Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Jake Kieran Hartwright who died on 17th January 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5th January 2026 concerning the death of Jake Kieran Hartwright on 17th January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jake’s family and loved ones. NHS England are keen to assure the family and yourself that the concerns raised about Jake’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Jake’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised the following concerns:

1. The urgent care pathway across Nottinghamshire poorly serves patients with systemic illness that is serious, but not immediately life threatening, and where the clinical assessment disposition reached is for a Category 3 ambulance response.
2. Detailed information in the East Midlands Ambulance Service (EMAS) Computer Aided Dispatch (CAD) transferred from the 111 service is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by Nottingham Emergency Medical Service (NEMS).
3. Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent.
4. Category 3 calls are viewed by non-clinicians who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation. Co-National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

4th March 2026

5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a Category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS.

We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.

Background

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that is used to support Urgent and Emergency Care (UEC) in England. 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 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 clinical and non-clinical health advisors. Their training is specific to the NHS Pathways product, and this enables them to use the information provided by callers to both request ambulance resources, or pass cases to suitable services, based on the patient’s health needs at the time of the call.

The NHS Pathways triage product does not provide a diagnosis. It is built to progress through a clinical hierarchy of urgency, enabling symptoms and discriminatory clinical features to be matched to appropriate services or endpoints, meaning 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’ (outcome) is reached.

The safety of clinical triage process endpoints from NHS 111 or 999 assessments 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 the latest guidelines from organisations including the National Institute for Health and Care Excellence (NICE), Resuscitation Council UK and UK Sepsis Trust, amongst others.

Concern 3: Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told that an ambulance will not be sent

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 Review Group (CCRG), the National Ambulance Services Medical Directors (NASMeD) and the 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), Clinical Coding Review Group, NHS England, NHS Pathways, NASMeD and Ambulance Heads of Control. 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 guidance requires Category 3 and 4 calls to be clinically navigated, validated and where appropriate triaged in ambulance control centres, as included in the NHS England » 2025/26 priorities and operational planning guidance, and the NHS England » 2026/27 ambulance emergency and urgent care service specification and the NHS England » Integrated urgent care service specification. This involves validation of the disposition by a clinician (arranged locally), which can result in a different disposition being subsequently reached. Following transfer of the case to the ambulance service, 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. For 999 calls, all ambulance services should have in place call exit scripts and procedures for dealing with response delays when under operational pressure. NHS England supports a position that callers should be provided with sufficient information to make informed decisions, including whether an ambulance has been dispatched to the patient. For incidents that are eligible for clinical validation, the call exit script should outline that patients may receive a call back from a clinician to conduct a further assessment and who may guide them towards an alternative pathway of care, and patients will be asked to keep their phone line free. The wording of the exit scripts is for local determination.

We are unable to comment on the concern that families are not informed that an ambulance is not being sent as it was NHS 111 and the Nottingham Emergency Medical Service (commissioned by NHS Nottingham and Nottinghamshire ICB) who spoke to the patient, rather than the ambulance service. The ICB will therefore be best placed to address any concerns on their exit scripts.

Regional Response

NHS England’s Regional Midlands Team have liaised with Nottingham and Nottinghamshire ICB. The ICB has advised that they facilitated a system-wide After Action Review (AAR) with EMAS, NEMS and 111 partners. This was held on 21st January 2026. The following next steps were agreed:
1. All participant organisations to the review agreed to refer to the fact that a system wide AAR had occurred involving the Derby-Nottingham footprint.
2. As improvement initiatives identified by the review will require collaboration, obtaining agreement to finalise the AAR was an important first step.
3. Those improvement initiatives once established will be taken through and monitored for assurance within the existing governance for the relevant systems. The AAR will be shared with the Regional Quality Board for oversight once it has been finalised and agreed by participating organisations. Should the Coroner require further information regarding the improvement initiatives agreed as part of the AAR, this can be provided in due course. 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 Jake, 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.

