Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Robert Shaun Gracey who died on 29 September 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6 January 2026 concerning the death of Robert Shaun Gracey on 29 September 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Robert’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Robert’s care have been listened to and reflected upon.

Your Report raised the following concerns:
1. Despite a clear recommendation by DAC Twist on behalf of the National Police Chief's Council (NPCC) that ‘police forces have established Acute Behavioural Disturbance (ABD) protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies’, there is still no such protocol in Lincolnshire.
2. Under the current NHS Pathways system, ABD does not have its own allocation pathway.
3. Under the current NHS Pathways system, a referral for ABD will only be allocated a Category 2 ambulance response in the absence of police restraint.

Background on Acute Behavioural Disturbance

The term “Acute Behavioural Disturbance” (ABD) is not a formal diagnosis within the International Classification of Diseases (ICD-11), which is the global diagnostic tool used in the NHS. ABD is generally used to describe behaviours linked with extreme agitation or distress, which may indicate a potentially life-threatening physical health emergency. NHS England recognises the importance of ensuring that individuals presenting in extreme distress receive timely, safe, and effective care. ABD is not a specific condition with a set of defined symptoms. It is not common and it is very difficult to identify the difference between agitation, antisocial behaviour, deliberate violent behaviour and ABD. There is no reliable way to determine mild or severe ABD in the pre-hospital setting nor over the phone during a triage process.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

23 February 2026

ABD is a complex but known clinical presentation and both the Royal College of Psychiatrists and the Royal College of Emergency Medicine have published guidelines on managing ABD.

NHS Pathways Triage

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.

NHS Ambulance services are required to process 999 calls through an approved triage system. There are currently two systems approved in England for primary 999 assessments; NHS Pathways and Medical Priority Dispatch System (MPDS). The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs). The East Midlands Ambulance Service moved to the NHS Pathways system in November 2023, but was using the MPDS system at the time of Mr Gracey’s death. MPDS is published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academy of Emergency Medical Dispatch (IAED). Any queries on the operation of the MPDS system should be directed to PDC.

The primary purpose of triage is to quickly identify priority symptoms (e.g.

unconsciousness, difficulty breathing, chest pain) and assign an appropriate response priority. The outcome (disposition) reached, based on the information provided by the caller, is mapped to approved, contracted standards. There is a requirement to map these outcomes to the five national categories (Categories 1 -5) set out within the NHS Constitution and Ambulance Service 999 contracts.

The categorisation of 999 calls is managed through a specific process within NHS England. The mapping of triage outcomes to response categories is undertaken by an expert group which has representatives from both NHS Pathways and MPDS ambulance trusts. The coding groups engage with the ambulance sector within England and consider reviews triggered by coroners, patient safety concerns identified by the ambulance services or changes in national guidance. This group makes recommendations to the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) for implementation across all NHS England ambulance service providers. This ensures appropriate prioritisation, equity of access and uniformity of response across the English ambulance services.

Under the current NHS Pathways system, ABD does not have its own allocation pathway

The NHS Pathways system is designed to support symptom-based assessment. It is a non-diagnostic system. This means its functioning does not depend on diagnostic “allocation” into pathways for specific named conditions. Rather, symptom presentation drives assessment, and additional information such as existing diagnoses may be sought where relevant.

Whilst it is NHS England’s understanding that Mr Gracey’s triage assessment was not done using the NHS Pathways system, given the details supplied in your Report, it is likely that a Category 1 response would have been triggered by the presenting symptoms of Mr Gracey at the time of the police call to the ambulance service (including that he was non-responsive, no longer breathing and only had a weak pulse).

Under the current NHS Pathways system, a referral for ABD will only be allocated a Category 2 ambulance response in the absence of police restraint

As indicated above, symptom-assessment drives the outcome of triage under the NHS Pathways system. This means that, in the absence of more immediately life- threatening presentations (e.g. unconsciousness, not breathing, etc.), the lowest response level that can be reached with ABD in the NHS Pathways system is a Category 2 emergency ambulance response. In other words, where appropriate, a Category 1 response can be triggered. Category 2 calls (not just Category 1) are treated as ‘medical emergencies’, requiring rapid assessment and intervention, and which, along with ABD, are reserved for a medical emergency such as suspected stroke, chest pain and sepsis.

