NHS Pathways

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First report 27 Apr 2016•Latest report 11 May 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 17
Published responses: 12%
Concerns addressed: 2
Stated actions: 3

Concerns and recipient responses

Statements from NHS Pathways linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 May2026
Surrey
Concerns raised4
1. Misleading public impression created by the Emergency Medical Advisor role title
2. Failure to provide compliant and timely follow-up call management
3. Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
1. Limited clinical capability of Emergency Medical Advisors to recognise serious illness
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Misleading public impression created by the Emergency Medical Advisor role title
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. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide compliant and timely follow-up call management
Wider context from the report
“1. The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls At 14:51 hours on 22nd July 2024, Oliver’s parents called 999 indicating their concern that Oliver was suffering from meningitis as he was suffering from a non-blanching rash, vomiting and reduced level of consciousness. The EMA began a triage using NHS Pathways algorithm but as they were unable to prioritise any of the listed symptoms, they requested operational support at 14:57 hours, to ask if there was a meningitis pathway within the system. This call was concluded at 15:51 with the EMA indicating to Oliver’s parents that a call back was scheduled within 20 minutes. A call back was not undertaken until 1 hr and 41 minutes later and in the absence of a response a further unsuccessful call was made 2 hrs and 18 minutes later before Secamb closed the referral. In the meantime, Oliver’s parents made the decision to convey Oliver to hospital arriving there at around 15:55 hours. On attendance it was recognised that Oliver was gravely unwell and despite maximal supportive management sadly died from overwhelming meningococcal septicaemia 7.5 hours after his arrival. In their investigation, Secamb acknowledged that the EMA’s management of the 999 call was not compliant and have taken the opportunity to offer ongoing training. However, it was also recognised EMA’s found it challenging to triage individuals when multiple signs and symptoms were present in relation to a possible sepsis diagnosis and that having a dedicated sepsis algorithm would assist them in being able to provide an appropriate response to callers and to ensure appropriate management. This has important implications for prioritising ambulance disposition, which may also include the ability of a paramedic to attend at the earliest opportunity to give antibiotics. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
Wider context from the report
“1. The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls At 14:51 hours on 22nd July 2024, Oliver’s parents called 999 indicating their concern that Oliver was suffering from meningitis as he was suffering from a non-blanching rash, vomiting and reduced level of consciousness. The EMA began a triage using NHS Pathways algorithm but as they were unable to prioritise any of the listed symptoms, they requested operational support at 14:57 hours, to ask if there was a meningitis pathway within the system. This call was concluded at 15:51 with the EMA indicating to Oliver’s parents that a call back was scheduled within 20 minutes. A call back was not undertaken until 1 hr and 41 minutes later and in the absence of a response a further unsuccessful call was made 2 hrs and 18 minutes later before Secamb closed the referral. In the meantime, Oliver’s parents made the decision to convey Oliver to hospital arriving there at around 15:55 hours. On attendance it was recognised that Oliver was gravely unwell and despite maximal supportive management sadly died from overwhelming meningococcal septicaemia 7.5 hours after his arrival. In their investigation, Secamb acknowledged that the EMA’s management of the 999 call was not compliant and have taken the opportunity to offer ongoing training. However, it was also recognised EMA’s found it challenging to triage individuals when multiple signs and symptoms were present in relation to a possible sepsis diagnosis and that having a dedicated sepsis algorithm would assist them in being able to provide an appropriate response to callers and to ensure appropriate management. This has important implications for prioritising ambulance disposition, which may also include the ability of a paramedic to attend at the earliest opportunity to give antibiotics. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
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. ”
Open source report
30 Apr2026
East Riding and Hull
Concerns raised1
1. Insufficient questioning to identify uncontrolled bleeding
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Dr Kenneth Wilson CULLY · 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

