Recurring concern

Failure to ensure NHS 111 health advisors are competent for safe clinical triage

Get email alerts

Request correction

First reported 27 May 2015•Latest report 11 May 2026

Definition

What this concern includes

Includes failures in NHS 111 health-advisor competence assurance, including initial or refresher training, supervised practice, medical-knowledge requirements, competence assessment and related safeguards needed for safe recognition and triage of potentially serious conditions.

Not included

Excludes deficiencies in the design, content or maintenance of NHS Pathways or other NHS 111 algorithms where advisor competence is not the unsafe condition.
Excludes generic telephone-service staffing, workload or access failures without a specific NHS 111 health-advisor competence deficiency.
Excludes failures in ambulance dispatch, response, treatment or follow-up after NHS 111 triage has been safely completed.
Excludes training or competence concerns involving non-NHS 111 personnel or non-triage functions.

Reports: 4
Individual concerns: 4
Date range: 2015–2026
Stated actions: 4

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.

Integrated Care 241

London Ambulance Service NHS Trust1

London Central & West Unscheduled Care Collaborative Limited1

NHS England1

NHS Pathways1

North East Ambulance Service NHS Foundation Trust1

South East Coast Ambulance Service NHS Foundation Trust1

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.

11 May2026
Surrey
Concerns raised1
1. Limited clinical capability of Emergency Medical Advisors to recognise serious illness
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.

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

Oliver Charles Major Shelley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Oliver Charles Major Shelley became seriously unwell on 22 July 2024 with symptoms including a non-blanching rash, vomiting and reduced consciousness. After no ambulance was dispatched, his parents took him to hospital, where he was treated for meningococcal septicaemia but died approximately 7.5 hours after arrival. The report identified concerns about the lack of a sepsis algorithm for emergency medical advisors and the training and description of those advisors’ role.

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
Limited clinical capability of Emergency Medical Advisors to recognise serious illness
Wider context from the report
“2. Emergency Medical Advisors Other than some in-house training, Emergency Medical Advisors (EMA’s), generally have no qualifications in medicine or nursing. As such, the use of this title to describe their role raises a real concern they are misleading the public who use the 111/999 service. Oliver’s parents gave an extreme clear assessment of Oliver’s condition and also informed the EMA that they were concerned it was meningitis. However, this was not recognised by the EMA reaffirming their limited abilities. This reinforces the need to provide further assistance to all EMA’s who use NHS Pathways by providing an appropriate ‘sepsis’ algorithm to assist in their role. ”
Source location
Oliver Charles Major Shelley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Oct2019
Newcastle upon Tyne
Concerns raised1
1. Triage of calls by health advisors with limited medical training and no medical qualifications
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.

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

Philip Richard Hayes · 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

Philip Richard Hayes suffered an aortic dissection on 14 April 2019 and died on 18 April 2019 after delays in ambulance response and diagnosis. The principal concerns included failure to reassess the emergency response despite five subsequent calls reporting additional symptoms and deterioration, inconsistent triage and referral for clinical input, and the appropriateness of algorithm-based 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
Triage of calls by health advisors with limited medical training and no medical qualifications
Wider context from the report
“(4) Calls triaged by health advisors with limited medical training and no medical qualifications ”
Source location
Philip Richard Hayes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
27 May2015
Inner North London
Concerns raised1
1. Insufficient training of 111 call handlers in recognising agonal breathing
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.

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

Yusuf ABDISMAD · 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

Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.

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
Insufficient training of 111 call handlers in recognising agonal breathing
Wider context from the report
“During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further. Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent. ”
Source location
Yusuf ABDISMAD · 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

Limited clinical capability of Emergency Medical Advisors to recognise serious illness

Concerns raised1

Triage of calls by health advisors with limited medical training and no medical qualifications

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

Insufficient training of 111 call handlers in recognising agonal breathing

Actions described in response 4

Respondent positions 2