A Category 2 response typically receives the immediate dispatch of an emergency ambulance (with a response time standard mean of 18 minutes) however, ambulance services are advised that a senior clinician within the control room should be made aware of the potential ABD incident to assist with further clinical oversight and decision

making. Where indicated, local discretion can be applied by ambulance services to rapidly upgrade the incident to a Category 1 if the patient’s condition indicated that it was appropriate to do so, for example, the patient’s condition has deteriorated or the patient is being restrained.

The response category for ABD continues to be actively considered and reviewed by the bodies, and their membership organisations, who set ambulance categories. This topic continues to be monitored by both the NHS Pathways and National Ambulance Teams within NHS England, as well as more broadly by ambulance service providers themselves, and in partnership with Health and Justice teams. These active investigations support the categorisation decisions, managed by NHS England. More information about ambulance categorisation updates can be found at NHS England » Ambulance Response Programme.

ABD Guidelines

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) provides clinical guidelines for paramedics, which include a comprehensive overview of various conditions they care for. The guidelines are updated with the latest evidence and developments in clinical practice, with expert advice and practical guidance, to ensure that paramedics have access to the most up to date information to support the delivery of patient care. ABD management is included in the guidelines and has been updated on three occasions between 2021 and 2025. The guidelines for the management of ABD are crucial for ensuring patient safety and effective emergency care. They provide a framework for paramedics and healthcare professionals to recognise, assess and manage ABD effectively, reducing the risk of death and improving patient outcomes.

ABD in NHS Pathways

As described above, life-threatening presentations such as a person falling unconscious or not breathing reach a Category 1 response in Module 0 of the NHS Pathways triage system. Where the patient is awake, and in the absence of other life- threatening symptoms, the triage system prompts call-takers to seek answers to the following questions relevant to ABD:

DOES EITHER OF THE FOLLOWING APPLY?

1) The patient is under active restraint RIGHT NOW

Additional supporting information for health advisors includes: ‘This means the patient is being actively restrained to reduce the risk of harm to themselves and/or to others. This includes restraint for acute behavioural disturbance (ABD), also known as excited delirium or acute behavioural disorder.’

OR

2) The patient is in need of restraint OR acute behavioural disturbance (ABD) has been declared

Additional supporting information for health advisors includes: ‘This means restraint is required but active restraint is not being applied currently. This includes any declared acute behavioural disturbance (ABD), also known as excited delirium or acute behavioural disorder. THE AMBULANCE SERVICE WILL NOT RESTRAIN THE PATIENT. LOCAL POLICY SHOULD BE FOLLOWED.’

If either of these 2 prompts are present, then the current Category 2 response is recommended. Should the patient be collapsed or unconscious, a Category 1 response does not depend on the declaration of these terms.

Attend Incident

It should be noted that, as well as the main triage assessment, ambulance services using the NHS Pathways system have access to a specially designed module to respond to incidents from custodial services. This is named “Attend Incident”. This module enables access to reduced detail, “high sorting” pathways, specifically designed for the types of contacts from services such as the Police and Prisons.

In the ‘Attend Incident’ functionality of 999 ambulance services, in the absence of life- threatening symptoms, when ABD is declared by the police, prison service or a healthcare professional, a Category 2 ambulance response is triggered, and the following question is presented:

1) Has active restraint been declared?

This question is presented to assist the onward transmission of information I.e. this information is collected to assist the attending practitioners and as part of the patient’s records.

Additional Training

NHS England’s teams closely monitor incidents relating to ABD to evolve and develop the NHS Pathways system, and training of its use, in step with emerging evidence.

To support health advisors, a training consolidation pack specifically covers ABD or Excited Delirium (as ABD was referred prior to being referred to as ABD) as follows:

“Acute behavioural disturbance (or disorder) is not an actual diagnosis, but rather an ‘umbrella’ term for several different conditions that cause a sudden and very noticeable change in someone’s behaviour. It is an emergency situation, that can be caused by several things including:

• Substance abuse or withdrawal
• Certain physical conditions such as a head injury or hypoglycaemia
• Other mental health conditions such as psychosis

Commons symptoms include:
• Agitation

• Feeling hot to touch, a high temperature and often profuse sweating
• Rapid breathing and rapid pulse
• Aggression, hostility and violence
• Extreme strength and insensitivity to pain”

Regional Response

NHS England’s Midlands regional colleagues have reached out to Derby and Derbyshire Integrated Care Board (ICB) who has advised that East Midlands Ambulance Service will be responding directly to the concerns you raised. The Trust has confirmed that, as part of the learning and actions arising from this process, a review of all existing Memorandums of Understanding (MOUs) is underway to ensure appropriate governance arrangements are in place for each agreement. Through their Mental Health lead, the Trust is also working collaboratively with system partners to revise the relevant clinical presentation protocols.

