Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Lee Armstrong who died on 2 February 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 October 2024 concerning the death of Lee Armstrong on 2 February 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Lee’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Lee’s care have been listened to and reflected upon.

Your first concern focused on the NHS Pathways system not asking callers to identify potentially relevant pre-existing health conditions and the potential risks posed by expecting patients to volunteer information about their conditions themselves.

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that is used to support Urgent & Emergency Care (UEC) in England. The product is owned by the Secretary of State for Health and Social Care and 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. It supports online triage on NHS 111 online, accessible to the public via the NHS website (www.111.nhs.uk) and the NHS App.

NHS Pathways was the triage product supporting calls at North West Ambulance Service (NWAS), where Lee’s case was managed. Calls to services using the NHS Pathways triage product are managed by specially trained clinical and non-clinical National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

27 December 2024

health advisors. Their training is specific to the Pathways product, and this enables them to use the information provided by callers to both request ambulance resources, or to pass cases to other suitable services, based on the patient’s health needs at the time of the call.

The NHS Pathways triage product – both online and via telephony – 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. 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, ranging from Emergency Ambulance to Self-Care.

Clinical Governance of the NHS Pathways Product The safety of the clinical triage process endpoints resulting 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 latest guidelines from organisations including NICE (National Institute for Health and Care Excellence), the Resuscitation Council UK and the UK Sepsis Trust, amongst others.

Outcomes of triage The system enables matching of relevant symptoms or clinical features to an appropriate service. In telephone services, demographic details are known from the start of the call. This information is more limited in online services, unless the patient is logged in on the NHS App. This means that triage outcomes can appear differently, depending on the necessity to gather demographic details to match the patient to their NHS number via the Personal Demographic Service (PDS).

Past medical history and triage using NHS Pathways The NHS Pathways system is symptom-based. This means that the presenting clinical picture drives the assessment. Where pre-existing conditions may alter the outcome of symptom assessment, these conditions are enquired a b o u t after the initial assessment. Such enquiry is limited to these circumstances because detailed or unnecessary enquiry into past medical history may delay assessment – not only of the caller in question, but globally across the system by affecting average call lengths – without impacting upon the disposition reached.

Implication of Reduced Conscious Level/Confusion As described above, it is not necessary for patients to recall complex medical information or medications, unless it is specifically enquired after. Symptoms such as confusion that could indicate a reduced conscious level are assessed based on the clinical hierarchy. NHS England has not had access to the specific

details of triage in this case, however, confusion that indicates a reduced conscious level will – in combination with other features – result in an emergency response such as an emergency ambulance or referral to the emergency department. Other acute presentations of more mild confusion will lead to very urgent outcomes such as urgent review for further clinical assessment within 1 or 2 hours.

Your second concern raised that information supplied to 111 online is not shared with North West Ambulance Service (NWAS).

111 online can reach a number of different disposition types:
• “Go to” – The person is advised to go to a specific local care setting/service. There is no formal referral and the receiving service has no information about the person including their activity on NHS 111 online e.g. a person is told to go to A&E.
• “Refer and Go to” – A referral is sent to a service including the demographic details and triage answers as entered by the user. The referral is not required for the service to see the person. The person is told the next action is for them to go to that setting e.g. when a person books an arrival time at an Urgent Treatment Centre (UTC) and is advised to make their way there.
• “Callback” – A referral is sent to a service providing clinical callbacks, including the demographic details and triage answers as entered by the person.
• “Phone” – The person reaches the end of their triage and is told to phone another service e.g. call 111, call 999, call a local service phone number (mental health crisis team).

It is correct that where, as in Lee’s case, the disposition is to ring 999 there is no transfer of information from 111 online to the 999 service, and following the advice and dialing 999 is reliant on the user following the instructions. NHS 111 online is a self-service, digital remote triage service for the public and is designed for anonymous use. It is unassisted, meaning there is no health advisor or 111 clinician input to probe and validate the call 999 outcomes. This means there is no automated ambulance dispatch facility. The advice to ‘call 999’ occurs where the triage indicates potential high acuity presenting symptoms, and leads to the user/patient being assessed further over the phone and advised if an ambulance is required.

This process is deliberately designed to enable further emergency assessment, to ensure there is a 999 health advisor assessment, and to ensure that ambulance dispatch is only recommended where clinically appropriate. The system design takes into account usability to ensure the user does ‘call 999’ without any requirement to provide further information online, and to avoid any delays.

