PFD report

Oscar Michael Thomas Keenan · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 12 Jun 2025•Oxfordshire

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
4

Of 2 recipients

Stated actions
24

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised3

  1. Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems
    Part of recurring concern: Unreliable algorithmic triage of unwell patients
  2. Total reliance on an algorithm that does not direct early clinical input
    Part of recurring concern: Unreliable algorithmic triage of unwell patientsPart of recurring concern: Unreliable remote assessment and triage of ill infants
  3. Delays and lack of direction in obtaining clinical assessment
    Part of recurring concern: Failure to conduct timely, appropriate clinical assessments
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.4

  1. Action

    Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
  2. Action

    Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  3. Action

    Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The review concluded that the NHS Pathways algorithm functioned as intended in this case and required no changes.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment (2) Total reliance on the algorithm which does not appear to direct early clinical input. (3) A delay/lack of direction in obtaining clinical assessment. I have concerns that this is widespread and could occur in other areas. ”

Is this part of a recurring concern?

Yes — Unreliable algorithmic triage of unwell patients.

Open source report

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

Total reliance on an algorithm that does not direct early clinical input

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment (2) Total reliance on the algorithm which does not appear to direct early clinical input. (3) A delay/lack of direction in obtaining clinical assessment. I have concerns that this is widespread and could occur in other areas. ”

Is this part of a recurring concern?

Yes — Unreliable algorithmic triage of unwell patients; Unreliable remote assessment and triage of ill infants.

Open source report

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

Delays and lack of direction in obtaining clinical assessment

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment (2) Total reliance on the algorithm which does not appear to direct early clinical input. (3) A delay/lack of direction in obtaining clinical assessment. I have concerns that this is widespread and could occur in other areas. ”

Is this part of a recurring concern?

Yes — Failure to conduct timely, appropriate clinical assessments.

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

Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.

Verbatim wording from the response

“We recognize that the remote assessment of very young babies is inherently challenging, and we continuously refine the system based on clinical feedback and real-world cases. In Oscar’s case – and in accordance with the investigation at SCAS - the review concluded that the algorithm functioned as intended, and no changes were required. However, every case contributes to our ongoing learning and improvement.”

Source location

Response from NHS England
Page 3 · response
Published 30 July 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

Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.

Verbatim wording from the response

“NHS Pathways System Issues”

Source location

Response from South Central Ambulance Service
Page 8 · response
Published 30 July 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

Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.

Verbatim wording from the response

“111 End to End Review Meetings”

Source location

Response from South Central Ambulance Service
Page 8 · response
Published 30 July 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

Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.

Verbatim wording from the response

“To further gauge understanding and comprehension of the content within any shared learning materials issued, there is a monthly Quick Quiz for both service lines (111 and 999) comprising of 10 true / false and / or multiple-choice questions. The questions are drawn from any recent Standard Operating Procedure (SOP) Change Notices, shared learning materials, existing SOPs, and general triage principles for the NHS Pathways system. The quiz is facilitated via MS Forms which allows staff who submit incorrect answers to see explanations of the correct answer with sign posting to the source reference materials. Quick Quizzes have included questions regarding assessing a patient’s breathing in July 2024, August 2024, September 2024 and April 2025 and regarding when and how to pass a call to a clinician every month since December 2024.”

Source location

Response from South Central Ambulance Service
Page 3 · response
Published 30 July 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 review concluded that the NHS Pathways algorithm functioned as intended in this case and required no changes.

Verbatim wording from the response

“We recognize that the remote assessment of very young babies is inherently challenging, and we continuously refine the system based on clinical feedback and real-world cases. In Oscar’s case – and in accordance with the investigation at SCAS - the review concluded that the algorithm functioned as intended, and no changes were required. However, every case contributes to our ongoing learning and improvement.”

Source location

Response from NHS England
Page 3 · response
Published 30 July 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

Local services manage the availability of services matched to the NHS Pathways recommended outcome.