Regional colleagues have highlighted that there was another PFD report within the region where similar themes relating to ABD pathways and protocols between police and EMAS. They have reached out to that ICB for an update on the actions identified as a result of that report.

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 Robert, 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.

Dear Mr Smith

Re: Report regarding the case of Mr Robert Shaun Gracey deceased.

I am writing to you in response to the concerns that you highlighted to the East Midlands Ambulance Service NHS Trust following the inquest hearing into the sad death of Mr Robert Shaun Gracey that concluded on 18 December
2025.

Thank you for your Regulation 28 report regarding the absence of a locally agreed protocol for the management of suspected Acute Behavioural Disturbance (ABD) incidents in Lincolnshire.

I am aware that you will share my response with Mr Gracey’s family, and I firstly wish to express my sincere condolences to them.

The Trust acknowledges the concerns raised by you and I would like to offer the following clarifications and commitments.

The concerns highlighted in your report have been reviewed and discussed by the Trust’s Incident Review Group, which convenes twice a week to consider issues raised through complaints/concerns raised, incident reporting, inquests and Regulation 28 reports. This process ensures that lessons are identified and appropriate actions are taken to address any systemic or procedural shortcomings.

Matters of Concerns raised on 18 December 2025

Although the letter issued on 24 July 2019 by Deputy Assistant Commissioner (DAC) Twist, on behalf of the National Police Chiefs’ Council (NPCC), clearly Private and Confidential Mr Paul D Smith HM Senior Coroner for the coroner area of Greater Lincolnshire

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recommended that police forces develop established ABD protocols with their local ambulance ensuring suspected ABD incidents are treated as medical emergencies with a Category 1, eight‑minute response standard, no such protocol has yet been implemented in Lincolnshire.

Under the current NHS Pathways system, ABD does not have its own allocation pathway and a referral for ABD will only be allocated a Category 2 response in the absence of police restraint.

ABD Protocols

We acknowledge the recommendation, referenced above, made by DAC Twist on behalf of the NPCC in the letter dated 24 July 2019.

Current Position

The Trust operates under NHS Pathways (NHSP), a nationally mandated triage system that determines clinical priority based on structured questioning during the 999 calls.

ABD is treated as a medical emergency; however, NHSP does not currently include a specific ABD protocol that automatically assigns Category 1 status (7 minutes). ABD has a specific answer stem within NHSP. This limitation means that suspected ABD cases are triaged according to presenting symptoms rather than a standalone ABD category at the time of the call being made. The police should always, at the earliest opportunity, contact 999 for any patient that they believe to be experiencing ABD symptoms.

Our clinical teams within our Emergency Operations Centre review ABD presentations from the police which can then be flagged for higher priority within existing NHS Pathways constraints if required. The Trust also has guidance for call handlers and clinicians to ensure suspected ABD cases are escalated promptly.

The Future

As NHS Pathways is a nationally mandated triage system, this is not something that the Trust can change individually and would require a change to the national triage system. This would need to be initiated by NHS England.

In addition, the Trust recognises that there is not currently a national pathway for ABD, however the Trust has in place a process for a response to ABD as governed by the Emergency Call Handling Protocols that was ratified by the

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Trust’s Clinical Governance Group in October 2023 when the Trust went live with NHS Pathways.

The Trust currently operates across six counties within the East Midlands, creating logistical hurdles when ensuring policies and response protocols are consistent across multiple counties and multiple police forces. The Trust will, however, continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD.

The Trust will also continue to work with regional police forces and health partners to explore the development of a single joint operational framework for ABD management.

In the meantime, The Trust will continue to review its internal clinical guidance to ensure consistency with police training and national best practice.

The Trust’s core purpose is to respond to patient needs in the right way, developing our organisation to become outstanding for patients and staff, and collaborating to improve wider healthcare. We always aim to deliver safe, effective, compassionate care for patients, embedding a culture of compassion and continuous improvement. We are committed to improving the recognition and response to ABD incidents.

Thank you for highlighting this important issue. Please do not hesitate to contact me should you require further information.