Dr Kenneth Wilson CULLY died after a catastrophic, uncontrollable bleed from the foot while taking blood-thinning medication. The report identified a concern that the ambulance service’s newer NHS Pathway system may lack sufficient questions to recognise the seriousness of an uncontrolled bleed, potentially leading to incorrect categorisation and delayed treatment.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Insufficient questioning to identify uncontrolled bleeding
Wider context from the report
“In the new NHS Pathway system there appeared to be an insufficiency in the questions to correctly identify the seriousness of an uncontrolled bleed (there is no question regarding whether the bleed is controlled or not). This could lead to the categorisation of the call being incorrect and a delay in treating a catastrophic event needing immediate attention. ”
Open source report
27 Apr2026
East Riding and Hull
Concerns raised1
1. Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Christine Joan Clegg · 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

Christine Joan Clegg died at Hull Royal Infirmary after an unwitnessed fall at her care home, in which she sustained a traumatic brain injury and later deteriorated. The report raises concern that inaccurate information given to NHS 111 led to a minor-wounds pathway being followed instead of the head-injury pathway, resulting in basic first-aid advice without clinical input. It also concerns the availability of the minor-wounds script for injuries above the neck, which may lead to a non-clinical outcome for head injuries.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck
Wider context from the report
“(1) The NHS 111 script for scratches grazes or minor wounds is available for head injuries but can lead to a non clinical outcome and basic first aid advice being given. The fact is, however, either a scratch, graze or nick above the neck indicates that either has been a head injury of some degree or other and so the script which should correctly be followed is the head injury pathway. If injuries above the neck were excluded from the scratches grazes and nicks pathway then the possibility of basic first aid advice being given is eliminated as all head injury answered result in clinician advice being sought. ”
Open source report
4 Mar2026
Coventry
Concerns raised6
1. Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
2. Delays in ambulance handover reducing emergency ambulance availability
3. Failure to reliably identify excessive or repeated requests for salbutamol inhalers
1. Lack of a consistent follow-up process for salbutamol overuse patterns
2. Limited awareness of the significance of salbutamol overuse in patients and families
3. Failure of NHS Pathways triage wording to be readily understood by callers in distress
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Roman Louie BARR · 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

Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
Wider context from the report
“4. Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Delays in ambulance handover reducing emergency ambulance availability
Wider context from the report
“3. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report
“2. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report
“2. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Limited awareness of the significance of salbutamol overuse in patients and families
Wider context from the report
“1. Limited awareness of salbutamol overuse Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report
“5. Clarity of NHS Pathways triage wording Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information. This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress. ”
Open source report
4 Mar2026
Coventry
Concerns raised6
1. Limited awareness of salbutamol overuse and its association with poorly controlled asthma
2. Delays in ambulance handover at local hospitals
3. Failure to reliably identify excessive or repeated requests for salbutamol inhalers
1. Failure of NHS Pathways triage wording to be readily understood by callers in distress
2. Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves
3. Lack of a consistent follow-up process for salbutamol overuse patterns
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Roman Louie BARR · 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

Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Limited awareness of salbutamol overuse and its association with poorly controlled asthma
Wider context from the report
“1. Limited awareness of salbutamol overuse Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Delays in ambulance handover at local hospitals
Wider context from the report
“3. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report
“2. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report
“5. Clarity of NHS Pathways triage wording Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information. This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves
Wider context from the report
“4. Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report
“2. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. ”
Open source report
3 Apr2025
Lancashire and Blackburn with Darwen
Concerns raised1
1. Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

James Paul Michael Masheter · 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

James Paul Michael Masheter died by hanging at his home on 1 April 2024, after experiencing a significant mental health crisis and making calls for ambulance assistance. The report raises concerns that existing NHS Pathways mental health triage may not properly risk-assess serious crises involving a risk to life, and that categorisation as category 3 contributed to significant delays in ambulance attendance. Incorrect information about the expected waiting time was also provided to his friend, who believed the ambulance was arriving imminently and left him.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises
Wider context from the report
“1. The NHS Pathways system is used for triage. This asks standard questions to ascertain the seriousness of the situation including whether the patient is awake and breathing and so on. The triage pathway includes some options for mental health situations but these are limited. Evidence was heard in the inquest that the North West Ambulance Service (NWAS) had liaised with NHS Pathways with a view to exploring how mental health calls are triaged. NHS Pathways declined to make any changes to mental health triage but offered advice to NWAS in how to triage mental health situations. 2. The evidence heard at the inquest was that notwithstanding the seriousness of the situation in which Mr Masheter presented, his appropriate categorisation was category 3. This led to significant delays in an ambulance attending. It is not clear to me whether it is possible for serious mental health crisis situations which present a risk to life are capable of being properly risk assessed on the basis of the NHS Pathways mental health triage which exists at present. ”
Open source report
27 Nov2023
Cheshire
Concerns raised1
1. Failure to risk-stratify high-risk overdoses for immediate clinical response
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Glyn Ackerley · 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

