PFD report

JARDINE WILLIAMS · Prevention of Future Deaths report

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Issued 16 Mar 2026•Cumbria

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Absence of pathway questions addressing the immediacy of a stated suicide plan
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Review NWAS operational practice for overdose and suicidal-ideation incidents against national guidance.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
  2. Action

    Issue and update guidance to ambulance services on overdose and suicidal-ideation calls, including clinical review requirements.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Suicidal presentations should be managed by NWAS under its established protocols, rather than transferred to Cumbria Health.

    Stated by Cumbria Health LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of pathway questions addressing the immediacy of a stated suicide plan

Wider context from the report

“As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered the Northwest Ambulance Service who, in taking information from Miss Williams, followed the pathway questions prescribed by NHS England. In the 999 call, Miss Williams had stated that she had a plan to take her own life, and an intent to do so. I was informed that there was no question in the pathway that sought to address the immediacy of that plan that was being stated. I noted that the absence of this information, and an absence of this question from the pathway, may not have assisted the call handler in compiling as clear a picture as possible about the case they were receiving. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review NWAS operational practice for overdose and suicidal-ideation incidents against national guidance.

Verbatim wording from the response

“NHS England’s Emergency Call Prioritisation Advisory Group (ECPAG) wrote to all ambulance trusts asking them to confirm compliance with all aspects of the NHS England guidance on ‘999 overdose and suicidal ideation calls’. NWAS confirmed that appropriate measures were in place as per NHS England guidance. To ensure this remains the case, NHS England will review NWAS’ current operational practise in relation to overdose and suicidal ideation incidents to ensure alignment with national guidance.”

Source location

Response from NHS England
Page 4 · response
Published 26 March 2026

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

Issue and update guidance to ambulance services on overdose and suicidal-ideation calls, including clinical review requirements.

Verbatim wording from the response

“In April 2021, NHS England issued guidance to ambulance services relating to overdoses taken with suicidal intent. This was further updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). The guidance highlights the critical importance of clinical oversight and review and sets out that:”

Source location

Response from NHS England
Page 3 · response
Published 26 March 2026

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

Suicidal presentations should be managed by NWAS under its established protocols, rather than transferred to Cumbria Health.

Verbatim wording from the response

“When Miss Williams' case was transferred by NWAS to Cumbria Health, the comments provided by NWAS were limited to the following: “F- can't do it anymore MH”. The PFD Report suggests that NWAS was aware of more information, including that Miss Williams was suicidal: "In this call Miss Williams confirmed she had been experiencing worsening mental health problems and had suicidal thoughts, as well as a plan and an intention to carry out that plan."”

Source location

Response from Cumbria Health
Page 2 · response
Published 26 March 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The NHS Pathways system includes an immediacy question and, in this case, elicited information triggering the correct approved ambulance response.

Verbatim wording from the response

“In this particular case, it appears from your report that the NHS Pathways triage system did elicit the correct information from the patient which triggered the correct nationally approved ambulance response.”

Source location

Response from NHS England
Page 3 · response
Published 26 March 2026

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

No further NHS Pathways system change is currently planned because substantial national changes, discussions and mandates have already addressed suicide-risk management.

Verbatim wording from the response

“significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content). This will remain under review as and when new evidence or guidance emerges.”

Source location

Response from NHS England
Page 3 · response
Published 26 March 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

  1. 1

    Share this response with the Integrated Care Board and CQC.

    Stated by Cumbria Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
  2. 2

    Disseminate learning from the case to clinicians through emails, newsletters and a Clinical Forum case review.

    Stated by Cumbria Health LimitedStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  3. 3

    Undertake targeted learning on key policies and procedures, including the No Show and Clinical Hub Operational Policies.

    Stated by Cumbria Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
  4. 4

    Implement and refine Clinical Hub processes requiring supervisors to manage APAS 999 calls, enforce category-based timelines and return breached calls to NWAS.