Verbatim wording from the response

“Health advisors using the NHS Pathways system must have access to clinical support and supervision. They are trained to use probing questions to better understand caller responses. If a call is complex, uncertain, or includes three “not sure” answers, advisors are expected to seek clinical input. This support should be available immediately through a ‘warm transfer’ to a clinician, as required by the system’s Licence. To encourage this, NHS Pathways promotes the motto: “If in doubt, shout.” The system generates a recommended outcome (disposition), which is then matched to services commissioned locally. The availability of these services is managed locally.”

Source location

Response from NHS England
Page 4 · response
Published 30 July 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 Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.

Verbatim wording from the response

“In addition to the above, our Clinical Coordination Centre (CCC) Quality Improvement Team have considered points 2 and 3 of the concerns raised and they are satisfied that there is not an inherent or recurrent issue of staff not seeking clinical advice when appropriate to do so within our call centres.”

Source location

Response from South Central Ambulance Service
Page 2 · response
Published 30 July 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

NHS England, not the Trust, is responsible for altering the NHS Pathways algorithms.

Verbatim wording from the response

“As indicated at the beginning of this letter, the Trust is a user of the NHS Pathways system, and we are consequently not able to alter the algorithms contained within it, only NHS England can do this. We have therefore focused our review and response on the training that is provided to Emergency Call Takers and Health Advisors who use the NHS Pathways system and the process in place for identifying any themes or that indicate additional wider training may be required.”

Source location

Response from South Central Ambulance Service
Page 2 · response
Published 30 July 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.20

  1. 1

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

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
  2. 2

    Continue liaising with the Integrated Care Board and local NHS England teams about addressing and disseminating the concerns.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
  3. 3

    Share incident details and findings with Primary Care inspection teams through the monthly update and upskilling call.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 30 July 2025.
  4. 4

    Continue monitoring intelligence about the practice through regulatory processes.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  5. 5

    Review the service risk profile and available information, including other reported concerns.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  6. 6

    Share the identified concerns with the relevant Integrated Care Board.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  7. 7

    Review recurring audit, complaint, case-review and other safety themes monthly and disseminate associated learning to relevant call-centre staff.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  8. 8

    Require staff to acknowledge shared learning and monitor compliance, with follow-up support for colleagues requesting clarification.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  9. 9

    Provide a bespoke breathing-assessment package with sound recordings for new starters and ongoing access by all staff.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  10. 10

    Include questions specifically addressing assessment of breathing in children, including neonates, in forthcoming learning quizzes.

    Stated by South Central Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2025.
  11. 11

    Maintain a dedicated staff-intranet page providing shared-learning materials and NHS Pathways reference content.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  12. 12

    Provide staff with training and knowledge-review materials for NHS Pathways software updates before each new release goes live.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  13. 13

    Develop a process for sharing collated patient-survey results with the Education Team to identify themes and inform training materials.

    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 30 July 2025.
  14. 14

    Conduct monthly random quality-assurance audits of NHS Pathways calls and provide feedback on compliance and development needs.

    Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  15. 15

    Implement and disseminate a new baby-registration process, including immediate Practice registration from birth notifications and training for new reception staff.

    Stated by Unity HealthStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  16. 16

    Audit external correspondence processing monthly and through daily random-letter checks, providing weekly feedback and corrective action where needed.

    Stated by Unity HealthStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  17. 17

    Return non-urgent correspondence requiring Practice action to a Docman inbox for daily clearance by the workflow team.

    Stated by Unity HealthStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  18. 18

    Review the process for handling incoming correspondence to assess whether it is operating as efficiently as possible.

    Stated by Unity HealthStated plannedThe respondent said that this action was planned when they made their response on 30 July 2025.
  19. 19

    Route urgent correspondence and birth notifications to the Practice workflow team for internal identification and action rather than external processing.

    Stated by Unity HealthStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
  20. 20

    Delete the pending folder used for the misfiled treatment instruction after amending the baby-registration process.