Glyn Ackerley became unresponsive at home on 4 September 2022 after reporting that he had swallowed medication; the cause of death could not be determined. The report raised concern that the NHS Pathways process in place at the time did not distinguish between high-risk and low-risk overdoses, potentially delaying treatment for a potentially fatal overdose.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to risk-stratify high-risk overdoses for immediate clinical response
Wider context from the report
“The current NHS Pathways process does not differentiate between a high risk and low risk overdose, categorising all such calls without additional symptoms as category 3. Evidence was heard during the inquest that time is of the essence when dealing with an opiate overdose, and giving reversal medication prior to any respiratory depression or cardiac arrest will likely have a better outcome. In light of the concerns raised by this case, NWAS have reviewed their process and added in additional questions for call handlers to identify high risk medications involved in an overdose, which they then automatically categorise as a category 2 and send for a call back from a clinician immediately. NWAS gave evidence in writing that they had raised the concern and their suggested management with the National NHS Pathways team on 6 April 2023, with the result that the national team would continue to review the process but with clinical review in 15 minutes and high risk medications being upgraded to category 2. It is unclear from the evidence whether this is a proposed change to the process in place in September 2022 which would mean Mr Ackerley would have had a category 2 response at 21.48, or whether the system remains the same. If the system is not for a category 2 response for high risk medication, it is my concern that this will not allow for prompt treatment of those who have taken a potentially fatal overdose. ”
Open source report
1 Jun2022
Hull and East Riding of Yorkshire
Concerns raised5
1. Failure to consider the timing of requests for advice in 111 dispositions
2. Failure to accommodate prior direct general practitioner review in 111 dispositions
3. Lack of detailed assessment of the degree of apparent concern
1. Unavailability of accessible paediatric infrastructure in an out-of-hours GP service
2. Failure to question the nature of vomitus in young children
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Esma GUZEL · 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

Esma Guzel, aged five, died on 10 May 2019 after developing vomiting and abdominal pain due to complications of a congenital diaphragmatic hernia. After a GP assessment and subsequent deterioration, the 111 service advised attendance at an out-of-hours GP service, where she arrived in cardiac arrest and could not be resuscitated. The principal concerns relate to questioning about vomitus, the 111 algorithm’s assessment and disposition, and referral to paediatric services.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider the timing of requests for advice in 111 dispositions
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to accommodate prior direct general practitioner review in 111 dispositions
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of detailed assessment of the degree of apparent concern
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of accessible paediatric infrastructure in an out-of-hours GP service
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to question the nature of vomitus in young children
Wider context from the report
“I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net. ”
Open source report
27 Jan2022
Birmingham and Solihull
Concerns raised1
1. Failure to allow a category 1 ambulance response for severe ABD involving restraint
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Adam Marshall Elliot STONE · 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

Adam Marshall Elliot Stone became distressed, agitated and paranoid after using cocaine, displayed signs of acute behavioural disturbance, and died after his condition deteriorated during restraint, ambulance transfer and hospital treatment. The report raised concern that the ambulance-service system did not allow a category 1 response for severe acute behavioural disturbance where restraint was taking place, which it stated was putting lives at risk.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to allow a category 1 ambulance response for severe ABD involving restraint
Wider context from the report
“5. The continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk. ”
Open source report
14 Jan2021
Surrey
Concerns raised1
1. Failure of emergency caller scripts to positively persuade lone callers to contact someone when paramedic attendance is delayed
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Karl James BOLAM · 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

