Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Simon Robert Boyd who died on 1 June 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6 November 2024 concerning the death of Simon Robert Boyd on 1 June 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Simon’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Simon’s care have been listened to and reflected upon.

Your Report raised concerns that the current wording used in the NHS Pathways script could create the impression that an ambulance has been dispatched to a caller when this is not the case, and that ambulance responses can be cancelled without first being discussed with the person who has dialled 999. I note that your Report has also been addressed to the Secretary of State for Health and Social Care, to address the issue of national targets for ambulance response times not being adhered to. NHS England has not dealt with this particular concern within this response.

Background information about NHS Pathways Clinical Decision Support System

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that is used to support Call Handlers (Health Advisors) in Urgent and Emergency services. The product is owned by the Secretary of State for Health and Social Care and is manufactured and managed by the Transformation Directorate of NHS England. It is used in NHS 111 and over half of 999 ambulance services. It is the triage product used by North West Ambulance Service (NWAS), who received Simon’s 999 call.

NHS Pathways supports the remote assessment of over 25 million calls a year. It is embedded within host systems in NHS 111 and 999 ambulance providers where it interacts with other technology products to support the assessment, sorting and onward management of calls received by those services.

Calls to services using the NHS Pathways triage product are managed by specially trained non-clinical health advisors and clinicians. Their training is specific to the NHS Pathways product, and this enables them to use the information provided by callers to pass cases to suitable services, based on the patient’s health needs at the time of the call. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 December 2024 A1

The NHS Pathways triage product is built to progress through a clinical hierarchy of urgency. This means that life-threatening symptoms or problems are assessed first, and less urgent symptoms or problems are assessed sequentially thereafter. The endpoint of an assessment is reached when a clinically significant factor cannot be ruled out and so a “disposition” is reached. Dispositions range from an emergency ambulance to self-care.

Clinical Governance of NHS Pathways

The safety of the clinical triage process endpoints resulting from an NHS 111 or 999 assessment using NHS Pathways is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate group hosted by the Academy of Medical Royal Colleges (AoMRC). Alongside this independent oversight, NHS Pathways ensures its clinical content and assessment protocols are consistent with the latest advice from respected bodies that provide evidence and guidance for clinical practice in the UK. This includes latest guidelines from:-

a. NICE (National Institute for Health and Care Excellence);
b. The UK Resuscitation Council; and
c. The UK Sepsis Trust.

Wording of scripts

In Simon’s case, an emergency ambulance response (Category 3) was generated and the wording in relation to that disposition is that an ambulance ‘is being arranged’. The wording which Health Advisors (HAs) are expected to convey is shown below:

Following the disposition, HA’s are trained to give care advice and worsening advice presented by the system as shown below. This includes any symptom specific advice, and advice about what to do should the situation change. This is an essential risk management technique, as it is vital that callers know what to do should the situation worsen, change or if they have any other concerns or develop new symptoms. Worsening advice should be used in its entirety as this has been specifically designed to address this range of situations. A2

The timelines within which an ambulance response should be provided vary according to the urgency of the call. Ambulance response standards and ambulance quality indicators are the nationally agreed timeframes for ambulances to arrive at the patient’s location following a call passed to the ambulance service. Further information can be found at https://www.england.nhs.uk/urgent-emergency-care/arp

All NHS Pathways ambulance response disposition codes are ratified by the Clinical Coding Reference Group (CCRG), the National Ambulance Services Medical Directors (NASMeD) and Emergency Call Prioritisation Advisory Group (ECPAG). NASMeD is an advisory group consisting of medical director representatives from all ambulance services in England, Wales, Scotland and Northern Ireland who endorse the categorisation of ambulance codes.

The purpose of ECPAG is to advise NHS England and the Department of Health & Social Care (DHSC) on issues of ambulance call prioritisation. Its principal remit is to recommend which disposition codes should be mapped to which ambulance responses. The group consists of membership from the Association of Ambulance Chief Executives (AACE), CCRG, NHS England, NHS Pathways, the National Ambulance Commissioning Network (NACN), NASMeD and Ambulance Heads of Control. A3

The information given to callers about ambulance dispatch is aligned with the ambulance response standards, and NHS Pathways is not designed to take account of operational delays as these can be very variable and do not represent the recommended clinical disposition.

In order to support ambulance providers to manage their available resources, NHS England has issued a national directive, requiring providers to undertake clinical validation of Category 3 and Category 4 ambulance responses within both NHS 111 and 999 services. This involves validation of the disposition by a clinician (arranged locally), which can result in a different disposition being subsequently reached. The information captured in NHS Pathways may allow a clinician to re-categorise the call without direct contact with the patient. The Ambulance Trust’s Computer Aided Dispatch (CAD) system, rather than NHS Pathways, is used to manage the validation process. It is a requirement that the CAD must be able to provide appropriate exit scripts for Category 3 / Category 4 codes or dispositions. The wording of the exit scripts is for local determination.

In addition, where there is high demand on a service, providers are permitted and do implement their own scripts when it comes to the delivery of dispositions to try and manage expectations.

Cancellation of ambulances

In Simon’s case, the Health Advisor followed the training provided by NHS Pathways in delivering the disposition and completing the relevant call.

Simon was subsequently spoken to by a clinician within the Greater Manchester Clinical Assessment Service, who would have cancelled the ambulance. This validation and cancellation of an ambulance is not within the remit of the NHS Pathways system, and no data is provided back to NHS Pathways or the provider as to the changing of a disposition. Should the Coroner wish to investigate this further, he would be best placed contacting the Greater Manchester Clinical Assessment Service.

The NHS 111 and 999 services have Standard Operating Procedures in place to manage this. These are determined locally and are not mandated nationally.

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 Simon, 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.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

A4

Dear Mr Morris,

Thank you for the Regulation 28 report of 6 November 2024 sent to the Secretary of State about the death of Simon Boyd. I am replying as the Minister with responsibility for urgent and emergency care. I am thankful for the extension you have granted.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Boyd’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns about ambulance response times and the script used by call handlers. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand NHS England are writing to you regarding the specific concerns you have raised on the current wording used in the NHS Pathways script by call handers.

This Government recognises that in recent years, ambulance response time performance has been below the high standards that patients should expect. That is why this Government has committed to supporting the National Health Service to improve performance, including ambulance services achieving the safe operational response times standards set out in the NHS Constitution.

On 5 December 2024 the Government published the Plan for Change, which set out clear milestones in five national missions that set the mandate for the direction of change, including building an NHS that is fit for the future. The Plan for Change is available here:

nge.pdf

The Government has been honest about the challenges facing the NHS and it is serious about tackling the issues, however we must be clear that there are no quick fixes. We are determined to turn things around through providing investment and implementing reforms. A6

That is why the Chancellor announced £25.6 billion of additional healthcare funding over the next two years covering 2024-2026. In Spring 2025, to accompany this additional investment the Government will publish its 10-Year Health Plan, that will set out the radical reforms for the NHS so it can tackle the problems of today and tomorrow.

The 10 Year Health Plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing for the future.

In the short-term, by this Spring we will set out the lessons learned from this winter and the improvements that we will put in place to improve urgent and emergency care ahead of next winter.

I hope this response is helpful. Thank you for bringing these concerns to my attention.