I am aware that the Coroner issued another PFD Report on 5 January 2026 which touches upon the same issues which have been raised in this case. NHS England will respond to that Report separately, for completeness, but it may be the case that there is an element of duplication in the information which has been provided. No disrespect is intended to the Coroner in this regard.

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.

Dear Dr Didcock

Re: Report regarding the case of Mr Jake Kieran Hartwright deceased.

I am writing in response to the concerns you raised following the inquest into the sad death of Mr Jake Kieran Hartwright, which concluded on 12 December
2025.

Thank you for your Regulation 28: Prevention of Future Deaths report regarding the contacts between Mr Hartwright and East Midlands Ambulance Service (EMAS), as well as the pathways involving NHS 111 and Nottingham Emergency Medical Services (NEMS).

I understand that you will be sharing this response with Mr Hartwright’s family, and I would like to express my sincere condolences to them for their loss.

The Trust acknowledges the concerns you have identified, and I provide below our clarifications, the actions already taken, and our ongoing commitments. All issues raised have been reviewed through the Trust’s Incident Review Group, which is responsible for considering matters escalated through inquests and Prevention of Future Deaths reports, ensuring that learning is identified and acted upon to address any systemic or procedural issues.

Matters of Concern Raised on 12 December 2025

1.The urgent care pathway across Nottinghamshire does not optimally support patients with serious systemic illness (e.g., sepsis) who receive a Category 3 ambulance disposition. Private and Confidential Dr Elizabeth Didcock Assistant Coroner for the coroner area of Nottinghamshire

Respond | Develop | Collaborate

The Trust recognises that, while the urgent care pathway performs well for most patients, those presenting with serious but not immediately life‑threatening systemic illness may not be supported as effectively as required. To address this, the Trust has worked in partnership with NEMS, DHU and other system organisations to develop a technological solution enabling the full, accurate transfer of patient information across services. This will strengthen clinical decision‑making and ensure that patients with complex or deteriorating conditions receive more appropriate and timely care.

2. Detailed clinical information received in the EMAS Computer Aided Dispatch (CAD) system from NHS 111 is not always reliably reviewed or considered when ambulance responses are cancelled and cases are referred to NEMS.

In December 2025, the Trust upgraded its CAD system to ensure that all information captured during the initial 999 call is automatically transmitted to subsequent receiving systems. This enhancement has been fully tested with the Trust and NEMS and now supports the transfer of more comprehensive clinical information at the point of referral.

Further improvements are planned as the Trust transitions to the national Booking and Referral Standard (BaRS) within the next 12 months. BaRS will enhance interoperability across urgent care services, streamline information flow, and reduce the potential for communication gaps between providers.

3. Families awaiting an ambulance following a 111 clinical assessment are not informed by EMAS if an ambulance will not be sent.

The current CAD system does not provide an automatic mechanism for notifying callers in these circumstances. To address this, the Trust has submitted a development request to the system supplier (MIS). The planned enhancement will ensure that, when a call is transferred through the Interoperability Toolkit (ITK), the caller receives a text message confirming the status of their request. The proposed message will be as follows:

“Hello from East Midlands Ambulance Service. We're currently experiencing extreme pressures and long delays. Your call has been passed over to a Clinical Assessment Service where a clinician will call you back to arrange the most appropriate treatment for you. If you decide that an ambulance is no longer required, please call back on 999 to cancel. Only call back on 999 if your condition worsens or you develop new symptoms. Do not call back for an ETA as our call handlers won’t be able to give you this information.”

Respond | Develop | Collaborate

This enhancement aims to provide clarity for patients and families, improve transparency, and reduce uncertainty during periods of operational pressure.

4. Category 3 calls have been reviewed by non‑clinicians in the EMAS Emergency Operations Centre (EOC) who may not have the required skills to safely transfer calls to NEMS.

Historically, non‑clinical staff reviewed Category 3 calls in the EOC, creating risk where inclusion and exclusion criteria required clinical interpretation. To address this, in January 2026, the Trust implemented a significant change to operational practice:
• A full reversal of the non‑clinical push model.
• All transfers now occur through a clinical push only.