Karl James BOLAM fell and sustained a head injury at his home in the early hours of 14 August 2018. He made several calls for an ambulance, but paramedics did not attend until 3.42am, by which time he was unconscious; he died on 17 August 2018 without regaining consciousness. The principal concern was that emergency call scripts did not positively encourage lone callers to contact someone to be with them, particularly when paramedic attendance was delayed.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of emergency caller scripts to positively persuade lone callers to contact someone when paramedic attendance is delayed
Wider context from the report
“I do not believe this issue has been adequately addressed by the amendment in Release 19.2, and that the script provided by NHS Pathways for use with emergency callers should be amended positively to persuade callers to call someone to be with them, and particularly when a delay in paramedic attendance is anticipated. SECAmb have also expressed disappointment with this response. 1. The script currently used by NHS Pathways in respect of emergency callers does not positively persuade callers to call someone to be with them, particularly in circumstances where paramedic attendance is delayed due to demands on the service. ”
Open source report
16 Dec2020
Cumbria
Concerns raised3
1. Failure to act on requests for a doctor visit from people feeling very unwell
2. Failure to maintain accurate telephone contact details to support appropriate action after call handling
3. Failure of initial telephone assessment pathways to give sufficient weight to anaemia and transfusion history
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Patricia Ann Douglas · 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

Patricia Ann Douglas contacted NHS 111 with severe breathlessness and a history of anaemia requiring a blood transfusion. Her referral to a Covid assessment service contained an incomplete telephone number, so the doctor could not contact her and the call was closed; she later deteriorated, collapsed at A&E and could not be resuscitated. Concerns included the initial triage pathway, the failure to follow up the referral, and a potentially missed opportunity to investigate and treat her.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to act on requests for a doctor visit from people feeling very unwell
Wider context from the report
“(3) This lady rang for help feeling very unwell, I am told she wanted a doctor to visit, unfortunately nothing happened and it seems very likely that an opportunity to investigate and treat her was missed. I note that two GPs would have been working for the OOH provider at Penrith Hospital –just a mile from Patricia’s home, that Sunday afternoon, one based in the hospital and the other doing home visits. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain accurate telephone contact details to support appropriate action after call handling
Wider context from the report
“(2) The call was closed by CCAS without further action due to an incorrect telephone number being recorded. The call was from an elderly lady who on the face of it seemed significantly unwell. Would referrals in similar circumstances to local providers [GP or out of hours services] who may be better placed to follow up be worth considering? ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of initial telephone assessment pathways to give sufficient weight to anaemia and transfusion history
Wider context from the report
“(1) The initial assessment by the NHS 111 call handler led her down a pathway leading to a referral to the Covid service and does not seem to have given weight to the history of anaemia and transfusion. Could the pathway be improved to give better guidance to call handlers? ”
Open source report
9 Dec2019
West Sussex
Concerns raised8
1. Failure to obtain complete medical and medication information from relevant sources
2. Early exit from NHS Pathways Module 0 for third-party calls
3. Failure to transfer important and accurate medical information to telecare and emergency services
1. Lack of a facility for call handlers to pass calls directly to ambulance triage staff
2. Lack of automatic flagging of medical and medication-related risks
3. Failure of unanswered patient call attempts to trigger clinical review of triage decisions
4. Different ambulance-call handling for third-party callers
5. Unavailability of responder telephone numbers within the call handling system
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

John Michael WELLS · 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

John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain complete medical and medication information from relevant sources
Wider context from the report
“(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete. RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls. During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form. Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties. I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello. Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers. Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property. Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet. As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Early exit from NHS Pathways Module 0 for third-party calls
Wider context from the report
“(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision. From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to transfer important and accurate medical information to telecare and emergency services
Wider context from the report
“(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete. RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls. During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form. Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties. I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello. Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers. Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property. Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet. As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of a facility for call handlers to pass calls directly to ambulance triage staff
Wider context from the report
“(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient. The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone. From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of automatic flagging of medical and medication-related risks
Wider context from the report
“(3) There is no mechanism for the automatic flagging of risks related to particular medical conditions or medications within Carenet. I heard evidence that Appello operators are not medically trained and are employed to handle a wide variety of calls. There is no system in place highlighting risk factors which might allow the operators to respond more appropriately to medical emergencies and ensure that they pass the most important information to the emergency services. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of unanswered patient call attempts to trigger clinical review of triage decisions
Wider context from the report
“(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision. From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Different ambulance-call handling for third-party callers
Wider context from the report
“(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient. The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone. From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of responder telephone numbers within the call handling system
Wider context from the report
“(2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet). Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not. The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet. ”
Open source report
7 Oct2019
Buckinghamshire
Concerns raised2
1. Failure of overdose call categorisation to ensure timely ambulance response
2. Failure to implement the local overdose response override at the outset
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Alf REWIN · 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