    Stated by Unity HealthStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.8

  1. 1

    ICBs and NHS England are better placed to implement a uniform treatment-transfer process and address concerns through contracting.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    GP registration and contract oversight fall outside CQC jurisdiction, so the ICB must oversee these matters.

    Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
  3. 3

    CQC cannot comment on communications between the GP surgery and external filtering company; the practice must provide that information.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  4. 4

    CQC lacks powers to implement or enforce a uniform hospital-to-provider treatment-transfer process.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  5. 5

    A wider Trust review or learning response was unnecessary because the error was not occurring Trust-wide.

    Stated by South Central Ambulance Service NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
  6. 6

    Existing processes and additional training were considered sufficient to mitigate recurrence of a similar call-handling error.

    Stated by South Central Ambulance Service NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  7. 7

    Existing workflow controls, internal handling of urgent correspondence and auditing are considered sufficient to prevent treatment instructions being lost.

    Stated by Unity HealthExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  8. 8

    Newborn babies do not need formal birth registration before being registered as patients at the Practice.

    Stated by Unity HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning nationally and regionally across the NHS.

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 Oscar, 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 30 July 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

Continue liaising with the Integrated Care Board and local NHS England teams about addressing and disseminating the concerns.

Verbatim wording from the response

“We have already flagged this issue with the ICB for the area and will continue liaising with them and the local NHS England teams. The ICB and NHS England will be able to consider how to address these concerns via their contracting processes and how to disseminate this to other practices.”

Source location

Response from Care Quality Commission
Page 3 · response
Published 30 July 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 incident details and findings with Primary Care inspection teams through the monthly update and upskilling call.

Verbatim wording from the response

“We will be sharing details of this incident and the associated findings with the Care Quality Commission’s Primary Care inspection teams at our monthly update and upskilling call. We will continue to monitor the intelligence about the practice in line with our regulatory processes.”

Source location

Response from Care Quality Commission
Page 3 · response
Published 30 July 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

Continue monitoring intelligence about the practice through regulatory processes.

Verbatim wording from the response

“We will be sharing details of this incident and the associated findings with the Care Quality Commission’s Primary Care inspection teams at our monthly update and upskilling call. We will continue to monitor the intelligence about the practice in line with our regulatory processes.”

Source location

Response from Care Quality Commission
Page 3 · response
Published 30 July 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

Review the service risk profile and available information, including other reported concerns.

Verbatim wording from the response

“Following the receipt of your letter the local inspection team reviewed the risk profile of the service and all information we held including any other concerns received.”

Source location

Response from Care Quality Commission
Page 1 · response
Published 30 July 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 identified concerns with the relevant Integrated Care Board.

Verbatim wording from the response

“We contacted Unity Health, the provider who confirmed they launched an investigation and were reviewing how to improve their systems to prevent reoccurrence. We also shared these concerns you flagged up with the relevant Integrated Care Board for the area.”

Source location

Response from Care Quality Commission
Page 1 · response
Published 30 July 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

Review recurring audit, complaint, case-review and other safety themes monthly and disseminate associated learning to relevant call-centre staff.

Verbatim wording from the response

“Core NHS Pathways training is set by NHS England, and it is a condition of the NHS Pathways licence that their training programme is followed. This training is delivered within SCAS by local trainers who have attended national ‘train the trainer’ sessions to ensure consistency across all providers. In addition to the core training, the Trust has a dedicated CCC Quality Improvement team who are responsible for sharing learning with call centre staff as new and emerging themes and trends are identified from a wide range of sources including, but not exclusively, case reviews in preparation for Coronial proceedings (See SCAS Shared Learning Processes_CCC document enclosed with this letter). Common themes are reviewed monthly by the Quality Improvement team and associated shared learning material is issued at least once a month.”

Source location

Response from South Central Ambulance Service
Page 2 · response
Published 30 July 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

Require staff to acknowledge shared learning and monitor compliance, with follow-up support for colleagues requesting clarification.

