Susan Longden · 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

Mrs. Susan Longden underwent a routine surveillance colonoscopy on 31 January 2018 and later developed severe abdominal pain. After NHS 111 triage arranged a doctor call rather than a Category 3 ambulance, she became unresponsive, suffered cardiac arrests and was pronounced deceased after arrival at hospital. The concerns included the NHS Pathways algorithm not asking about recent procedures, insufficient emphasis on speaking directly with the patient when the caller is someone else, and previous concerns raised with the organisation.

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
Lack of NHS Pathways questions about recent surgical or interventional procedures for patients reporting severe abdominal pain
Wider context from the report
“(1) The NHS Pathways algorithm does not include a question with regard to recent surgical or interventional procedures where a patient is reporting severe abdominal pain. The close association in time between such a procedure and the onset of symptoms may well be significant in ensuring prompt action is taken to investigate the cause of the symptoms. ”
Source location
Mrs. Susan Longden · Prevention of Future Deaths report
Page 3 · 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
Review abdominal pain pathways with Royal College subject-matter experts, including whether to add recent-procedure questions to the severe-pain section.

Verbatim wording from the response
“NHS Pathways regularly review the algorithms and our abdominal pain pathways are currently undergoing a review with our external subject matter experts from the Royal Colleges. This review will include the severe pain section specifically, and inclusion of a question asking about a recent surgical procedure or intervention has specifically been requested for review as part of this work. I can further reassure HM Coroner that this comprehensive review of our abdominal pain algorithms will be concluded by 1st May 2019, and that any changes to NHS Pathways will be implemented later this year, pending successful safety testing.”

Source location
2018-0394-Response-by-NHS-Digital
Page 3 · response
Published 17 May 2019
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
For severe abdominal pain, urgent primary-care referral and symptom-based questions are considered sufficient without asking about recent procedures.

Verbatim wording from the response
“We acknowledge that we do not specifically include a question about recent procedures within the sub-section of the abdominal pain algorithm where callers describe severe pain. This is because, at present, any patient describing severe pain will, as a minimal response, be referred to primary care urgently regardless of such background. Before this backstop is reached, other questions are asked, looking to identify key symptoms that warrant prompt action to investigate their cause, including ambulance dispatch.”

Source location
2018-0394-Response-by-NHS-Digital
Page 3 · response
Published 17 May 2019
Open published response
30 Aug2016
Blackburn, Hyndburn and Ribble Valley
Concerns raised1
1. Failure of vomiting pathways to ensure an appropriate response
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review vomiting pathways with NWAS input and identify improvements to the vomiting questions.
  Stated by NHS EnglandStated completed
2. Action
  Introduce amended vomiting questions with separate prompts and supporting information for coffee-ground vomit, blood and faeces.
  Stated by NHS EnglandStated planned
3. Action
  Issue the amended vomiting-question content to all NHS Pathways sites in the next algorithm release.
  Stated by NHS EnglandStated planned
1. Action
  Enhance the site training package for managing vomiting during remote third-party telephone triage.
  Stated by NHS EnglandStated completed
AI-generated summary

Harry Stuart Gill · 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

Harry Gill became unwell with vomiting, made five calls to NHS 111, and collapsed and died shortly after an ambulance was being arranged on 2 June 2016. The inquest concluded that he died from a heart attack brought on by vomiting caused by an intermittent bowel blockage, and that his death could probably have been prevented if his condition had been appropriately assessed. The principal concern was that only one of five calls received the appropriate response, indicating that the vomiting pathway was not sufficiently robust.

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 vomiting pathways to ensure an appropriate response
Wider context from the report
“That on four out of five telephone conversations between Mr Gill and his wife and NHS 111 only one call elicited the appropriate response. It would therefore appear that the vomiting pathways is not sufficiently robust to ensure an appropriate response. ”
Source location
Harry Stuart Gill · Prevention of Future Deaths report
Page 2 · 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
Review vomiting pathways with NWAS input and identify improvements to the vomiting questions.

Verbatim wording from the response
“The Coroner has requested that NHS Pathways review its management of the vomiting pathways and report on any improvements that have been made.”

Source location
2016-0323-Response-by-NHS-Digital
Page 1 · response
Published 30 August 2016
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
Introduce amended vomiting questions with separate prompts and supporting information for coffee-ground vomit, blood and faeces.

