Dear Ms Bisset, Re: Regulation 28 Report to Prevent Future Deaths – James Paul Michael Masheter who died on 1 April 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 April 2025 concerning the death of James Paul Michael Masheter on 1 April 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to James’s family and loved ones. NHS England are keen to assure the family and yourself that the concerns raised about James’s care have been listened to and reflected upon.

Your Report raised concerns around the use of NHS Pathways to triage mental health situations. Specifically, James was triaged as Category 3 which led to significant delays in an ambulance attending. You have noted that it is not clear whether it is possible for serious mental health crisis situations, which present a risk to life, to be properly risk assessed on the basis of the current NHS Pathways mental health triage.

My response focuses on those areas of concern that sit within NHS Pathways’ remit and has been aided by engagement with NHS England’s national NHS Pathways Team and North West regional colleagues.

The Triage Product

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

4 June 2025

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.

Ambulance Response

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. The response time standards vary according to the urgency of the call.

NHS Pathways’ ambulance response disposition codes are ratified by the National Ambulance Services Medical Directors Group (NASMeD). 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. Ambulance codes are further ratified by the Emergency Call Prioritisation Advisory Group (ECPAG). The purpose of the ECPAG is to advise NHS England and the Department of Health and 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), College of Paramedics, NHS England, DHSC, Advanced Medical Priority Dispatch System (AMPDS), National Ambulance Commissioning Network (NACN), NASMeD and Ambulance Heads of Control.

The Category 3 ambulance response standard does not have an average response target, but a 90th percentile response target of 120 minutes, meaning these types of calls will be responded to at least 9 times out of 10 before 120 minutes. However, there is a 60-minute average response indicator which is collected nationally by the ambulance quality indicators.

Managing Suicide Risk

NHS England has led a number of 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.

In the NHS Pathways triage system, where the patient or caller reports either a suicide attempt or active suicidal intent, the lowest disposition that may be reached is a Category 3 emergency ambulance response. A higher category of ambulance response would be reached where other relevant symptoms/conditions – such as loss of consciousness or difficulty breathing – are present at the time of assessment. These align to the Ambulance Response standards set by the Ambulance Response Programme (ARP).

In early 2019, NHS England, with endorsement of NASMeD and other associated groups, instructed ambulance and NHS 111 providers that any such suicide-related cases reaching a Category 3 ambulance outcome should receive an urgent remote clinical review facilitated by a clinician working with the 999 ambulance control room. This enables a prioritised clinical assessment, considering the individual circumstances of each case. Such assessments should determine the appropriate level of response, which could include upgrading the response to a Category 1 or 2 emergency ambulance 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. Furthermore, NHS Pathways provides a code identifying suicidal intent – the means and a plan to complete suicide
– (SD4244 – AMB suicidal means and a plan). The new disposition code was created within the NHS Pathways system in April 2019, following the presentation and ratification of the changes to the NHS Pathways National Clinical Governance Group (NCGG) in February 2019. This new disposition code was deployed to all service users as part of Release 19 in October 2019 as planned and following sign-off by ECPAG on 3 July 2019.

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 had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above.

The view from the Ambulance Response Programme Implementation Group at NHS England, supported by NASMeD, was that cases involving suicidal ideation are often multi-factorial and therefore too complex for Health Advisors to apply a definitive disposition without assessment by a clinician. Instead, they require an urgent remote clinical risk assessment in the absence of priority airway, breathing or circulation symptoms during triage. This means that for those cases which do not automatically result in a Category 1 or 2 emergency ambulance response, an urgent remote clinical assessment will take place, pending which the case will be dealt with as a Category 3 emergency ambulance response. If, on review, the clinical view is that, given the individual factors of the case this should be upgraded to a Category 1 or 2 emergency ambulance response, this should be done without delay.

In November 2023, the 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document which was issued in April 2021, was reissued following a review by the ECPAG and NASMed.

In addition to the guidance and reviews in 2019, 2021 and 2023 referenced above, there have been ongoing discussions and reviews at various stakeholder groups.

NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions and has offered to advise North West Ambulance Service (NWAS) on how to triage mental health situations. Regional clinical quality colleagues for the North West have also been made aware of your Report for the appropriate assurance purposes.

NHS Pathways does not have oversight of local ambulance queues or their management, and we do note that it can be the case that waiting times may be longer than NHS Pathways recommends due to local resourcing and demand pressures. Given the significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content) this will remain under review as and when new evidence or guidance emerges. In this particular case, it appears from the Report that the NHS Pathways triage system did elicit the correct information which triggered the correct nationally approved ambulance 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 James, 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.