Verbatim wording from the response

“Shared learning is issued via email with an embedded MS Forms acknowledgement link that is mandatory for colleagues to click on to acknowledge that they have read and understood”

Source location

Response from South Central Ambulance Service
Page 2 · response
Published 30 July 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

Provide a bespoke breathing-assessment package with sound recordings for new starters and ongoing access by all staff.

Verbatim wording from the response

“The Quality Improvement team have confirmed to me that because assessing the adequacy of breathing can be difficult over the telephone, a bespoke ‘breathing’ package was developed to aid the education of staff. In this package, staff select a sound recording to play which demonstrates a type of breathing pattern and they then have to confirm which type of breathing they have heard. This package is provided to all new starters and is available for all staff to access on an ongoing basis. All shared learning material is available for staff to access on a dedicated page on the staff intranet along with Hot Topics issued by NHS Pathways. It is the intention of the Quality Improvement team to include questions specifically related to assessing breathing in children (including neonates) over the coming months.”

Source location

Response from South Central Ambulance Service
Page 3 · response
Published 30 July 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

Include questions specifically addressing assessment of breathing in children, including neonates, in forthcoming learning quizzes.

Verbatim wording from the response

“To further gauge understanding and comprehension of the content within any shared learning materials issued, there is a monthly Quick Quiz for both service lines (111 and 999) comprising of 10 true / false and / or multiple-choice questions. The questions are drawn from any recent Standard Operating Procedure (SOP) Change Notices, shared learning materials, existing SOPs, and general triage principles for the NHS Pathways system. The quiz is facilitated via MS Forms which allows staff who submit incorrect answers to see explanations of the correct answer with sign posting to the source reference materials. Quick Quizzes have included questions regarding assessing a patient’s breathing in July 2024, August 2024, September 2024 and April 2025 and regarding when and how to pass a call to a clinician every month since December 2024.”

Source location

Response from South Central Ambulance Service
Page 3 · response
Published 30 July 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

Maintain a dedicated staff-intranet page providing shared-learning materials and NHS Pathways reference content.

Verbatim wording from the response

“The Quality Improvement team have confirmed to me that because assessing the adequacy of breathing can be difficult over the telephone, a bespoke ‘breathing’ package was developed to aid the education of staff. In this package, staff select a sound recording to play which demonstrates a type of breathing pattern and they then have to confirm which type of breathing they have heard. This package is provided to all new starters and is available for all staff to access on an ongoing basis. All shared learning material is available for staff to access on a dedicated page on the staff intranet along with Hot Topics issued by NHS Pathways. It is the intention of the Quality Improvement team to include questions specifically related to assessing breathing in children (including neonates) over the coming months.”

Source location

Response from South Central Ambulance Service
Page 3 · response
Published 30 July 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

Provide staff with training and knowledge-review materials for NHS Pathways software updates before each new release goes live.

Verbatim wording from the response

“NHS Pathways System Updates”

Source location

Response from South Central Ambulance Service
Page 8 · response
Published 30 July 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

Develop a process for sharing collated patient-survey results with the Education Team to identify themes and inform training materials.

Verbatim wording from the response

“Patient Surveys”

Source location

Response from South Central Ambulance Service
Page 7 · response
Published 30 July 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

Conduct monthly random quality-assurance audits of NHS Pathways calls and provide feedback on compliance and development needs.

Verbatim wording from the response

“All NHS Pathways trained staff taking 111/999 calls from the public receive monthly routine audits for quality assurance purposes. The audits are conducted according to the NHS Pathways Licence requirements which has two audit tiers: those staff taking more than 200 calls per month receive a minimum of 3 random audits per month; those staff taking less than 200 calls per month (or who have been employed for less than 6 months) receive a minimum of 5 random audits per month. Side-by-side audits are considered the gold standard as they facilitate immediate feedback post-call, and potentially in-call support. Calls are audited against defined NHS Pathways Audit Competencies and correct adherence to local Standard Operating Procedures (SOPs).”