Therefore, other than when used via the NHS App, no demographic details are collected, and so it would not be possible to send information to a 999 service by reference to a particular patient.

This is however communicated to users. For people with an existing medical condition, who follow the route “help with an existing medical condition”, the NHS 111 online system explicitly states, “we cannot take any existing long-term conditions you have into account”. Further, “if you are advised to speak to a nurse or visit a service you should tell them about your long-term condition”.

For those who start a triage from “help for my symptoms or injury”, the “Start now” page again prompts those with complex problems caused by an existing medical condition to contact telephony services. This is designed because the Complex Call process that is available in telephony services, as described below, cannot be provided online given it is self-service.

Your third concern raised that NWAS call handlers are not provided with access to a patient’s medical records or a summary of their medical history.

Although comprehensive system training is provided, it is not within the scope or remit of the Health Advisor to understand or interpret the full range of medical elements as would be encountered in summary medical records, or from access to information on current medications. It is not safe or effective to expect this staff group to make sense of such information and it could add confusion or delays and cause harm if incorrect conclusions were drawn. It is for these reasons that questions on past medical history or pharmacology are only asked where it is deemed that a clear understanding can be sought and where it might make a difference to the outcome.

Provision is made in the NHS Pathways system for those cases where complex medical history or terminology is volunteered, however.

Complex Calls and Clinical oversight The NHS Pathways Licence Agreement with provider services mandates that Health Advisors are supported by round the clock ready access to clinical support. This means that clinicians may provide in-call support or take over an assessment. Where patients, or their representatives, volunteer complex or complicated clinical information is one such scenario where it is expected that Health Advisors request clinical input. This is described as the “Complex Call” process.

The Complex Call process provides Heath Advisors with a clear process to ask for help or transfer the call to a clinician. This process is engaged when the call relates to medication, medical procedures or medical language that complicates the triage process, or when Health Advisors recognise that they are at the limit of their knowledge or understanding. It is supported through the recently introduced motto, “If in doubt, shout”.

The recognition and management of complex calls is comprehensively taught in the initial training period. It is tested at the end of this period, prior to live call-taking, and is repeatedly reinforced through Continuous Quality Improvement (CQI) and mandatory call audits.

Hot Topics NHS Pathways produces learning materials called ‘Hot Topics' which can be reviewed at any time. There is a Hot Topic that touches on Addison’s disease. This Hot Topic gives an overview of how this condition presents in extremis, though health advisors are not expected to act independently of the system based on this.

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 Lee, 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 Cohen,

Thank you for the Regulation 28 report of 29 October 2024 sent to the Secretary of State for Health and Social Care about the death of Mr Armstrong. 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 Armstrong’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. I understand that your report and matters of concerns have also been sent to NHS England (NHSE), who are responding to each of your concerns.

The NHS Pathways Clinical Decision Support System triage product is used to support urgent and emergency care in England and is embedded in NHS 111 and 999 call systems of ambulance providers. Your report raises concerns that NHS Pathways does not ask call handlers to ascertain if patients have preexisting conditions. You also highlight concerns that patient information gathered from NHS 111 online and patient medical records more generally, are not available to 999 call handlers.

Ambulance services are required to use an approved triage system to aid initial 999 call prioritisation – the two approved systems are the Advanced Medical Dispatch Priority System (AMPDS) and the NHS Pathways system. These systems are approved on the basis of being able to determine (as far as possible) differing levels of acuity, from immediately life-threatening emergencies to patients with an urgent care need. NHSE has advised the Department that it has in place a process to appropriately map the outcomes of 999 call triage systems against ambulance response time categories. NHSE has responsibility for the production, maintenance, review and revision of the dataset used in these systems, which is managed by the NHSE-chaired Emergency Call Prioritisation Advisory Group (ECPAG). ECPAG keeps the categorisation of calls under continual review, and ambulance services support this process through providing evidence and expertise to

reduce unwarranted variation across services, helping ensure appropriate prioritisation, equity of access and uniformity of response across England. In the case of Mr Armstrong, I understand that his pre-existing condition of Addison’s disease would have changed his call categorisation, and that NHS England, as the appropriate body, will be responding to your concerns raised on this matter as well as on the issue of appropriate patient record sharing and access to information gained from NHS 111. However, I would note that interpreting full medical records is outside of the scope and expectations of call handlers.

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