JARDINE WILLIAMS · Prevention of Future Deaths report

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Issued 16 Mar 2026•Cumbria

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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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

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

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. Cumbria Health Limited

    Share this response with the Integrated Care Board and CQC.

  2. Cumbria Health Limited

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

  3. Cumbria Health Limited

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

  4. Cumbria Health Limited

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

  5. Cumbria Health Limited

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

  6. Cumbria Health Limited

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

  7. NHS England

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

  8. NHS England

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

  9. NHS England

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

  10. NHS England

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

  11. NHS England

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

  12. NHS England

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

  13. NHS England

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Cumbria Health Limited

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

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Cumbria Health Limited

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

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. NHS England

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

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. NHS England

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

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  5. NHS England

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

    Outside remitThe respondent said that this matter was outside its role or authority.
  6. NHS England

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

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

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

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 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 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

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

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

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
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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