Recurring concern

Failure to establish and address patients’ ability to access advised emergency care

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First reported 24 Jun 2016•Latest report 7 Apr 2025

Definition

What this concern includes

Includes dedicated emergency-care access assessment and support controls that establish whether a patient can reach advised emergency care or remain safely supported while awaiting it, including enquiries about transport, mobility, another person’s assistance and other material practical barriers.

Not included

Excludes general ambulance delays, emergency-department waiting times or service-capacity problems where the patient's ability to access care is not the identified concern.
Excludes clinical triage, diagnosis or treatment failures that do not involve assessing or addressing a practical barrier to accessing advised emergency care.
Excludes generic communication or social-care deficiencies unless they directly prevent the emergency-care access assessment or support process from operating safely.

Reports: 2
Individual concerns: 2
Date range: 2016–2025
Stated actions: 2

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 England2

Department of Health and Social Care1

South Central Ambulance Service NHS Foundation Trust1

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.

7 Apr2025
Berkshire
Concerns raised1
1. Failure to apply additional caller enquiries when a person is unable to move from any position
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Maintain NHS Pathways functionality for assessing patients unable to move from their current position.
  Stated by NHS EnglandStated completed
2. Action
  Implement the approved staff directive requiring enhanced questioning, contact details, falls triage, position documentation, clinical referral and appropriate case closure.
  Stated by South Central Ambulance Service NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  Writing NHS Pathways triage algorithms is outside the Trust’s responsibility, so it cannot directly change the questions asked.
  Stated by South Central Ambulance Service NHS Foundation TrustOutside remit
1. Position
  NHS England designs and manages NHS Pathways and must consider whether the algorithm should be changed.
  Stated by South Central Ambulance Service NHS Foundation TrustRedirects responsibility
AI-generated summary

Sandra Ann MILLARD · 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

Sandra Ann Millard called 111 on 19 May 2024 because she was unable to move from her chair. A clinician could not reach her by telephone, no ambulance was dispatched, and she was found deceased by a neighbour the following day; the cause of death was recorded as sepsis from infected leg ulcers, with ischaemic heart disease, coronary artery atheroma and chronic kidney disease also noted. The concern was that additional enquiries and support arrangements used for people lying on the floor were not applied to people unable to move from other positions, such as a chair.

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 apply additional caller enquiries when a person is unable to move from any position
Wider context from the report
“I heard that when SCAS call takers using the NHS Pathways triage tool exit a module indicating a person is lying on the floor with no reported injuries they are prompted to ask additional questions of the caller; including whether someone else is with the caller; whether the caller can provide a number for next of kin or other person who may be able to attend the caller whilst they wait for an ambulance. This is due to the likely delay of a number of hours before an ambulance can attend. This same procedure is not applied when someone reports that they are stuck in situ, for example they are unable to move from their chair. My concern is that the additional risks of a long lie, for example rhabdomyolysis, may well apply when someone in unable to move from any position. SCAS agreed to change their standard operating procedures to incorporate additional enquiries in these circumstances. I am pleased that they have agreed to amend their procedures swiftly. However this matter has wider significance and should be considered by other users of the NHS Pathways triage tool. ”
Source location
Sandra Ann MILLARD · 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
Maintain NHS Pathways functionality for assessing patients unable to move from their current position.

Verbatim wording from the response
“Between 2017 and 2018, NHS Pathways collaborated with its ambulance service stakeholders to enhance the assessment of patients who may not have fallen but are nonetheless unable to move from their current position. Since 2018, the system has included functionality to assess patients in this situation, regardless of whether their immobility is due to disability, frailty, weakness, pain, or another factor.”

Source location
Response from NHSE
Page 1 · response
Published 11 April 2025
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 the approved staff directive requiring enhanced questioning, contact details, falls triage, position documentation, clinical referral and appropriate case closure.

Verbatim wording from the response
“In response to your concerns, a change in process has now been written by ████████ in the form of a directive to staff. The changes will include:”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 11 April 2025
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
Writing NHS Pathways triage algorithms is outside the Trust’s responsibility, so it cannot directly change the questions asked.

Verbatim wording from the response
“Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 11 April 2025
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
NHS England designs and manages NHS Pathways and must consider whether the algorithm should be changed.

Verbatim wording from the response
“Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 11 April 2025
Open published response
24 Jun2016
West Yorkshire (Western)
Concerns raised1
1. Failure to establish whether patients have the means to attend advised emergency care
This report raised 8 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

Kirsty Childs · 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

Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.

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 establish whether patients have the means to attend advised emergency care
Wider context from the report
“8. On the one occasion when NHS Direct advised Kirsty to attend her nearest accident and emergency service, no enquiry was made as to whether Kirsty had the means to attend. ”
Source location
Kirsty Childs · Prevention of Future Deaths report
Page 5 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to apply additional caller enquiries when a person is unable to move from any position

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to establish whether patients have the means to attend advised emergency care

Actions described in response 2

Respondent positions 2