    Stated by Cumbria Health LimitedStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  5. 5

    Continue joint work with NWAS through adverse-incident sharing, quarterly meetings and ad hoc reactive meetings.

    Stated by Cumbria Health LimitedStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
  6. 6

    Report the PFD concerns to the Integrated Care Board and CQC.

    Stated by Cumbria Health LimitedStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  7. 7

    Develop and deploy a disposition code identifying emergency ambulance responses for suicide risk.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  8. 8

    Provide mental-health assessment training materials to NHS 111 and ambulance service providers.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  9. 9

    Disseminate the Report to regional clinical quality colleagues for assurance purposes.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  10. 10

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
  11. 11

    Request ambulance trusts to confirm compliance with national guidance on overdose and suicidal-ideation calls.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    The existing No Show Standard Operating Procedure is considered fit for purpose for handling unsuccessful patient contact after three call attempts.

    Stated by Cumbria Health LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    NWAS is responsible for providing further information on its system changes and incident review through its own response or direct contact.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. 3

    NHS Pathways has no oversight of local ambulance queues or their management, including waiting times affected by local demand and resourcing pressures.

    Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.

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

Share this response with the Integrated Care Board and CQC.

Verbatim wording from the response

“In line with our statutory duty, Cumbria Health has reported themselves to the North East and North Cumbria Integrated Care Board and the CQC following the receipt of the PFD Report. This response will also be shared with those bodies.”

Source location

Response from Cumbria Health
Page 1 · response
Published 26 March 2026

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

Disseminate learning from the case to clinicians through emails, newsletters and a Clinical Forum case review.

Verbatim wording from the response

“Wider learning has also taken place in the form of emails and monthly newsletters circulated to all clinicians in March 2025 and November 2025. The case was also presented as a case review at the August 2025 Cumbria Health Clinical Forum, which was attended by Cumbria Health clinicians”

Source location

Response from Cumbria Health
Page 2 · response
Published 26 March 2026

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

Undertake targeted learning on key policies and procedures, including the No Show and Clinical Hub Operational Policies.

Verbatim wording from the response

“During a supervision session in April 2026, I discussed Miss Williams' case with the relevant clinician. The clinician identified their error and its origin, confirmed that they will reflect on our discussion and amend their practice going forward to avoid a reoccurrence, and agreed to undertake further targeted learning in the form of reviewing Cumbria Health's key policies and procedures, including the ‘No Show’ Standard Operating Procedure (discussed above) and the Clinical Hub Operational Policy (discussed below).”

Source location

Response from Cumbria Health
Page 2 · response
Published 26 March 2026

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

Implement and refine Clinical Hub processes requiring supervisors to manage APAS 999 calls, enforce category-based timelines and return breached calls to NWAS.

Verbatim wording from the response

“In addition to the clinicians actioning the APAS 999 service calls, Cumbria Health has control room supervisors who have a role in overseeing Cumbria Health's working call list to ensure that calls are not left unattended and do not breach time guidelines.”

Source location

Response from Cumbria Health
Page 3 · response
Published 26 March 2026

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

Continue joint work with NWAS through adverse-incident sharing, quarterly meetings and ad hoc reactive meetings.

Verbatim wording from the response

“A learning event meeting was held with NWAS in March 2026. A key issue discussed and subsequently agreed was that, as set out above, Miss Williams' case should not have been sent to Cumbria Health. It was also agreed that NWAS and Cumbria Health will continue to work closely together in relation to the management of APAS 999 service calls. They will continue to share significant adverse incidents with each other and hold quarterly meetings, and ad hoc reactive meetings if a pressing concern arises. The next meeting is anticipated to take place in July 2026.”

Source location

Response from Cumbria Health
Page 2 · response
Published 26 March 2026

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

Report the PFD concerns to the Integrated Care Board and CQC.

Verbatim wording from the response

“In line with our statutory duty, Cumbria Health has reported themselves to the North East and North Cumbria Integrated Care Board and the CQC following the receipt of the PFD Report. This response will also be shared with those bodies.”

