Recurring concern

Inadequate clinical expertise for safe emergency patient assessment

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First reported 12 Sep 2014•Latest report 4 Oct 2021

Definition

What this concern includes

Includes failures in emergency clinical advice, triage or assessment where insufficiently relevant clinical expertise, experience or specialty input undermines safe assessment of the patient's condition, including the anchor's inadequate 111 clinical-advisor expertise and assessment and inadequate paediatric expertise in A&E assessment.

Not included

Excludes generic workforce, training or experience deficiencies not directly tied to the expertise required for emergency patient assessment.
Excludes failures limited to treatment, monitoring or escalation after an adequately expert emergency assessment has occurred.
Excludes specialty- or condition-specific competence concerns where the report does not connect them to emergency patient assessment.
Excludes non-clinical advice, administrative assessment and routine outpatient assessment processes.

Reports: 3
Individual concerns: 3
Date range: 2014–2021
Stated actions: 5

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

South East Coast Ambulance Service NHS Foundation Trust2

Integrated Care 241

Royal College of Emergency Medicine1

Royal College of Paediatrics and Child Health1

University Hospitals Sussex 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.

4 Oct2021
West Sussex
Concerns raised1
1. Inadequate clinical advisor expertise and assessment of patient condition
This report raised 6 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
  Expand the Clinical Assessment Service with clinicians from a broadening range of clinical disciplines to meet diverse patient needs.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  The 111 provider is responsible for setting clinician employment criteria and conducting ongoing clinician audit and performance management.
  Stated by NHS EnglandRedirects 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
Inadequate clinical advisor expertise and assessment of patient condition
Wider context from the report
“3. The skill and expertise of the ‘clinical advisor’ was wholly inadequate for her position as she had no contemporaneous or relevant experience in working in an emergency department as a nurse. She was also insufficiently robust in her assessment and understanding of Hannah’s condition when the call handler contacted her for advice. ”
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
Expand the Clinical Assessment Service with clinicians from a broadening range of clinical disciplines to meet diverse patient needs.

Verbatim wording from the response
“In autumn 2020, SECAmb entered into a contract to provide a Clinical Assessment Service (“CAS”). The CAS is a national framework whereby 111 providers are required to employ a range of various clinical skill sets to cater for various patient needs in a virtual environment. The CAS incorporates clinicians from a very wide range of disciplines including GPs, midwives, registered Mental Health nurses, Paediatric Nurses and others; the number of clinicians and range of disciplines is increasing on a monthly basis. The objective of the CAS in the longer term is to”

Source location
2021-0327-Response-from-South-East-Coast-Ambulance-Service_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
The 111 provider is responsible for setting clinician employment criteria and conducting ongoing clinician audit and performance management.

Verbatim wording from the response
“Safe and appropriate use of NHS Pathways by NHS care providers is governed by way of a ‘Licence to Use’. The ‘Licence to Use’ is managed by NHS Digital and all providers using NHS Pathways must enter into and comply with it. It defines the type of Clinician that can potentially receive training to use NHS Pathways in a clinical capacity as follows:”

Source location
2021-0327-Response-from-NHS-Digital_Published
Page 3 · response
Published 13 October 2021
Open published response
16 Jun2016
West Sussex
Concerns raised1
1. Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions
This report raised 6 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
  Deliver core, common-learning and shadow-shift training for KMSS 111 call takers.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
2. Action
  Introduce supervised live support and Pathways update training within KMSS 111 training provision.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
3. Action
  Deliver three hours of face-to-face KMSS 111 training introduced during 2016.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progress
1. Action
  Expand 2016 face-to-face KMSS 111 training to six hours during October or November 2016.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated planned
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
Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions
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
Deliver core, common-learning and shadow-shift training for KMSS 111 call takers.

Verbatim wording from the response
“Developments in training issued by Pathways are incorporated into KMSS 111 training packages and we can confirm the following levels of training/developments have taken place;”

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 action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce supervised live support and Pathways update training within KMSS 111 training provision.

Verbatim wording from the response
“Developments introduced November 2015;”

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 action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver three hours of face-to-face KMSS 111 training introduced during 2016.

Verbatim wording from the response
“Developments being or have been introduced in 2016;”

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 action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Expand 2016 face-to-face KMSS 111 training to six hours during October or November 2016.

Verbatim wording from the response
“• 3 hours face to face training thus far”

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
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
12 Sep2014
Warwickshire
Concerns raised1
1. Lack of paediatric expertise in the sole clinical contact for children attending A&E
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Evelyn Mary 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

Evelyn Mary Smith was 7 years old when she died after an acute deterioration in her breathing at home on 13 September 2013, following several healthcare consultations for croup-like symptoms. A post-mortem examination identified Parainfluenza Virus Type 2 and Staphylococcus Aureus, resulting in Acute Ulcerative Laryngotracheobronchitis. The principal concern was that a relatively inexperienced paediatric doctor was the only clinical contact for a child attending A&E, and that discussion with the paediatric team might have led to longer observation and consideration of non-viral causes.

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 paediatric expertise in the sole clinical contact for children attending A&E
Wider context from the report
“(1) The care provided to Miss Smith was reviewed by an independent paediatrician, who raised concerns regarding the paediatric experience of the FY2 doctor in A&E. His concern was that, whilst the care provided was not manifestly inappropriate or incorrect, he considered that discussion with the paediatric team may have prompted a longer period of observation and consideration of non-viral causes of croup-like signs. I share his overarching concern that a doctor, relatively inexperienced in paediatrics, should be the only clinical contact for a child taken to A&E. I heard from the Hospital Trust that mandating all FY2 doctors to have postgraduate experience in paediatrics, before they were allocated to work in A&E, might have significant resource implications and may not be feasible. ”
Source location
Evelyn Mary Smith · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate clinical advisor expertise and assessment of patient condition

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 raised1

Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions

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.2

Concerns raised1

Lack of paediatric expertise in the sole clinical contact for children attending A&E

Actions described in response 1

Respondent positions 1

Actions described in response 4

Respondent positions 2