Source location

Response from South Central Ambulance Service
Page 6 · response
Published 30 July 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

Implement and disseminate a new baby-registration process, including immediate Practice registration from birth notifications and training for new reception staff.

Verbatim wording from the response

“As set out in my statement of 12 March 2024, a baby does not and did not need to have been named or formally registered with the Registrar in order to be registered as a patient at the Practice. Unfortunately, it transpired subsequently that Oscar’s parents had been told incorrectly by a member of the reception team that they could not register Oscar at the Practice until they had formally registered his birth for which I sincerely apologise. The Practice conducted a Serious Event Analysis after this issue and Oscar’s sad death came to light. Following this, a new process was put in place for new baby registrations which was circulated to the Practice team on 11 December 2024.”

Source location

Response from Unity Health
Page 1 · response
Published 30 July 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

Audit external correspondence processing monthly and through daily random-letter checks, providing weekly feedback and corrective action where needed.

Verbatim wording from the response

“The work undertaken by the external company is audited on a monthly basis by our Data Quality and Compliance Lead at the Practice and an audit on random letters is also carried out on a daily basis by the same person. Any issues that may have been identified are fed back on a weekly basis with appropriate action then put in place to deal with any concerns. The Practice intends to shortly carry out a review of the process in place concerning how incoming correspondence is dealt with to ensure that matters are being dealt with as efficiently as possible.”

Source location

Response from Unity Health
Page 3 · response
Published 30 July 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

Return non-urgent correspondence requiring Practice action to a Docman inbox for daily clearance by the workflow team.

Verbatim wording from the response

“All other documents are filed onto the patients’ records by the workflow team (and so are immediately available for clinicians to see) and are sent to the external company in a batch every Friday. The external company will then summarise and code all relevant correspondence into patient’s records. Any correspondence that requires action on the part of the Practice will be returned on a daily basis and highlighted to the Practice as requiring action. Under the agreement between the Practice and the external company, they have 5 working days to deal with any correspondence which is passed to them. As indicated above, however, anything requiring urgent action will already have been picked up and dealt with by the workflow team.”

Source location

Response from Unity Health
Page 3 · response
Published 30 July 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

Review the process for handling incoming correspondence to assess whether it is operating as efficiently as possible.

Verbatim wording from the response

“The work undertaken by the external company is audited on a monthly basis by our Data Quality and Compliance Lead at the Practice and an audit on random letters is also carried out on a daily basis by the same person. Any issues that may have been identified are fed back on a weekly basis with appropriate action then put in place to deal with any concerns. The Practice intends to shortly carry out a review of the process in place concerning how incoming correspondence is dealt with to ensure that matters are being dealt with as efficiently as possible.”

Source location

Response from Unity Health
Page 3 · response
Published 30 July 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

Route urgent correspondence and birth notifications to the Practice workflow team for internal identification and action rather than external processing.

Verbatim wording from the response

“Any urgent correspondence received by the Practice will be filtered out and actioned by the workflow team when accessing this via Docman. The workflow team scan read every piece of correspondence and are trained to identify matters requiring urgent attention even if a letter is not obviously marked as “urgent”. Any urgent correspondence therefore will not be sent externally as it will already have been picked up and dealt with by the workflow team based at the Practice. In addition, as set out above, all new birth notification letters will be picked up and actioned by the Practice team with the baby being immediately then registered with the Practice. These letters are therefore no longer sent externally.”

Source location

Response from Unity Health
Page 3 · response
Published 30 July 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

Delete the pending folder used for the misfiled treatment instruction after amending the baby-registration process.

Verbatim wording from the response

“As indicated above, anything requiring urgent action will be picked up by the workflow team and dealt with internally. It will not therefore be sent externally. Correspondence requiring non-urgent action would be returned to the Practice by the external company who are regularly audited by the Practice to ensure that they are providing an appropriate level of service. In Oscar’s case, the letter from the Trust regarding the prescription of antibiotics was not sent externally. As Oscar had not been registered with the Practice, there was no patient record to attach the letter to on our system. The “pending” folder that this letter was erroneously moved to has now been deleted as the Practice process for new baby registrations has been amended as above and thus there is no need for this folder.”