Source location

Response from Cumbria Health
Page 1 · response
Published 26 March 2026

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

Develop and deploy a disposition code identifying emergency ambulance responses for suicide risk.

Verbatim wording from the response

“A new disposition code was developed in the NHS Pathways product in April 2019. ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ enables clearer visibility of such cases in the Computer Assisted Dispatch (CAD) system used by staff in ambulance services, supporting them to readily identify the cases requiring prioritised review due to suicide attempt. Furthermore, NHS Pathways provides a code identifying suicidal intent – the means and a plan to complete suicide (SD4244-AMB suicidal means and a plan). The new disposition code was created within the NHS Pathways system in April 2019, following the presentation and ratification of the changes to the former NHS Pathways National Clinical Governance Group (NCGG) in February 2019.”

Source location

Response from NHS England
Page 2 · response
Published 26 March 2026

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

Provide mental-health assessment training materials to NHS 111 and ambulance service providers.

Verbatim wording from the response

“NHS Pathways has additionally provided a significant volume of training materials regarding the assessment of patients with mental health conditions to all provider of NHS 111 and the ambulance services that use NHS Pathways, and has offered to work with and to advise North West Ambulance Service (NWAS) on how best to triage mental health situations. Regional clinical quality colleagues for the North West have also been made aware of your Report for the appropriate assurance purposes.”

Source location

Response from NHS England
Page 2 · response
Published 26 March 2026

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

Disseminate the Report to regional clinical quality colleagues for assurance purposes.

Verbatim wording from the response

“NHS Pathways has additionally provided a significant volume of training materials regarding the assessment of patients with mental health conditions to all provider of NHS 111 and the ambulance services that use NHS Pathways, and has offered to work with and to advise North West Ambulance Service (NWAS) on how best to triage mental health situations. Regional clinical quality colleagues for the North West have also been made aware of your Report for the appropriate assurance purposes.”

Source location

Response from NHS England
Page 2 · response
Published 26 March 2026

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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Miss Williams, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 4 · response
Published 26 March 2026

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

Request ambulance trusts to confirm compliance with national guidance on overdose and suicidal-ideation calls.

Verbatim wording from the response

“NHS England’s Emergency Call Prioritisation Advisory Group (ECPAG) wrote to all ambulance trusts asking them to confirm compliance with all aspects of the NHS England guidance on ‘999 overdose and suicidal ideation calls’. NWAS confirmed that appropriate measures were in place as per NHS England guidance. To ensure this remains the case, NHS England will review NWAS’ current operational practise in relation to overdose and suicidal ideation incidents to ensure alignment with national guidance.”

Source location

Response from NHS England
Page 4 · response
Published 26 March 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The existing No Show Standard Operating Procedure is considered fit for purpose for handling unsuccessful patient contact after three call attempts.

Verbatim wording from the response

“Cumbria Health's ‘No Show’ Standard Operating Procedure states that a clinician should attempt to call a patient three times with five minute intervals. In relation to APAS 999 service calls, if the clinician is unsuccessful in speaking with the patient after following this procedure, the call should be handed back to NWAS stating “failed contact”, and then NWAS will manage the case in line with their established protocols.”

Source location

Response from Cumbria Health
Page 2 · response
Published 26 March 2026

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

NWAS is responsible for providing further information on its system changes and incident review through its own response or direct contact.

Verbatim wording from the response

“NWAS have advised that colleagues from the Trust attended the Inquest and are currently drafting its own formal response to the Regulation 28 concerns raised by HM Coroner.”

Source location

Response from NHS England
Page 4 · response
Published 26 March 2026

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 Pathways has no oversight of local ambulance queues or their management, including waiting times affected by local demand and resourcing pressures.

Verbatim wording from the response

“NHS Pathways does not have oversight of local ambulance queues or their management, and note that it can be the case that waiting times may be longer than the national response times due to local resourcing and demand pressures. Given the”

Source location

Response from NHS England
Page 2 · response
Published 26 March 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026