First reported 24 Sep 2019•Latest report 6 Jan 2026
Definition
What this concern includes
Includes failures in remote or telephone assessment and triage of ill newborns, infants and young children, including unsuitable algorithms or pathways, reliance on adult-oriented questions, inadequate recognition of respiratory or other serious symptoms, delayed clinical input and failure to escalate for early assessment.
Not included
Excludes face-to-face assessment failures where remote or telephone assessment is not the deficient process.
Excludes generic NHS 111, ambulance or emergency-call system failures unless the assertion specifically concerns remote assessment and triage of ill infants.
Excludes failures in treatment or follow-up after an appropriate infant assessment and escalation have occurred.
Excludes generic communication, staffing or training deficiencies unless they directly make remote assessment and triage of ill infants unreliable.
Reports
3
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2019–2026
First to latest report issue date
Stated actions
8
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England2
Herts Urgent Care Limited1
NHS 1111
Public Health England1
South Central Ambulance Service NHS Foundation Trust1
Executive non-departmental public body2
Executive agency1
NHS trust1
Social-care provider1
Sub-organisation1
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.
Devon, Plymouth and Torbay
Concerns raised2
Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
Failure of NHS Pathways to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Continue refining and aligning the MPDS and NHS Pathways triage systems.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Action
Continue monitoring triage categorisation and strengthening clinical oversight.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Oxfordshire
Concerns raised1
Total reliance on an algorithm that does not direct early clinical input
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Local services manage the availability of services matched to the NHS Pathways recommended outcome.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England, not the Trust, is responsible for altering the NHS Pathways algorithms.
Stated by South Central Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.
Stated by South Central Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cambridgeshire and Peterborough
Concerns raised1
Difficulty of remote assessment of very unwell children and infants using adult-oriented symptom pathways
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.
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Includes failures in remote or telephone assessment and triage of ill newborns, infants and young children, including unsuitable algorithms or pathways, reliance on adult-oriented questions, inadequate recognition of respiratory or other serious symptoms, delayed clinical input and failure to escalate for early assessment.