Enhanced clinical review:
• Clinicians now review all available information prior to transferring any call.
• No clinically assessed calls are pushed to any EMAS Clinical Assessment Service (CAS).
• NEMS no longer supports the manual push of calls into their system; therefore, this model now applies across all regional CAS providers.

This change ensures that only suitably qualified clinicians make decisions regarding call transfers, thereby improving patient safety and mitigating risks arising from ambiguous criteria.

5. There is no agreed set of criteria between EMAS and NEMS for the transfer of Category 3 calls, including whether previous clinical validation should prevent transfer.

The Trust acknowledges that there is currently no formal agreement in place defining the criteria for Category 3 call transfer between the Trust and NEMS. Manual ITK push transfers to NEMS have now ceased.

Ongoing collaborative work continues between the Trust, the Integrated Care Board and NEMS to ensure safe and sustainable staffing models that will support the reinstatement of the manual push process where appropriate. This joint approach is aimed at strengthening system capacity and ensuring that patients across Nottinghamshire consistently receive the right care, first time.

Conclusion The core purpose of the Trust is to respond to patients’ needs in the right way, continually improving our organisation so that we deliver safe, effective, and

Respond | Develop | Collaborate

compassionate care. We remain committed to developing a culture of compassion, continuous learning, and system-wide collaboration to improve patient outcomes.

I trust that this response provides assurance of the steps we have taken, and our continued commitment to learning and improvement across our services.

Please do not hesitate to contact me if I can be of any further assistance in this matter.

Dear Dr Didcock Response to Matters of Concern Regulation 28 Report Re: Jake Kieran Hartwright NEMS acknowledges the coroner’s findings and the concerns raised under Regulation 28 following the inquest into the death of Jake Kieran Hartwright. NEMS wishes at the outset to express our sincere condolences to Jake’s family and to acknowledge the gravity of the coroner’s findings. We recognise the profound impact of this case and are committed to responding in a way that is open, reflective and proactive. We fully accept the importance of learning from the matters identified and are approaching this response not simply as a statutory requirement, but as an opportunity to strengthen systems, improve clarity across pathways and reduce the risk of future harm. Both before and following the inquest, we have undertaken detailed review of our processes and engaged with system partners to deliver meaningful, sustainable improvements. This response therefore sets out the immediate mitigation measures already implemented, the ongoing governance actions currently in place, and the further work proposed to reduce risk and strengthen patient safety across the urgent care pathway. I acknowledge that the coroner issued a further identical Prevention of Future Death Notice on the same day relating to another linked, but different case. The response to both PFD reports are the same as there is considerable overlap but I wanted to assure the Coroner and the families involved, that no disrespect is intended by this.
1. Urgent Care Pathway Coroner’s Concern: The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response Actions Taken Confidential Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire Platform One Station Street Nottingham NG2 3AJ