Verbatim wording from the response
“We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate a localised gastric bleed. The question that will be asked in the next release of the algorithms will be;”

Source location
2016-0323-Response-by-NHS-Digital
Page 2 · response
Published 30 August 2016
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
Issue the amended vomiting-question content to all NHS Pathways sites in the next algorithm release.

Verbatim wording from the response
“We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate a localised gastric bleed. The question that will be asked in the next release of the algorithms will be;”

Source location
2016-0323-Response-by-NHS-Digital
Page 2 · response
Published 30 August 2016
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 the site training package for managing vomiting during remote third-party telephone triage.

Verbatim wording from the response
“This work has been concluded and will be issued to all NHS Pathways sites for the next release in the spring of next year. In addition we have further enhanced our site training package for the management of vomiting in recognition of the difficulties in identifying the nature of vomit remotely via third party telephone triage.”

Source location
2016-0323-Response-by-NHS-Digital
Page 2 · response
Published 30 August 2016
Open published response
16 Jun2016
West Sussex
Concerns raised2
1. Failure to consult clinical advisors in complex KMSS 111 cases
2. Imprecision and unresolved improvement of the NHS Pathways clinical algorithm
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 1
1. Action
  Raise and follow up concerns about anticoagulant-related NHS Pathways algorithm risks through governance channels.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  Existing NHS Pathways training and call-handling arrangements are considered sufficient to provide a safe service.
  Stated by South East Coast Ambulance Service NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  Concerns about Pathways training content, algorithm design and auditing requirements should be addressed to the Department of Health, which owns the system.
  Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibility
AI-generated summary

Valerie Margaret Ellis · 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

Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.

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 to consult clinical advisors in complex KMSS 111 cases
Wider context from the report
“2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February. ”
Source location
Valerie Margaret Ellis · Prevention of Future Deaths report
Page 2 · concerns
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
Imprecision and unresolved improvement of the NHS Pathways clinical algorithm
Wider context from the report
“2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February. ”
Source location
Valerie Margaret Ellis · Prevention of Future Deaths report
Page 2 · 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
Raise and follow up concerns about anticoagulant-related NHS Pathways algorithm risks through governance channels.

Verbatim wording from the response
“Indeed as you note in your report, our Senior Manager for Quality and Clinical Governance had previously raised concerns to the Pathways team regarding the algorithm and impact regarding not only Mrs Ellis’ case but anyone in a similar situation regarding anticoagulants. The principle areas of concern raised regarded the blood loss, clinical shock and anticoagulant questions.”

Source location
2016-0252-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 16 June 2016
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
Existing NHS Pathways training and call-handling arrangements are considered sufficient to provide a safe service.

Verbatim wording from the response
“Firstly and with regards to the NHS Pathways training KMSS 111 deliver, this is in line with requirements set out by the Department of Health who own the system. As commented during proceedings if three answers of ‘unknown’ are provided by the caller this would flag to pass the call to a clinician in the room. This is considered the mechanism to provide a safe service, with call takers operating within the scope of the algorithm.”

Source location
2016-0252-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 16 June 2016
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
Concerns about Pathways training content, algorithm design and auditing requirements should be addressed to the Department of Health, which owns the system.

Verbatim wording from the response
“Any concerns regarding the content and degree of training I would consider be appropriately directed to the Department of Health as suggested during the proceedings as they own the system, training and auditing requirements.”

Source location
2016-0252-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 16 June 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to consider the timing of requests for advice in 111 dispositions

Failure to accommodate prior direct general practitioner review in 111 dispositions

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

NHS Pathways tool failing to support triage of fluctuating or impaired consciousness

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Failure of 111 call handlers to correctly complete the algorithm

Failure to recognise complex 111 cases requiring transfer to a more senior member of the service

Failure of the 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Early exit from NHS Pathways Module 0 for third-party calls

Concerns raised3

Lack of NHS Pathways questioning about cold hands and feet in children aged over five

Failure of NHS Pathways questions to allow meaningful assessment of pain in children

Inappropriately high NHS Pathways threshold for questioning about green vomit in children over five

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Respondent positions 4

Actions described in response 1

Respondent positions 1

Actions described in response 5

Respondent positions 3

Actions described in response 4

Respondent positions 3