Chloe Ellis
PFD Report
All Responded
Ref: 2025-0298
All 1 response received
· Deadline: 8 Aug 2025
Coroner's Concerns (AI summary)
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.
View full coroner's concerns
(1) The inquest was told that it is possible for the outcomes of NHS 111 online assessments to be made accessible to Emergency Department clinicians, and that the decision whether or not to commission that accessibility in a particular hospital rests with the relevant Integrated Care Board.
(2) The inquest was told that the West Yorkshire Integrated Care Board has not commissioned accessibility to NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust.
(3) If the NHS online assessment completed by Chloe had been available to the relevant clinicians at Dewsbury District Hospital, her history of oral contraceptive use and the suspicion of a pulmonary embolism would have been visible to them.
(4) The availability of NHS 111 online assessments to clinicians in Emergency Departments may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in Emergency Departments.
(2) The inquest was told that the West Yorkshire Integrated Care Board has not commissioned accessibility to NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust.
(3) If the NHS online assessment completed by Chloe had been available to the relevant clinicians at Dewsbury District Hospital, her history of oral contraceptive use and the suspicion of a pulmonary embolism would have been visible to them.
(4) The availability of NHS 111 online assessments to clinicians in Emergency Departments may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in Emergency Departments.
Responses
Action Planned
The ICB is working to implement the Better Ambulatory Record Sharing (BaRS) system, which would allow EDs to access NHS 111 Online assessment data, with a target date of March 2026. They are also promoting access to medical histories through the Yorkshire and Humber Care Record. (AI summary)
The ICB is working to implement the Better Ambulatory Record Sharing (BaRS) system, which would allow EDs to access NHS 111 Online assessment data, with a target date of March 2026. They are also promoting access to medical histories through the Yorkshire and Humber Care Record. (AI summary)
View full response
Dear Mr Longstaff, Thank you for your letter of 13th June 2025 in relation to the Regulation 28 report to prevent future deaths following the inquest into the death of Chloe Ellis. This was issued to the West Yorkshire Integrated Care Board (WYICB), White Rose House, West Parade, Wakefield, WF1 1LT. I would like to offer my sincere condolences to Chloe’s family on behalf of the NHS West Yorkshire Integrated Care Board. I am sorry for their loss and for the circumstances surrounding Chloe’s death. You raised the following Matters of Concern:
• The inquest was told that it is possible for the outcomes of NHS 111 online assessments to be made accessible to Emergency Department (ED) clinicians, and that the decision whether or not to commission that accessibility in a particular hospital rests with the relevant Integrated Care Board.
• The inquest was told that the WYICB has not commissioned accessibility to NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust (MYTT).
• If the NHS online assessment completed by Ms Ellis had been available to the relevant clinicians at Dewsbury District Hospital, her history of oral contraceptive use and the suspicion of a pulmonary embolism would have been visible to them.
• The availability of NHS 111 online assessments to clinicians in EDs may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in EDs.
I will respond to these points and hope to provide assurance around actions that WYICB is taking as a result.