79580172v1 NEMS confirms that it has not continued with manually pushed calls since 3rd December
2026. Prior to 27th June 2025, Category 3 calls assessed by EMAS as potentially suitable for management within the Urgent Care Coordination Hub (UCCH) were at times manually pushed to NEMS. In practice, this meant that an EMAS Emergency Operations Centre (EOC) colleague would transfer a case directly into the NEMS clinical queue, based on the agreed inclusion and exclusion criteria at that time. As the evidence unfolded during the inquest, it became clear that the manual push model had the unintended consequence of positioning NEMS in a role more akin to an Emergency Operations Centre (EOC), rather than functioning as an urgent care provider operating within a clearly defined admission avoidance model. This was neither aligned with national GIRFT (Get it Right First Time) guidance nor consistent with the intended purpose of an Urgent Care Coordination Hub. GIRFT describes UCCHs as a single point of access supporting admission avoidance, coordinating community-based responses and enabling ambulance crews to access alternatives to conveyance. Since this time, we have strengthened our governance arrangements to ensure clear operational boundaries, robust clinical oversight, and full alignment with urgent primary care guidelines, thereby preventing a recurrence of this situation. Since cessation of manual pushes, referrals now occur via Directory of Services (DoS) or automated ITK pathways. These pathways present lower risk because they are generated through NHS Pathways and meet defined criteria, and no further sepsis-related patient safety incidents have been identified since pathway changes in June 2025. Since 27th June 2025, NEMS implemented a pause on manually pushed calls while improvements were agreed with EMAS. Although manual pushes resumed on 21st July following assurance regarding CAD note quality and governance arrangement, NEMS confirms that it has not continued with manually pushed calls since 3rd December 2025.NEMS continues to proactively review cases transferred from EMAS and escalate concerns through joint governance structures, alongside close monitoring of monthly UCCH highlight reports to identify emerging themes In parallel, NEMS has worked closely with the Integrated Care Board (ICB) to review national GIRFT models for UCCH delivery, ensuring alignment with best practice. It is our clear position that interception or re-triage of EMAS calls should sit within the clinical expertise and statutory responsibility of EMAS. NEMS’ role is to provide urgent primary care expertise for appropriate admission avoidance pathways and not seek to replicate ambulance triage functions. Accordingly, our strategic focus has shifted towards preventing avoidable ambulance callouts in defined cohorts such as frail patients, care home residents and those at end of life, where proactive planning, anticipatory care and coordinated community response can safely reduce escalation to 999. This reflects the intended GIRFT model of supporting admission avoidance and coordinated care in the community, rather than intercepting higher-acuity ambulance demand. We will continue to work closely with system

79580172v1 partners to ensure the pathway operates safely, with clear accountability and well- understood professional roles. Further Work NEMS will continue to share recurring themes and individual cases of concern with EMAS through established governance processes to ensure that identified risks are reviewed and that learning is clearly documented. We have requested that EMAS report back on the outcomes of those reviews and share any learning relevant to NEMS, so that the process operates as a genuinely reciprocal and joint approach rather than a one-directional escalation pathway. NEMS will continue to participate in joint After Action Reviews with EMAS where appropriate, maintain focused review of systemic illness presentations within the pathway, and escalate any identified risks to system partners to ensure timely mitigation and shared learning.
2. CAD Information Not Reliably Considered Coroner’s Concern: There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS. NEMS Position Ideally, CAD notes should mirror the structured format of a DHU 111 report, with clear separation of positive findings, negative findings, outcome rationale, and advice given . At present, this level of clarity is not consistently achieved. We also acknowledge that the proposed national BARS (Booking and Referral Standard) solution has been identified as a potential mechanism to improve data transfer and prevent Category 3 calls being deprioritised within the system. However, there has been no confirmed implementation timeline, and its formatting and functionality benefits have not yet been fully tested. Notwithstanding the cessation of manually pushed calls, improved data transfer remains essential for safe ITK and DoS referrals, and BARS may form part of that longer-term solution. Actions Undertaken NEMS has engaged in ongoing discussions with EMAS and OneAdvanced, the software provider responsible for Adastra (the electronic patient record system used by NEMS) to improve the formatting, structure and clarity of CAD-to-Adastra transfers. This has included identifying the duplication arising from the multiple message structure and formally requesting technical solutions to improve legibility and presentation of narrative information