Alf Rewin died at Wexham Park Hospital on 22 November 2018 after taking an overdose of Quetiapine, Methylphenidate and Duloxetine and becoming unresponsive before arrival. The principal concern was that overdose cases could receive a Category 3 ambulance response with a target of up to 120 minutes, despite the risk of unconsciousness, cardiac arrest or other potentially fatal events requiring earlier attendance.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of overdose call categorisation to ensure timely ambulance response
Wider context from the report
“The National Ambulance Call Categories prescribed by NHS Pathways to ambulance services, including South Central Ambulance Service, who were the attending service in relation to Alf Rewin's death, indicate that an individual contacting emergency services himself or herself, having taken an overdose may be triaged through the national call handling pathway to a Category 3 Urgent Call. This category currently prescribes a target ambulance within 120 minutes. There is a concern that in cases of overdose, the patient is at risk of becoming unconscious or having a cardiac arrest or other potentially fatal event and will be unable to contact emergency services or be contacted by them subsequently, such that his or her call should at that stage then be regarded as Category 1 (with a 7 minute response time) or Category 2 (with an 18 minute response time). In Alf Rewin’s case, there existed a local policy to override the Category 3 120-minute response in overdose cases to provide a specific triage which could lead to a Category 2 18-minute response (although the 18-minute response was not, in fact, implemented at the outset in Alf Rewin’s case and he was initially allocated the national Category 3 response). It is understood that the national categorisation of overdose cases is under review. Whilst the Category 3 120-minute target may be the standard, subject to local variation, in relation to overdose cases where the patient is conscious, the risk of deaths arising during this period remains where the circumstances of the overdose might enable some counteractive treatment to be given, or successful resuscitation measures to be carried out, if there were to be earlier attendance and / or earlier hospitalisation. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement the local overdose response override at the outset
Wider context from the report
“The National Ambulance Call Categories prescribed by NHS Pathways to ambulance services, including South Central Ambulance Service, who were the attending service in relation to Alf Rewin's death, indicate that an individual contacting emergency services himself or herself, having taken an overdose may be triaged through the national call handling pathway to a Category 3 Urgent Call. This category currently prescribes a target ambulance within 120 minutes. There is a concern that in cases of overdose, the patient is at risk of becoming unconscious or having a cardiac arrest or other potentially fatal event and will be unable to contact emergency services or be contacted by them subsequently, such that his or her call should at that stage then be regarded as Category 1 (with a 7 minute response time) or Category 2 (with an 18 minute response time). In Alf Rewin’s case, there existed a local policy to override the Category 3 120-minute response in overdose cases to provide a specific triage which could lead to a Category 2 18-minute response (although the 18-minute response was not, in fact, implemented at the outset in Alf Rewin’s case and he was initially allocated the national Category 3 response). It is understood that the national categorisation of overdose cases is under review. Whilst the Category 3 120-minute target may be the standard, subject to local variation, in relation to overdose cases where the patient is conscious, the risk of deaths arising during this period remains where the circumstances of the overdose might enable some counteractive treatment to be given, or successful resuscitation measures to be carried out, if there were to be earlier attendance and / or earlier hospitalisation. ”
Open source report
3 Jul2019
Cornwall and Isles of Scilly
Concerns raised2
1. Failure of the free text box to generate automatic red flags from identified symptoms
2. Separate organisational time limits causing avoidable delay in the patient pathway
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Jennifer Withey · 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