111 Online Assessments and Data Sharing Timely access to comprehensive medical records — including NHS 111 online assessments — is an important contributor to supporting effective and safe clinical assessments within Emergency Departments (EDs). At the time of the case involving Chloe, no Emergency Departments across West Yorkshire had access to NHS 111 Online assessment data. This meant that the assessment information could not be shared with Emergency Department clinicians. At present, NHS 111 Online is commissioned nationally by NHS England (NHSE) and not directly by the West Yorkshire Integrated Care Board (WYICB). When a patient completes an NHS 111 Online assessment, the system advises them on the most appropriate local service to attend. We have been considering options for the development of “interoperable” systems locally that can routinely share data, including these assessments, between NHS111 and EDs. However, there is now a national solution in development which is designed to enable the safe, structured transfer of such information across systems. This is called the Booking and Referral Standard (BaRS). Our approach will be to use the BaRS in West Yorkshire. Implementation of the Booking and Referral Standard (BaRS) BaRS is a national interoperability standard that enables the secure sharing of patient information, supporting both clinical care and operational processes. It is expected to enhance patient safety, especially within urgent and emergency care, by ensuring essential clinical information is available to clinicians in real-time. The national development and implementation of BaRS was first signalled in the 2022 Plan for Digital Health and Social Care. NHS England has recently confirmed that BaRS is now being rolled out to support urgent and emergency care pathways. Adoption of BaRS is the responsibility of individual NHS trusts and their suppliers. However, compatibility with many existing NHS IT systems — such as Symphony, currently used within Mid Yorkshire Teaching Trust (MYTT) — is not yet in place and still under development. WYICB is working actively with national and local partners to facilitate this integration. It is anticipated that NHS 111 Online assessment data could be available to EDs in West Yorkshire by March 2026. Broader Efforts to Improve Access to Clinical Information In addition to supporting BaRS implementation, WYICB is also promoting access to medical histories through the Yorkshire and Humber Care Record, which offers clinicians improved visibility of a patient’s broader health information. This is another important step towards more joined-up and informed care. Medical history information is shared via the Yorkshire and Humber Care Record, providing
clinicians with a holistic view of a patient’s health. This comprehensive information enables clinicians to make a more informed assessment. We are aware that the inquest into the death of Chloe was informed of actions being taken by Mid Yorkshire Teaching Trust to improve the assessment of patients presenting at the Emergency Department. WYICB is committed to working in close partnership with MYTT to further support these improvements. I hope this letter provides reassurance of our commitment to improving both patient safety and interoperability between services. We will continue to engage with colleagues from both MYTT and NHSE to support continued improved interoperability and transfer a critical patient information. Should you have any further questions, or need for clarification please do not hesitate to contact me again.
• The inquest was told that it is possible for the outcomes of NHS 111 online assessments to be made accessible to Emergency Department (ED) clinicians, and that the decision whether or not to commission that accessibility in a particular hospital rests with the relevant Integrated Care Board.
• The inquest was told that the WYICB has not commissioned accessibility to NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust (MYTT).
• If the NHS online assessment completed by Ms Ellis had been available to the relevant clinicians at Dewsbury District Hospital, her history of oral contraceptive use and the suspicion of a pulmonary embolism would have been visible to them.
• The availability of NHS 111 online assessments to clinicians in EDs may assist in the obtaining of a full history and may act as a failsafe against inadequate history taking in EDs.
I will respond to these points and hope to provide assurance around actions that WYICB is taking as a result.
111 Online Assessments and Data Sharing Timely access to comprehensive medical records — including NHS 111 online assessments — is an important contributor to supporting effective and safe clinical assessments within Emergency Departments (EDs). At the time of the case involving Chloe, no Emergency Departments across West Yorkshire had access to NHS 111 Online assessment data. This meant that the assessment information could not be shared with Emergency Department clinicians. At present, NHS 111 Online is commissioned nationally by NHS England (NHSE) and not directly by the West Yorkshire Integrated Care Board (WYICB). When a patient completes an NHS 111 Online assessment, the system advises them on the most appropriate local service to attend. We have been considering options for the development of “interoperable” systems locally that can routinely share data, including these assessments, between NHS111 and EDs. However, there is now a national solution in development which is designed to enable the safe, structured transfer of such information across systems. This is called the Booking and Referral Standard (BaRS). Our approach will be to use the BaRS in West Yorkshire. Implementation of the Booking and Referral Standard (BaRS) BaRS is a national interoperability standard that enables the secure sharing of patient information, supporting both clinical care and operational processes. It is expected to enhance patient safety, especially within urgent and emergency care, by ensuring essential clinical information is available to clinicians in real-time. The national development and implementation of BaRS was first signalled in the 2022 Plan for Digital Health and Social Care. NHS England has recently confirmed that BaRS is now being rolled out to support urgent and emergency care pathways. Adoption of BaRS is the responsibility of individual NHS trusts and their suppliers. However, compatibility with many existing NHS IT systems — such as Symphony, currently used within Mid Yorkshire Teaching Trust (MYTT) — is not yet in place and still under development. WYICB is working actively with national and local partners to facilitate this integration. It is anticipated that NHS 111 Online assessment data could be available to EDs in West Yorkshire by March 2026. Broader Efforts to Improve Access to Clinical Information In addition to supporting BaRS implementation, WYICB is also promoting access to medical histories through the Yorkshire and Humber Care Record, which offers clinicians improved visibility of a patient’s broader health information. This is another important step towards more joined-up and informed care. Medical history information is shared via the Yorkshire and Humber Care Record, providing
clinicians with a holistic view of a patient’s health. This comprehensive information enables clinicians to make a more informed assessment. We are aware that the inquest into the death of Chloe was informed of actions being taken by Mid Yorkshire Teaching Trust to improve the assessment of patients presenting at the Emergency Department. WYICB is committed to working in close partnership with MYTT to further support these improvements. I hope this letter provides reassurance of our commitment to improving both patient safety and interoperability between services. We will continue to engage with colleagues from both MYTT and NHSE to support continued improved interoperability and transfer a critical patient information. Should you have any further questions, or need for clarification please do not hesitate to contact me again.