79580172v1 In relation to role identification, OneAdvanced has updated role types to allow differentiation between Clinical Advisors and Health Advisors within NHS 111. In addition, EMAS’ CAD supplier (MIS) is scheduled, in early March 2026, to commence development work to enable transfer of advisor skillset information into the receiving system. This represents a positive step towards improving visibility of prior clinical validation and supporting safer downstream decision-making. In addition, this process has generated learning and further improvement work between DHU 111 and NEMS in relation to the direct transfer of information from the 111 provider into NEMS systems will improve clinical safety for all patients. NEMS confirms that it has formally agreed with OneAdvanced to implement the Booking and Referral Standard (BaRS) within Adastra and is progressing this work in partnership with DHU. Following system configuration, a formal multi-agency project involving NEMS, DHU, OneAdvanced, NHIS and the ICB Directory of Services team will oversee the migration of CAS and Out of Hours profiles from the legacy ITK framework to BARS, alongside necessary system configuration to ensure structured, complete and clearly displayed clinical information transfer. Although there are national technical dependencies, including firewall configuration and NHS England certification requirements that have affected wider system timelines, both organisations remain actively engaged and on track to implement BaRS, which will significantly strengthen the quality, reliability and safety of electronic note transfer between DHU 111 and NEMS. Further Action Proposed NEMS will continue engagement with EMAS, MIS (CAD Supplier) and OneAdvanced so that reliable identification of prior NHS 111 clinical validation is achieved and narrative transfer is consistently legible and structured. NEMS will:
• Continue to press for structured CAD formatting aligned to the model outlined in verbal evidence provided at inquest (clear overview, further information, outcome and advice fields).
• Seek clarity on the implementation timeline for BARS and its anticipated impact on formatting and prioritisation.
• Review whether additional internal NEMS risk flags should be applied where duplication or poor formatting obscures clinical clarity.
• Continue to raise concerns formally where transferred information does not allow safe clinical decision-making. Whilst many of the technical solutions sit outside NEMS’ direct control, we remain committed to constructive system engagement to ensure that data transfer supports safe and informed clinical assessment across organisational boundaries.

79580172v1
3. Families Not Told Ambulance Will Not Be Sent Coroner’s Concern: Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent NEMS recognises that patients often believe an ambulance is already en route when referred to our service via EMAS. Immediate Mitigation Implemented NEMS has introduced a standardised opening statement: “I am calling on behalf of NEMS, an urgent care provider. The Ambulance Service has passed your call to us to determine whether an ambulance is required or whether we can provide an alternative option.” This is now embedded into clinical introductions to reduce misunderstanding and improve transparency. Further Action
• Audit of call recordings to ensure compliance.
• Ongoing discussion with EMAS to ensure consistent public messaging across services.
4. Non-Clinician Review of Category 3 Calls Coroner’s Concern: Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation. NEMS Position The manually pushed call model, which relied on interpretation of locally applied inclusion and exclusion criteria, has ceased within Nottingham and Nottinghamshire. Current referrals received by NEMS are either Directory of Services (DoS) driven or generated through automated ITK pathways. These routes follow nationally defined NHS Pathways clinical coding and disposition criteria and therefore do not require additional locally derived screening criteria. They are structured within established national algorithms rather than discretionary interpretation.
5. No Agreed Criteria for Transfer (Including Prior Clinical Validation) Coroner’s Concern: There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS

79580172v1 NEMS Position There is joint agreement in principle that calls which have already undergone clinical validation within NHS 111 should not ordinarily be transferred to NEMS for further validation. Where a clinician within NHS 111 has assessed a patient and determined an appropriate disposition, particularly where ambulance or ED attendance is indicated, this should not routinely result in a further layer of telephone assessment unless there is a clearly defined clinical rationale. However, NEMS is currently unable to reliably identify whether a call received via EMAS has already been clinically validated within NHS 111. As outlined under Point 2, this relates directly to the transfer of advisor skillset information and the current limitations within CAD- to-Adastra data transfer. Without visibility of whether the original 111 disposition was clinician-led, NEMS cannot consistently differentiate between pathway-generated dispositions and those that have already undergone clinical review. Further Proposed Action NEMS proposes continued joint work with EMAS and system partners to formalise clear transfer principles. This should include explicit agreement that clinically validated NHS 111 calls should not be routinely transferred for re-validation, and that where EMAS reassesses a call as requiring ED attendance, it should be conveyed directly to ED without further telephone triage. Further system-level review may be required to determine whether adjustments to Directory of Services positioning or internal EMAS processes are necessary to prevent avoidable sequential assessments. The shared objective is to minimise fragmentation within the patient journey and reduce the risk of higher-acuity patients being delayed through multiple telephone contacts before definitive care is accessed. Update on Internal NEMS Actions NEMS remains fully committed to learning from the tragic death of Jake and to ensure that the lessons identified translate into meaningful and sustained improvement in clinical practice and system processes. The Organisational Learning Statement previously submitted to the coroner outlined the actions taken to strengthen the Urgent Care Coordination Hub (UCCH) service, enhance telephone consultation standards, improve digital processes, and formalise joint governance with system partners. Those commitments have not only been maintained but continue to be actively progressed and embedded within routine operational and educational practice. Immediately following the conclusion of the inquests, key learning points were formally shared with the entire NEMS workforce on 14th December. This communication summarised the clinical findings, system themes and professional reflections arising from both cases, with particular emphasis on cumulative contacts, symptom evolution, structured history-

