Concerns raised 2
Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways View source Failure of NHS Pathways to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
View source
NHS England
Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
View source
NHS England
Continue refining and aligning the MPDS and NHS Pathways triage systems.
View source
NHS England
Continue monitoring triage categorisation and strengthening clinical oversight.
View source See 1 more action
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AI-generated summary
Theo Gordon Tuikubulau · 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
Theo Gordon Tuikubulau, a three-year-old boy, died on 8 July 2022 from sepsis arising from an invasive Group A streptococcal infection. The report identified variation between the MPDS and NHS Pathways triage systems in assessing respiratory distress and cyanosis in children under five, resulting in different ambulance response categories for similar symptoms. The report stated that this two-tiered system continued to exist while work to review and align the systems had not yet occurred.
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 Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
Wider context from the report “The difference in assessment and triage of calls under these two systems appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally). It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to prevent future deaths was engaged in this case. However, I was conscious that I did not hear evidence directly from those responsible for the NHS Pathways or MPDS systems during the inquest.
I therefore requested further information from both of the organisations responsible for NHS Pathways and MPDS about why there appears to be a two tier system in Devon (and potentially nationally) which would result in a different ambulance categorisation (category 1 under MPDS and category 2 under NHS Pathways) when a caller describes breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both, for further information about what is being done to address those differences in call assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls triaged via the MPDS system and confirmed that these calls had been properly assigned a category 1 response time. They were unable to comment on the calls triaged by NHS Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED)… NHS England does not manage or oversee the MPDS and we are therefore unable to provide comment on their system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is developed and maintained by the Transformation Directorate at NHS England, and is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and acuity (severity and urgency of the symptoms/condition) of the patient based on the identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest pain). If, during the call, the patient’s condition changed (either improves or worsens), then there is an exception that the call handler will re-triage with the new information which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC) Teams, it is clear that there is variation between the two triage systems with regards to respiratory distress in children under 5 , specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS triage. However, the presence of cyanosis is not interrogated within NHS Pathways and as such this symptom/sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways, instead resulting in the generation of a Respiratory Distress disposition that is mapped to a Category 2 response."
I was advised within the letter that NHS England will work with the clinical coding groups and NHS Pathways to review this to ensure that the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate, for which I am grateful. However, as this has not yet occurred and the two tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter.
” Source location Theo Gordon Tuikubulau · Prevention of Future Deaths report
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 to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition
Wider context from the report “The difference in assessment and triage of calls under these two systems appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally). It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to prevent future deaths was engaged in this case. However, I was conscious that I did not hear evidence directly from those responsible for the NHS Pathways or MPDS systems during the inquest.
I therefore requested further information from both of the organisations responsible for NHS Pathways and MPDS about why there appears to be a two tier system in Devon (and potentially nationally) which would result in a different ambulance categorisation (category 1 under MPDS and category 2 under NHS Pathways) when a caller describes breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both, for further information about what is being done to address those differences in call assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls triaged via the MPDS system and confirmed that these calls had been properly assigned a category 1 response time. They were unable to comment on the calls triaged by NHS Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED)… NHS England does not manage or oversee the MPDS and we are therefore unable to provide comment on their system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is developed and maintained by the Transformation Directorate at NHS England, and is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and acuity (severity and urgency of the symptoms/condition) of the patient based on the identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest pain). If, during the call, the patient’s condition changed (either improves or worsens), then there is an exception that the call handler will re-triage with the new information which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC) Teams, it is clear that there is variation between the two triage systems with regards to respiratory distress in children under 5, specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS triage. However, the presence of cyanosis is not interrogated within NHS Pathways and as such this symptom/sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways , instead resulting in the generation of a Respiratory Distress disposition that is mapped to a Category 2 response. "
I was advised within the letter that NHS England will work with the clinical coding groups and NHS Pathways to review this to ensure that the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate, for which I am grateful. However, as this has not yet occurred and the two tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter.
” Source location Theo Gordon Tuikubulau · Prevention of Future Deaths report
Open source report
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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 MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Verbatim wording from the response “Your Report raises the concern that the triage and categorisation of ineffective breathing and respiratory distress is still not consistent across the two triage systems; NHS Pathways and the Medical Priority Dispatch System (MPDS). NHS England had informed you that a review would be undertaken of this, to ensure that the two triage systems are consistent and remain clinically appropriate. As you have not been informed that the review has occurred, this remains a concern.” Source location Response from NHS England
Open published response
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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 Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
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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 Continue refining and aligning the MPDS and NHS Pathways triage systems.
Verbatim wording from the response “NHS England welcomes the feedback from HM Coroner and will continue to refine and align both systems, monitor categorisation, and strengthen clinical oversight. I hope that this further response sufficiently addresses the outstanding concern raised within your Report.” Source location Response from NHS England
Open published response
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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 Continue monitoring triage categorisation and strengthening clinical oversight.
