PFD report

Sandra Ann MILLARD · Prevention of Future Deaths report

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Issued 7 Apr 2025•Berkshire

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

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. Failure to apply additional caller enquiries when a person is unable to move from any position
    Part of recurring concern: Failure to establish and address patients’ ability to access advised emergency care
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

    Maintain NHS Pathways functionality for assessing patients unable to move from their current position.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
  2. Action

    Implement the approved staff directive requiring enhanced questioning, contact details, falls triage, position documentation, clinical referral and appropriate case closure.

    Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 April 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Writing NHS Pathways triage algorithms is outside the Trust’s responsibility, so it cannot directly change the questions asked.

    Stated by South Central Ambulance Service NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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

Failure to apply additional caller enquiries when a person is unable to move from any position

Wider context from the report

“I heard that when SCAS call takers using the NHS Pathways triage tool exit a module indicating a person is lying on the floor with no reported injuries they are prompted to ask additional questions of the caller; including whether someone else is with the caller; whether the caller can provide a number for next of kin or other person who may be able to attend the caller whilst they wait for an ambulance. This is due to the likely delay of a number of hours before an ambulance can attend. This same procedure is not applied when someone reports that they are stuck in situ, for example they are unable to move from their chair. My concern is that the additional risks of a long lie, for example rhabdomyolysis, may well apply when someone in unable to move from any position. SCAS agreed to change their standard operating procedures to incorporate additional enquiries in these circumstances. I am pleased that they have agreed to amend their procedures swiftly. However this matter has wider significance and should be considered by other users of the NHS Pathways triage tool. ”

Is this part of a recurring concern?

Yes — Failure to establish and address patients’ ability to access advised emergency care.

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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

Maintain NHS Pathways functionality for assessing patients unable to move from their current position.

Verbatim wording from the response

“Between 2017 and 2018, NHS Pathways collaborated with its ambulance service stakeholders to enhance the assessment of patients who may not have fallen but are nonetheless unable to move from their current position. Since 2018, the system has included functionality to assess patients in this situation, regardless of whether their immobility is due to disability, frailty, weakness, pain, or another factor.”

Source location

Response from NHSE
Page 1 · response
Published 11 April 2025

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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

Implement the approved staff directive requiring enhanced questioning, contact details, falls triage, position documentation, clinical referral and appropriate case closure.

Verbatim wording from the response

“In response to your concerns, a change in process has now been written by ████████ in the form of a directive to staff. The changes will include:”

Source location

Response from South Central Ambulance Service
Page 1 · response
Published 11 April 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Writing NHS Pathways triage algorithms is outside the Trust’s responsibility, so it cannot directly change the questions asked.

Verbatim wording from the response

“Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.”

Source location

Response from South Central Ambulance Service
Page 1 · response
Published 11 April 2025

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

NHS England designs and manages NHS Pathways and must consider whether the algorithm should be changed.

Verbatim wording from the response

“Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.”

Source location

Response from South Central Ambulance Service
Page 1 · response
Published 11 April 2025

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.2

  1. 1

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
  2. 2

    Share the process changes with patient safety counterparts to support national learning.

    Stated by South Central Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    The local service provider decides next steps after unsuccessful clinician contact under its operational policies and procedures.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The 111 provider is responsible for operational management when a call is ended and a clinician callback is arranged.

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

    Determining next steps when a clinician cannot contact a patient is beyond NHS Pathways’ scope.

    Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
  4. 4

    Capturing next-of-kin details falls outside the NHS Pathways triage tool’s remit because local protocols should address it.

    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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning nationally and regionally.

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 Sandra, 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 NHSE
Page 2 · response
Published 11 April 2025

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Share the process changes with patient safety counterparts to support national learning.

Verbatim wording from the response

“In addition to any potential changes that NHS England may make to NHS Pathways, to ensure that there is the opportunity for national learning to take place, our patient safety team will also share the changes that we have made to our processes with their counterparts.”

Source location

Response from South Central Ambulance Service
Page 2 · response
Published 11 April 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The local service provider decides next steps after unsuccessful clinician contact under its operational policies and procedures.

Verbatim wording from the response

“It is also expected that local protocols are in place to capture demographic details such as next of kin, as this information falls outside the remit of the NHS Pathways triage tool. Similarly, where a clinician is unable to make contact with the patient (noting that the clinician in this case attempted to call Sandra 4 times before closing the call), it is beyond the scope of NHS Pathways to determine the next steps. This decision lies with the local service provider in accordance with their operational policies and procedures. We understand that South Central Ambulance Service (SCAS) are changing their standard operating procedure as a result of the concerns raised by your Report, and that they will be sharing learnings through national forums.”

Source location

Response from NHSE
Page 2 · response
Published 11 April 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The 111 provider is responsible for operational management when a call is ended and a clinician callback is arranged.

Verbatim wording from the response

“In scenarios where the call is transferred immediately to a clinician, the Pathways system does not prompt the question about whether someone can stay with the patient, as this consideration should form a part of the clinician’s overall assessment. In Sandra’s case, the call was not immediately transferred but was instead ended by the call taker, who arranged for a clinician to call her back. The 111 provider would have responsibility for the operational management of this, however the system recommended disposition is for immediate clinical assessment.”

Source location

Response from NHSE
Page 2 · response
Published 11 April 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Determining next steps when a clinician cannot contact a patient is beyond NHS Pathways’ scope.

Verbatim wording from the response

“It is also expected that local protocols are in place to capture demographic details such as next of kin, as this information falls outside the remit of the NHS Pathways triage tool. Similarly, where a clinician is unable to make contact with the patient (noting that the clinician in this case attempted to call Sandra 4 times before closing the call), it is beyond the scope of NHS Pathways to determine the next steps. This decision lies with the local service provider in accordance with their operational policies and procedures. We understand that South Central Ambulance Service (SCAS) are changing their standard operating procedure as a result of the concerns raised by your Report, and that they will be sharing learnings through national forums.”

Source location

Response from NHSE
Page 2 · response
Published 11 April 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Capturing next-of-kin details falls outside the NHS Pathways triage tool’s remit because local protocols should address it.

Verbatim wording from the response

“It is also expected that local protocols are in place to capture demographic details such as next of kin, as this information falls outside the remit of the NHS Pathways triage tool. Similarly, where a clinician is unable to make contact with the patient (noting that the clinician in this case attempted to call Sandra 4 times before closing the call), it is beyond the scope of NHS Pathways to determine the next steps. This decision lies with the local service provider in accordance with their operational policies and procedures. We understand that South Central Ambulance Service (SCAS) are changing their standard operating procedure as a result of the concerns raised by your Report, and that they will be sharing learnings through national forums.”

Source location

Response from NHSE
Page 2 · response
Published 11 April 2025

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