79580172v1 taking, recognition of sepsis, and the limitations of transferred documentation. The purpose of this communication was to promote transparency, reflection and collective ownership of learning across all clinical staff. On 23rd December 2025, the Medical Director met directly with all telephone practitioners involved in delivering the UCCH and Clinical Assessment Service. This session provided a structured opportunity to review the inquest findings, discuss the process changes that have been implemented, and allow clinicians to ask questions, raise concerns and reflect openly on their practice. The discussion was constructive and professionally engaged, reinforcing a culture of psychological safety and shared accountability for improvement. On 21st January, alongside the Medical Director, I attended a formal system After Action Review alongside the ICB Quality Team, EMAS and DHU. This review considered both cases in detail, identified shared learning themes and examined the collaborative approaches required to strengthen inter-organisational working. Focus was given to information transfer, recognition of clinical deterioration across multiple contacts, and clarity of role boundaries within the urgent care pathway. This system-level discussion reinforced that the risks identified were not isolated to one organisation and require coordinated improvement across providers. On 23rd January, the Medical Director attended the Learning from Death System Forum and formally requested that the ICB Quality Team undertake a deep dive into other Prevention of Future Death (PFD) reports across Nottingham and Nottinghamshire where communication failures and inter-organisational information transfer were contributory factors. The themes identified in Jake’s cases, particularly fragmentation of care and incomplete data transfer across providers, are not unique risks. It is therefore important that system learning extends beyond individual cases to identify wider patterns across the region. On 3rd February, the Medical Director hosted a dedicated clinical teaching session in collaboration with Mr Chauhan, the consultant general surgeon who provided evidence at inquest. This session focused on the presentation of appendicitis, the variability of clinical features, the evolution of intra-abdominal sepsis, and the importance of considering differential diagnoses when symptoms appear non-classical. The session was well attended by NEMS clinicians and formed part of our strengthened education programme. It provided valuable specialist insight and reinforced the importance of clinical curiosity, escalation when uncertainty persists, and recognition of evolving systemic illness. These initiatives build upon the strengthened educational processes already described in the Organisational Learning Statement including enhanced sepsis training, structured competency assessments for UCCH clinicians, repeated clinical audits with reflective feedback, digital prompts such as the sepsis screening tool within Adastra, and tighter allocation of appropriately trained staff to high-acuity services.

79580172v1 NEMS recognises that learning from such cases must be ongoing rather than reactive. We remain committed to maintaining enhanced audit cycles, embedding structured reflective practice, strengthening inter-organisational communication processes, and ensuring that clinicians feel supported, trained and equipped to manage complex and evolving presentations safely. In responding to this Prevention of Future Death report, we remain acutely aware that behind the clinical detail, governance processes and system changes sits the devastating loss of a young life. Jake’s death has had a profound impact on his family, and we recognise that no review, response or action plan can undo the pain they continue to experience. We extend our sincere condolences to them and acknowledge the courage and dignity shown throughout the inquest process. NEMS have taken this inquest, and the learning arising from it, extremely seriously. The work undertaken before, during and after the inquest has involved detailed reflection, engagement with clinicians, system partners and digital teams, and a careful review of both individual practice and organisational processes. This commitment does not end with the submission of this Prevention of Future Death response. The actions described are not reactive measures tied to a statutory deadline; they form part of an ongoing programme of scrutiny, education and improvement that will continue. These cases have been approached not simply as governance matters, but as deeply human events that require humility, honesty and sustained effort. We remain committed to learning, to strengthening our clinical practice and inter-organisational working, and to ensuring that the lessons identified contribute to safer care for others. Above all, we remain mindful that at the centre of this response is a family living with an irreplaceable loss, and it is with that understanding that we continue this work. We remain committed to honouring Jake’s memory through sustained improvement, transparency and collaboration. Our responsibility is to ensure that the lessons identified lead to safer care for others, and that we never lose sight of the human impact that sits at the heart of our work.

