PFD report

Hollie Elizabeth Loraine · Prevention of Future Deaths report

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Issued 1 Apr 2026•Sunderland

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised2

  1. Lack of guidance on conducting telephone contact to ameliorate the risk of suicide
    Part of recurring concern: Telephone triage that is unreliable and can delay necessary care
  2. Lack of guidance on maintaining telephone contact with patients expressing suicidal intent
    Part of recurring concern: Telephone triage that is unreliable and can delay necessary 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.1

  1. Action

    Provide mandatory NHS Pathways training on sensitive management of calls involving mental health conditions, including active listening and when to remain on the phone.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Whether health advisers remain on calls is an operational decision for each ambulance service, based on its real-time demand levels.

    Stated by NHS EnglandRedirects 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

Lack of guidance on conducting telephone contact to ameliorate the risk of suicide

Wider context from the report

“I am concerned that the evidence revealed that the national NHS pathways telephone triage system provides no guidance to health advisers dealing with such calls about whether to maintain telephone contact with a patient who is clearly expressing suicidal intent and, if maintaining contact, how to do so to ameliorate a risk of that patient ending their own life. Hollie made it clear she had a noose around her neck and was going to jump. ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care.

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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

Lack of guidance on maintaining telephone contact with patients expressing suicidal intent

Wider context from the report

“I am concerned that the evidence revealed that the national NHS pathways telephone triage system provides no guidance to health advisers dealing with such calls about whether to maintain telephone contact with a patient who is clearly expressing suicidal intent and, if maintaining contact, how to do so to ameliorate a risk of that patient ending their own life. Hollie made it clear she had a noose around her neck and was going to jump. ”

Is this part of a recurring concern?

Yes — Telephone triage that is unreliable and can delay necessary care.

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

Provide mandatory NHS Pathways training on sensitive management of calls involving mental health conditions, including active listening and when to remain on the phone.

Verbatim wording from the response

“NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions, including training around the sensitive management of calls with a mental health element. This training is included in Core Module One which all Health Advisors must complete. Core Module One includes mandatory assessments which must be passed.”

Source location

2026-0193 - Response from NHS England
Page 3 · response
Published 17 April 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

Whether health advisers remain on calls is an operational decision for each ambulance service, based on its real-time demand levels.

Verbatim wording from the response

“However, it is overall an operational decision for each ambulance service whether a health advisor should stay on the line with any caller. Ambulance services have access to their real time demand levels which NHS Pathways does not.”

Source location

2026-0193 - Response from NHS England
Page 5 · response
Published 17 April 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.4

  1. 1

    Develop and introduce the Dx0124 disposition code to identify suicide-risk cases requiring prioritised ambulance review.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  2. 2

    Implement a national process requiring urgent clinical review of suicide-related Category 3 ambulance outcomes.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  3. 3

    Publish and reissue national operational guidance for assessing lethality and toxicity in Category 3 overdose and suicidal-ideation calls.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
  4. 4

    Operate the Regulation 28 Working Group to discuss reports and share patient-safety learning nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.

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 introduce the Dx0124 disposition code to identify suicide-risk cases requiring prioritised ambulance review.

Verbatim wording from the response

“To facilitate this, 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.”

Source location

2026-0193 - Response from NHS England
Page 3 · response
Published 17 April 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 a national process requiring urgent clinical review of suicide-related Category 3 ambulance outcomes.

Verbatim wording from the response

“NHS England has led several national discussions regarding the management of suicidal callers. The NHS Pathways system has been adjusted to accommodate changes and the introduction of a national process. In this process, ambulance and NHS 111 providers facilitate an urgent clinical review for cases flagged as ‘Risk of Suicide’, which is further described below. These changes acknowledge that risks relating to suicidal intent are complex and may be multifactorial. Although non-clinical health advisers receive significant, structured training to use the NHS Pathways system, this system is organised to triage cases for further clinical input or assessment in most cases.”

Source location

2026-0193 - Response from NHS England
Page 2 · response
Published 17 April 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

Publish and reissue national operational guidance for assessing lethality and toxicity in Category 3 overdose and suicidal-ideation calls.

Verbatim wording from the response

“In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled ‘Category 3/999 Overdose and Suicidal Ideation Calls: Initial Assessment of Lethality/Toxicity Principles Document’. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes to ensure suicidal patients receive the correct clinical response. This review was also the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above.”

Source location

2026-0193 - Response from NHS England
Page 3 · response
Published 17 April 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

Operate the Regulation 28 Working Group to discuss reports and share patient-safety 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 Hollie,”

Source location

2026-0193 - Response from NHS England
Page 5 · response
Published 17 April 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