Miles Robinson
PFD Report
No Identified Response
Ref: 2025-0340
Coroner's Concerns (AI summary)
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.
View full coroner's concerns
In the UK, 999 calls are triaged using one of two approved triage tools (also referred to as call prioritisation systems) approved by NHS England: the Medical Priority Dispatch System (“MPDS”) and NHS Pathways. LAS uses MPDS. The MPDS looks at signs and symptoms and prioritises them into dispatch codes, which assign a level of priority to the call, and in turn inform the type of ambulance resource that will be allocated to manage the incident.
MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS.
In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack. The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response, with an average response time of 7 minutes and 90% of calls responded to within 15 minutes.
This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances.
MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS.
In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack. The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response, with an average response time of 7 minutes and 90% of calls responded to within 15 minutes.
This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances.
Sent To
- Emergency Call Prioritisation Advisory Group
- London Ambulance Service NHS Trust
Response Status
Linked responses
0 of 2
56-Day Deadline
2 Sep 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 15 February 2023, an inquest was opened, and an investigation commenced, into the death of Miles Brian Robinson, who was aged 66 at the time of his death. The investigation concluded at the end of the inquest, which was heard over 3 days between 4 and 6 June 2025.
The medical cause of death was: 1a. Myocardial Infarction. 1b. Atherosclerosis.
2. End-stage renal failure.
The conclusion was natural causes.
The medical cause of death was: 1a. Myocardial Infarction. 1b. Atherosclerosis.
2. End-stage renal failure.
The conclusion was natural causes.
Circumstances of the Death
In the early hours of the morning on 19 December 2022, Miles Robinson started to have chest pains and was vomiting. He had multiple co-morbidities including end-stage renal failure, hypertension, heart failure and pleural effusion. His granddaughter called 999 at 03:37. Due to extreme demand on the London Ambulance Service (“LAS”), there was a significant delay in that call and a later 999 call being answered and there were significant delays in allocation and dispatch of ambulances. The 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required.
Having been informed that an emergency ambulance was not immediately required and of the wait times for an ambulance, Mr Robinson made his own way in an Uber to the nearest urgent treatment centre (“UTC”) at Queen Mary’s Hospital. Upon arrival, he had a cardiac arrest. This was due to a massive myocardial infarction. After prolonged CPR and shocks by staff at the UTC and attending LAS paramedics, a return of spontaneous circulation was achieved at 05:04.
Mr Robinson was then transferred by ambulance to the local emergency department at Princess Royal University Hospital (“PRUH”). He had two further cardiac arrests shortly before and after his arrival at PRUH, which were fatal. He died at 06:36 on 19 December 2022.
Having been informed that an emergency ambulance was not immediately required and of the wait times for an ambulance, Mr Robinson made his own way in an Uber to the nearest urgent treatment centre (“UTC”) at Queen Mary’s Hospital. Upon arrival, he had a cardiac arrest. This was due to a massive myocardial infarction. After prolonged CPR and shocks by staff at the UTC and attending LAS paramedics, a return of spontaneous circulation was achieved at 05:04.
Mr Robinson was then transferred by ambulance to the local emergency department at Princess Royal University Hospital (“PRUH”). He had two further cardiac arrests shortly before and after his arrival at PRUH, which were fatal. He died at 06:36 on 19 December 2022.
Copies Sent To
King’s College Hospital NHS Foundation Trust
Hurley Group
NHS England, as the Emergency Call Prioritisation Advisory Group, is part of NHS England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.