Dear Dr Didcock

Re: Regulation 28 Report regarding the case of Mr Jake Kieran Hartwright

I am writing on behalf of NHS Nottingham and Nottinghamshire Integrated Care Board (NNICB) regarding the recent inquest into the tragic death of Jake Kieran Hartwright, which concluded on 12 December 2025 with a Regulation 28 (Prevention of Future Deaths) report issued. On behalf of the Nottingham and Nottinghamshire Integrated Care Board (ICB), I wish to extend our sincere condolences to Mr Hartwright’s family.

The ICB proactively ensures that learning stemming from operational challenges translates into system‑wide improvement. This includes assuring that learning from incidents is systematically captured, analysed, and translated into coordinated actions across partners; that cross‑organisational interfaces are governed robustly; and that progress against improvement actions is monitored, evidenced, and embedded into ongoing quality oversight. We will also continue to oversee the governance of cross‑organisational interfaces and track the sustainability of improvement actions, in line with expectations for sharing learning from Regulation 28 reports.

Actions taken to coordinate system learning and improvement Following receipt of the report, the ICB facilitated a system wide After-Action Review (AAR) to enable collaborative learning and improvement across relevant partners.

The AAR identified improvement priorities relevant to system safety and reliability at service interfaces, including:
• The UCCH pathway may not consistently meet the needs of patients with serious systemic illness where disposition is a Category 3 response.

• Risks in information transfer and visibility, including whether information transferred into EMAS systems is consistently available and acted upon at decision points.
• The importance of clear patient/family communication where an ambulance will not be sent, including what to do next.
• Clarity of roles, skills and governance at points where Category 3 calls are reviewed/handled and transferred between services.
• The need for agreed criteria for transfer between services (including how prior clinical validation affects subsequent decision-making).

NNICB will use these identified themes to structure oversight and ensure improvement actions are coherent and measurable. As an ICB we have met jointly with both EMAS and NEMS to ensure that their planned actions (as described in their responses to the Regulation 28 report) are clear, time specific and address the issues above.

We have ensured the manual push remains paused and there are no plans for reinstatement of this pathway at this point in time, as not all actions agreed have been completed. Several codes that were being automatically transferred to NEMS by EMAS have also ceased since December 2025 and we are in the process of reviewing these with other similar services across the East Midlands to assess whether they should be removed on a larger scale.

As the commissioner of the UCCH we have also reviewed and redefined the existing service specification that is included in the contract we have with NEMS, ensuring that all learning has been included.

Our analytics team have recently developed the ability to join up multiple data sets that will from March 2026 allow us to understand the patient journey and outcomes across this entire pathway. This will support us to review and refine the journey for our patients, enhancing our ability to evaluate and adjust accordingly the service offer.

Actions and assurance NNICB’s oversight actions are aimed at ensuring that provider actions are coherent, measurable, sustained, and transparently governed across the pathway. Maintenance of this oversight and assurance will continue following the recommendations of oversight framework designed to identify where support is needed, with a focus on improving patient safety, experience, and outcomes. This will include a comprehensive quarterly review process on progress towards these actions.

As per the ICB’s statutory responsibilities for PFD learning and assurance actions from this report will be shared and embedded in:
• ICB Joint Quality and Service Improvement Committee
• Provider review processes
• ICS System Learning from Deaths Forum
• Regional Quality Committee

We have also offered and committed to joining the clinical governance meeting set up between NEMS and EMAS to support the continued work between the two organisations.