Jennifer Withey died from sepsis following infection associated with a spinal fusion operation, after contacting the 111 service three times. During one call, recorded symptoms included inability to weight bear, no urine for 30 hours, and a dead-feeling left arm and leg, but the call was not immediately referred to a clinician. The report raised concerns about the lack of an automatic sepsis alert and separate timeframes operated by the 111 and out-of-hours GP services, which could introduce avoidable delay.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of the free text box to generate automatic red flags from identified symptoms
Wider context from the report
“A) The free text box could be set up so that identified symptoms, where appropriate, could generate an automatic red flag. By way of illustration, a non-blanching rash could automatically justify immediate hospital admission by ambulance in a case of suspected meningitis. Similarly, in this case, where a number of sepsis indicators were present, a red flag could have been raised requiring the call adviser specifically to consider a sepsis pathway. This would act as a second level of security, the first step being to allocate a patient to a correct pathway in the first instance. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Separate organisational time limits causing avoidable delay in the patient pathway
Wider context from the report
“B) is it possible to establish a single patient orientated pathway with a key performance indicator of, for example, ‘patient to be seen within two hours’ rather than two separate time limits for two or more organisations (here, 111 and Cornwall Health) which cumulatively introduces unnecessary and avoidable delay into the process. ”
Open source report
2 May2019
Nottinghamshire
Concerns raised5
1. Delays in updating electronic patient records with NHS 111 triage documents
2. Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
3. Variation in admission for observation of paediatric patients returning to the Emergency Department
1. Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
2. Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Alexander James Davidson · 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

Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Delays in updating electronic patient records with NHS 111 triage documents
Wider context from the report
“(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report
“(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Variation in admission for observation of paediatric patients returning to the Emergency Department
Wider context from the report
“(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report
“(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit. Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
Wider context from the report
“(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard, on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard. I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms. ”
Open source report
14 Feb2019
Brighton and Hove
Concerns raised6
1. Failure of the callback process to remain safe for lone callers who become unresponsive
2. Failure to manage support arrangements safely for callers who are alone
3. Failure to ask patients with abdominal pain about a pulsating mass
1. Failure to establish whether an emergency caller is alone and whether another person can be spoken to
2. Failure to address alternative hospital transport when ambulance arrival is expected to take two hours or more
3. Failure to explain the likely ambulance timing and estimated time of arrival
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

John SCOTT · 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

John SCOTT’s death was investigated and the inquest concluded that he died from natural causes. The concerns raised related to emergency call handling, including support for callers who are alone, ambulance estimated arrival times, whether lone callers could re-contact the service if they became unresponsive, and questions about symptoms that might indicate an abdominal aortic aneurysm.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure of the callback process to remain safe for lone callers who become unresponsive
Wider context from the report
“3. With regard to Pathways I understand that they have their particular questions but how can a person who is alone when they ring the ambulance service phone the ambulance back if they become unresponsive? This is a nonsense and may well confuse the patient who is ringing. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to manage support arrangements safely for callers who are alone
Wider context from the report
“(1) With regard to the questions asked when an emergency call is made to South East Coast Ambulance Service my view is that the additional questions should be asked: 1. Is there anyone else with you or are you alone? If there is anyone else with you may I please speak to them. 2. If the caller is alone: we will be asking you not to ring anybody because we need to consider the possibility that we will need to ring you back however, if you want to phone for somebody to come and bring you some support and company could you please do that within the next 15 minutes from now. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to ask patients with abdominal pain about a pulsating mass
Wider context from the report
“4. Since we were dealing at this Inquest with a case of previously undiagnosed abdominal aortic aneurysm and since this is not an unusual scenario for Pathways or South East Coast Ambulance to come across, is it not possible to ask the patient whether they can feel anything at the site of the pain e.g., a pulsating mass. This if it is felt, could be a clear diagnostic sign. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish whether an emergency caller is alone and whether another person can be spoken to
Wider context from the report
“(1) With regard to the questions asked when an emergency call is made to South East Coast Ambulance Service my view is that the additional questions should be asked: 1. Is there anyone else with you or are you alone? If there is anyone else with you may I please speak to them. 2. If the caller is alone: we will be asking you not to ring anybody because we need to consider the possibility that we will need to ring you back however, if you want to phone for somebody to come and bring you some support and company could you please do that within the next 15 minutes from now. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to address alternative hospital transport when ambulance arrival is expected to take two hours or more
Wider context from the report
“At the end of the call when the Pathways aspect of the call is ended why do you not explain to the person ringing you, about the likely timing of the ambulance at that stage and therefore, the estimated time of arrival. If at that stage the estimated time of arrival is two hours or more, why do you not suggest to the patient that they may like to make arrangements to get themselves to hospital without an ambulance? ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Failure to explain the likely ambulance timing and estimated time of arrival
Wider context from the report
“At the end of the call when the Pathways aspect of the call is ended why do you not explain to the person ringing you, about the likely timing of the ambulance at that stage and therefore, the estimated time of arrival. If at that stage the estimated time of arrival is two hours or more, why do you not suggest to the patient that they may like to make arrangements to get themselves to hospital without an ambulance? ”
Open source report
27 Apr2016
Inner North London
Concerns raised1
1. Lack of a triage tool to recognise agonal or inadequate breathing
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Caragh Melling · 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