Sent To
- West Yorkshire Integrated Care Board
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Aug 2025
All responses received
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 06 September 2024 I commenced an investigation into the death of Chloe Alicia Ellis who died on 03 September 2024 in Leeds General Infirmary. The investigation concluded at the end of the Inquest on 09 June 2025. The medical cause of death was 1a) Pulmonary Embolism; 1b) Endometriosis, Treated with Oral Contraceptive Pill.
In summary, the narrative conclusion to the inquest was that, had a history of her oral contraceptive use been obtained when Chloe attended a local hospital Emergency Department on 31 August 2024, she would have been given anticoagulation medication and undergone tests that would have revealed the pulmonary embolism. She would have received effective treatment for the pulmonary embolism and, on the balance of probabilities, would not have died three days later.
In summary, the narrative conclusion to the inquest was that, had a history of her oral contraceptive use been obtained when Chloe attended a local hospital Emergency Department on 31 August 2024, she would have been given anticoagulation medication and undergone tests that would have revealed the pulmonary embolism. She would have received effective treatment for the pulmonary embolism and, on the balance of probabilities, would not have died three days later.
Circumstances of the Death
Chloe Ellis had been taking the Yasmin contraceptive pill to manage her endometriosis since September 2023.
On 31 August 2024 she undertook an NHS 111 online assessment in which she reported chest and back pain and breathlessness and gave a history of her oral contraceptive use. The assessment algorithm advised her to attend a local Emergency Department, having concluded via the algorithmic process that she had a suspected pulmonary embolism. The assessment algorithm did not tell Chloe herself that she had a suspected pulmonary embolism.
The outcome of the NHS online assessment was not available to clinical staff at the Emergency Department at Dewsbury District Hospital where Chloe attended. There, an inadequate history was obtained from her, in that she was not asked about her medication history and specifically about her use of oral contraception. The inquest was informed of measures taken by the Mid Yorkshire Teaching NHS Trust in relation to that inadequate history taking, and no Reg 28 report is being made in respect of it.
Chloe was diagnosed with a viral illness and discharged. She collapsed at home on 03 September 2024 and, despite the best efforts of attending paramedics and clinicians at Leeds General Infirmary, she died later that day.
On 31 August 2024 she undertook an NHS 111 online assessment in which she reported chest and back pain and breathlessness and gave a history of her oral contraceptive use. The assessment algorithm advised her to attend a local Emergency Department, having concluded via the algorithmic process that she had a suspected pulmonary embolism. The assessment algorithm did not tell Chloe herself that she had a suspected pulmonary embolism.
The outcome of the NHS online assessment was not available to clinical staff at the Emergency Department at Dewsbury District Hospital where Chloe attended. There, an inadequate history was obtained from her, in that she was not asked about her medication history and specifically about her use of oral contraception. The inquest was informed of measures taken by the Mid Yorkshire Teaching NHS Trust in relation to that inadequate history taking, and no Reg 28 report is being made in respect of it.
Chloe was diagnosed with a viral illness and discharged. She collapsed at home on 03 September 2024 and, despite the best efforts of attending paramedics and clinicians at Leeds General Infirmary, she died later that day.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.