Source location

Response from Unity Health
Page 3 · response
Published 30 July 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

ICBs and NHS England are better placed to implement a uniform treatment-transfer process and address concerns through contracting.

Verbatim wording from the response

“Integrated Care Boards and NHS England will be better placed to assist with implementation of a uniform process to avoid a situation such as this occurring in the future.”

Source location

Response from Care Quality Commission
Page 3 · response
Published 30 July 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

GP registration and contract oversight fall outside CQC jurisdiction, so the ICB must oversee these matters.

Verbatim wording from the response

“The Care Quality Commission does not regulate against the GP contract, and therefore the oversight of this process is better placed with the practice's ICB as the commissioner.”

Source location

Response from Care Quality Commission
Page 2 · response
Published 30 July 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

CQC cannot comment on communications between the GP surgery and external filtering company; the practice must provide that information.

Verbatim wording from the response

“We are unable to comment on the communication between the GP surgery and the external filtering company, and the practice is best placed to provide this information.”

Source location

Response from Care Quality Commission
Page 2 · response
Published 30 July 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

CQC lacks powers to implement or enforce a uniform hospital-to-provider treatment-transfer process.

Verbatim wording from the response

“It is not in the Care Quality Commission’s powers to implement or enforce a uniform process whereby treatment of patients is transferred from hospitals to other providers to avoid a similar incident occurring in the future.”

Source location

Response from Care Quality Commission
Page 2 · response
Published 30 July 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

A wider Trust review or learning response was unnecessary because the error was not occurring Trust-wide.

Verbatim wording from the response

“under the Patient Safety Incident Response Framework when a concern is identified. The outcome of this meeting was that the Patient Safety Team were satisfied a wider review by the Trust was not required.”

Source location

Response from South Central Ambulance Service
Page 2 · response
Published 30 July 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

Existing processes and additional training were considered sufficient to mitigate recurrence of a similar call-handling error.

Verbatim wording from the response

“Having considered the robust processes and additional training that the Trust currently has in place, I am satisfied that these measures are sufficient to mitigate the chance of a similar error occurring when a call is taken by a member of our call centre team. This does not take away from how truly tragic baby Oscar’s death was. Should NHS England decide to update the algorithm contained within NHS Pathways, this will of course mean that SCAS staff will have access to this updated version upon its release.”

Source location

Response from South Central Ambulance Service
Page 3 · response
Published 30 July 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

Existing workflow controls, internal handling of urgent correspondence and auditing are considered sufficient to prevent treatment instructions being lost.

Verbatim wording from the response

“Any urgent correspondence received by the Practice will be filtered out and actioned by the workflow team when accessing this via Docman. The workflow team scan read every piece of correspondence and are trained to identify matters requiring urgent attention even if a letter is not obviously marked as “urgent”. Any urgent correspondence therefore will not be sent externally as it will already have been picked up and dealt with by the workflow team based at the Practice. In addition, as set out above, all new birth notification letters will be picked up and actioned by the Practice team with the baby being immediately then registered with the Practice. These letters are therefore no longer sent externally.”

Source location

Response from Unity Health
Page 3 · response
Published 30 July 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

Newborn babies do not need formal birth registration before being registered as patients at the Practice.

Verbatim wording from the response

“As set out in my statement of 12 March 2024, a baby does not and did not need to have been named or formally registered with the Registrar in order to be registered as a patient at the Practice. Unfortunately, it transpired subsequently that Oscar’s parents had been told incorrectly by a member of the reception team that they could not register Oscar at the Practice until they had formally registered his birth for which I sincerely apologise. The Practice conducted a Serious Event Analysis after this issue and Oscar’s sad death came to light. Following this, a new process was put in place for new baby registrations which was circulated to the Practice team on 11 December 2024.”

Source location

Response from Unity Health
Page 1 · response
Published 30 July 2025

Open published response
Back to top

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