Caragh Melling collapsed at home after an episode of dizziness and died shortly after arriving at hospital following unsuccessful resuscitation attempts. The ambulance call triage failed to recognise her agonal breathing, and the report raised concerns that the NHS Pathways system lacked a tool to identify inadequate breathing and that it was unclear whether action was being taken to address this.

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. The report was sent to NHS Pathways; that does not assign responsibility.
PFD Monitor interpretation
Lack of a triage tool to recognise agonal or inadequate breathing
Wider context from the report
“(1) I heard evidence from the Ambulance Trust that a previous triage system included a tool which could recognise the presence of agonal or inadequate breathing. The call handler would record every point at which the patient was noted to inspire. The tool would then alert the call handler to the presence of inadequate breathing. The Ambulance Trust noted that their current triage system, NHS Pathways, does not include this tool. They have instituted a local ‘workaround’; a question that asks whether the patient’s breathing is ‘noisy’. If this is answered affirmatively, agonal breathing is presumed and the call categorised as the fastest response time being required (R1). I heard evidence that NHS Pathways were contacted in 2014 to raise the absence of the breathing analysis tool as being a cause for concern. No action appears to have been taken. I also understand that the Medical Director of the Ambulance Trust has again raised concerns at the national level but it is unclear whether any action is being taken. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Misleading public impression created by the Emergency Medical Advisor role title

Failure to provide compliant and timely follow-up call management

Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls

Limited clinical capability of Emergency Medical Advisors to recognise serious illness

Concerns raised1

Insufficient questioning to identify uncontrolled bleeding

Concerns raised1

Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck

Concerns raised6

Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies

Delays in ambulance handover reducing emergency ambulance availability

Failure to reliably identify excessive or repeated requests for salbutamol inhalers

Lack of a consistent follow-up process for salbutamol overuse patterns

Limited awareness of the significance of salbutamol overuse in patients and families

Failure of NHS Pathways triage wording to be readily understood by callers in distress

Concerns raised6

Limited awareness of salbutamol overuse and its association with poorly controlled asthma

Delays in ambulance handover at local hospitals

Failure to reliably identify excessive or repeated requests for salbutamol inhalers

Failure of NHS Pathways triage wording to be readily understood by callers in distress

Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves

Lack of a consistent follow-up process for salbutamol overuse patterns

Concerns raised1

Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises

Concerns raised1

Failure to risk-stratify high-risk overdoses for immediate clinical response

Concerns raised5

Failure to consider the timing of requests for advice in 111 dispositions

Failure to accommodate prior direct general practitioner review in 111 dispositions

Lack of detailed assessment of the degree of apparent concern

Unavailability of accessible paediatric infrastructure in an out-of-hours GP service

Failure to question the nature of vomitus in young children

Concerns raised1

Failure to allow a category 1 ambulance response for severe ABD involving restraint

Concerns raised1

Failure of emergency caller scripts to positively persuade lone callers to contact someone when paramedic attendance is delayed