Recurring concern

Unreliable transfer of NHS 111 information to emergency departments

First to latest report 18 Apr 2017 — 13 Jun 2025

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes failures in the dedicated process for transferring or making NHS 111 information and assessment outcomes available to Emergency Department clinicians, including delayed sharing, absent commissioning or access arrangements, unsuitable formats and failures that prevent relevant NHS 111 information from reaching the receiving Emergency Department.

What is not included
  • Excludes ambulance-service information transfer to ambulance crews or other responders where Emergency Department access to NHS 111 information is not the deficient process.
  • Excludes generic NHS 111 call handling, triage or clinical-advice failures where transfer or access of information to Emergency Department clinicians is not the shared unsafe condition.
  • Excludes Emergency Department assessment or treatment failures occurring after relevant NHS 111 information was reliably made available.
  • Excludes generic electronic-record, commissioning or inter-agency communication deficiencies unless they directly impair NHS 111 information access by Emergency Department clinicians.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire Eastern

    AI-generated summary

    Chloe Alicia 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

    Chloe Alicia Ellis died on 3 September 2024 after attending an Emergency Department with chest and back pain and breathlessness, where she was diagnosed with a viral illness and discharged. The principal concern was that the outcome of her NHS 111 online assessment, which suspected pulmonary embolism and recorded her oral contraceptive use, was not available to Emergency Department clinicians. The report also raised concern that NHS 111 online assessments were not commissioned to be accessible to clinicians at the relevant hospital, although such access might help obtain a full history and provide a failsafe against inadequate history taking.

    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 commission access to NHS 111 online assessment outcomes for Emergency Department clinicians

    Wider context from the report

    “(1) The inquest was told that it is possible for the outcomes of NHS 111 online assessments to be made accessible to Emergency Department clinicians, and that the decision whether or not to commission that accessibility in a particular hospital rests with the relevant Integrated Care Board. (2) The inquest was told that the West Yorkshire Integrated Care Board has not commissioned accessibility to NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust. (3) If the NHS online assessment completed by Chloe had been available to the relevant clinicians at Dewsbury District Hospital, her history of oral contraceptive use and the suspicion of a pulmonary embolism would have been visible to them. (4) The availability of NHS 111 online assessments to clinicians in Emergency Departments may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in Emergency Departments. ”

    Source location

    Chloe Alicia 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

    Adopt the Booking and Referral Standard in West Yorkshire to enable secure transfer of NHS 111 online assessment data to emergency departments.

    Verbatim wording from the response

    “However, there is now a national solution in development which is designed to enable the safe, structured transfer of such information across systems. This is called the Booking and Referral Standard (BaRS). Our approach will be to use the BaRS in West Yorkshire.”

    Source location

    Response from West Yorkshire Integrated Care Board
    Page 2 · response
    Published 23 June 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

    Work with national and local partners, including MYTT and NHS England, to facilitate interoperability and transfer of critical patient information.

    Verbatim wording from the response

    “Adoption of BaRS is the responsibility of individual NHS trusts and their suppliers. However, compatibility with many existing NHS IT systems — such as Symphony, currently used within Mid Yorkshire Teaching Trust (MYTT) — is not yet in place and still under development. WYICB is working actively with national and local partners to facilitate this integration. It is anticipated that NHS 111 Online assessment data could be available to EDs in West Yorkshire by March 2026.”

    Source location

    Response from West Yorkshire Integrated Care Board
    Page 2 · response
    Published 23 June 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, not the Integrated Care Board, directly commissions NHS 111 Online services.

    Verbatim wording from the response

    “At present, NHS 111 Online is commissioned nationally by NHS England (NHSE) and not directly by the West Yorkshire Integrated Care Board (WYICB). When a patient completes an NHS 111 Online assessment, the system advises them on the most appropriate local service to attend. We have been considering options for the development of “interoperable” systems locally that can routinely share data, including these assessments, between NHS111 and EDs.”

    Source location

    Response from West Yorkshire Integrated Care Board
    Page 2 · response
    Published 23 June 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

    Individual NHS trusts and their suppliers are responsible for adopting the Booking and Referral Standard.

    Verbatim wording from the response

    “Adoption of BaRS is the responsibility of individual NHS trusts and their suppliers. However, compatibility with many existing NHS IT systems — such as Symphony, currently used within Mid Yorkshire Teaching Trust (MYTT) — is not yet in place and still under development. WYICB is working actively with national and local partners to facilitate this integration. It is anticipated that NHS 111 Online assessment data could be available to EDs in West Yorkshire by March 2026.”

    Source location

    Response from West Yorkshire Integrated Care Board
    Page 2 · response
    Published 23 June 2025

    Open published response
  2. Avon

    AI-generated summary

    David Lee BIRTWISTLE · 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

    David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.

    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 provide NHS 111 information to ED departments in a user-friendly format

    Wider context from the report

    “2. NHS 111 should share information with ED departments immediately. This needs to be in a user friendly format. ”

    Source location

    David Lee BIRTWISTLE · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Delays in NHS 111 sharing information with emergency departments

    Wider context from the report

    “2. NHS 111 should share information with ED departments immediately. This needs to be in a user friendly format. ”

    Source location

    David Lee BIRTWISTLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026