Verbatim wording from the response “There has been a significant increase in clinical support within 999 Emergency Operations Centres, providing enhanced oversight for patients who may not initially receive a Category 1 triage outcome, but who may benefit from clinical reassessment and potential ambulance re-categorisation. This includes patients at the extremes of age and those presenting with symptoms such as severe breathing difficulty.” Source location Response from NHS England
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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 Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Verbatim wording from the response “The information above confirms that another child presenting as Theo did would result in a category 1 response being reached, when triaged appropriately using either MPDS or NHS Pathways.” Source location Response from NHS England (2)
Open published response
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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 two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
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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 No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
12 Jun 2025 Oscar Michael Thomas Keenan · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Total reliance on an algorithm that does not direct early clinical input View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England South Central Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.
View source
South Central Ambulance Service NHS Foundation Trust
Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
View source
South Central Ambulance Service NHS Foundation Trust
Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.
View source
South Central Ambulance Service NHS Foundation Trust
Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
View source See 1 more action
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AI-generated summary
Oscar Michael Thomas Keenan · 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
Oscar was born with a pelvi-ureteric junction obstruction and later developed a bacterial infection after prescribed antibiotics were not received. On 26 June 2024, he was taken to hospital after a call to NHS 111 about breathing difficulties, was found to have sepsis, and died the same day. Concerns included inadequacies in the algorithm for assessing ill newborns, reliance on the algorithm without early clinical input, and delay or lack of direction in obtaining clinical assessment.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Total reliance on an algorithm that does not direct early clinical input
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” Source location Oscar Michael Thomas Keenan · Prevention of Future Deaths report
Open source report
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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 Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.
Verbatim wording from the response “We recognize that the remote assessment of very young babies is inherently challenging, and we continuously refine the system based on clinical feedback and real-world cases. In Oscar’s case – and in accordance with the investigation at SCAS - the review concluded that the algorithm functioned as intended, and no changes were required. However, every case contributes to our ongoing learning and improvement.” Source location Response from NHS England
Open published response
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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 Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
Verbatim wording from the response “To further gauge understanding and comprehension of the content within any shared learning materials issued, there is a monthly Quick Quiz for both service lines (111 and 999) comprising of 10 true / false and / or multiple-choice questions. The questions are drawn from any recent Standard Operating Procedure (SOP) Change Notices, shared learning materials, existing SOPs, and general triage principles for the NHS Pathways system. The quiz is facilitated via MS Forms which allows staff who submit incorrect answers to see explanations of the correct answer with sign posting to the source reference materials. Quick Quizzes have included questions regarding assessing a patient’s breathing in July 2024, August 2024, September 2024 and April 2025 and regarding when and how to pass a call to a clinician every month since December 2024.” Source location Response from South Central Ambulance Service
Open published response
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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 Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.
Verbatim wording from the response “NHS Pathways System Issues” Source location Response from South Central Ambulance Service
Open published response
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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 Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
Verbatim wording from the response “111 End to End Review Meetings” Source location Response from South Central Ambulance Service
Open published response
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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 Local services manage the availability of services matched to the NHS Pathways recommended outcome.
Verbatim wording from the response “Health advisors using the NHS Pathways system must have access to clinical support and supervision. They are trained to use probing questions to better understand caller responses. If a call is complex, uncertain, or includes three “not sure” answers, advisors are expected to seek clinical input. This support should be available immediately through a ‘warm transfer’ to a clinician, as required by the system’s Licence. To encourage this, NHS Pathways promotes the motto: “If in doubt, shout.” The system generates a recommended outcome (disposition), which is then matched to services commissioned locally. The availability of these services is managed locally.” Source location Response from NHS England
Open published response
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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, not the Trust, is responsible for altering the NHS Pathways algorithms.
Verbatim wording from the response “As indicated at the beginning of this letter, the Trust is a user of the NHS Pathways system, and we are consequently not able to alter the algorithms contained within it, only NHS England can do this. We have therefore focused our review and response on the training that is provided to Emergency Call Takers and Health Advisors who use the NHS Pathways system and the process in place for identifying any themes or that indicate additional wider training may be required.” Source location Response from South Central Ambulance Service
Open published response
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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 Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.
Verbatim wording from the response “In addition to the above, our Clinical Coordination Centre (CCC) Quality Improvement Team have considered points 2 and 3 of the concerns raised and they are satisfied that there is not an inherent or recurrent issue of staff not seeking clinical advice when appropriate to do so within our call centres.” Source location Response from South Central Ambulance Service
Open published response
Concerns raised 1
Difficulty of remote assessment of very unwell children and infants using adult-oriented symptom pathways View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Myla DEVIREN · 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
Myla Deviren, who had congenital intestinal malrotation, developed a volvulus and was found unresponsive on 27 August 2015 after calls to NHS 111 and an out-of-hours service. She was taken to hospital, where resuscitation attempts were unsuccessful, and post-mortem examination revealed small bowel infarction from untreated small intestinal volvulus. The principal concerns were failures to recognise the significance of her symptoms and the need for robust systems, training, paediatric specialist support and precautionary ambulance advice when children may be seriously unwell.
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 Difficulty of remote assessment of very unwell children and infants using adult-oriented symptom pathways
Wider context from the report “Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information.
” Source location Myla DEVIREN · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.