Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Sandra Ann Millard who died on 20 May 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 April 2025 concerning the death of Sandra Ann Millard on 20 May 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sandra’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sandra’s care have been listened to and reflected upon.

Your Report raises concerns over how the NHS Pathways triage tool works when patients report they are stuck in situ (e.g. unable to move from a chair), as opposed to lying on the floor which prompts further questions.

NHS Pathways triaging progresses through a clinical hierarchy of different urgencies, 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” (outcome) is reached. Dispositions range from an emergency ambulance being called out to self-care.

Between 2017 and 2018, NHS Pathways collaborated with its ambulance service stakeholders to enhance the assessment of patients who may not have fallen but are nonetheless unable to move from their current position. Since 2018, the system has included functionality to assess patients in this situation, regardless of whether their immobility is due to disability, frailty, weakness, pain, or another factor.

If a patient who is unable to move reaches a disposition on the basis of high acuity symptoms (acuity being the measure of severity of the patient’s condition and the urgency with which they need to be seen), and if this results in an ambulance being dispatched without any clinical input, a question about whether someone can stay with the patient is included, particularly to support them in case of any delay, or to request additional support if symptoms change.

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

30 May 2025

If a patient who is unable to move does not reach such a disposition, they will progress further into the NHS Pathways triage. Given the wide range of potential causes of immobility and the complexity of individual needs, the system is deliberately designed to trigger a disposition of “speak to a clinician immediately”. This ensures that a clinical professional can assess the specific circumstances and determine the most appropriate response. The possible outcomes following this assessment can include dispatching an emergency ambulance, referring to a community response team, involving social services, or contacting the police if there are any concerns about the individual’s welfare.

In scenarios where the call is transferred immediately to a clinician, the Pathways system does not prompt the question about whether someone can stay with the patient, as this consideration should form a part of the clinician’s overall assessment. In Sandra’s case, the call was not immediately transferred but was instead ended by the call taker, who arranged for a clinician to call her back. The 111 provider would have responsibility for the operational management of this, however the system recommended disposition is for immediate clinical assessment.

It is also expected that local protocols are in place to capture demographic details such as next of kin, as this information falls outside the remit of the NHS Pathways triage tool. Similarly, where a clinician is unable to make contact with the patient (noting that the clinician in this case attempted to call Sandra 4 times before closing the call), it is beyond the scope of NHS Pathways to determine the next steps. This decision lies with the local service provider in accordance with their operational policies and procedures. We understand that South Central Ambulance Service (SCAS) are changing their standard operating procedure as a result of the concerns raised by your Report, and that they will be sharing learnings through national forums.

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 Sandra, 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 Simpson,

I am writing to you in response to the concerns that you highlighted following the inquest hearing into the sad death of Sandra Ann Millard that concluded on 7th April 2025. Thank you for allowing us the time to review and respond to your concerns.

To confirm, your Regulation 28 report detailed your concerns regarding the difference in the questions asked by the NHS Pathways triage system when a patient is unable to get up from the floor compared to when they are stuck in situ. You highlighted that when a patient is lying on the floor with no reported injuries, questions are asked regarding whether the patient is alone and contact information for their next of kin or another person who may be able to attend to be with the patient whilst they wait for an ambulance. When a patient is unable to move from another position, such as from a chair, these questions are not asked. Your Regulation 28 report was also issued to NHS England due to your awareness that the Trust is a user of the triage system and is not responsible for writing the algorithms which direct which questions are asked as part of the assessment. NHS England design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is appropriate.

At the inquest hearing you heard evidence from , Senior Quality Auditor at the Trust. indicated to you that she understood your concerns and she would ensure that the issue was reviewed and addressed by the Trust. Thank you for including reference to this within your report.

In response to your concerns, a change in process has now been written by in the form of a directive to staff. The changes will include:

• Ascertaining whether the patient is alone
• If they are alone, requesting the phone number for a relative, friend or neighbour who can be contacted on their behalf
• Triaging a patient who advises they are slipping from a piece of furniture under the NHS Pathways falls triage algorithm to ensure the assessment reaches a minimum of a Category 3 ambulance response disposition despite the patient not being on the floor at the time of assessment
• Documentation of the position the patient is in to aid any subsequent clinical assessment that is undertaken

2
• Referring the case to a clinician within the call centre once the triage has been completed so that a clinical assessment and where appropriate upgrade can be undertaken
• The direction that a case must not be closed without an appropriate response being sent to the patient.

The new directive was approved on 29th May 2025 and will be issued to all staff within the call centre along with an educational tool to clarify the importance of the change this month. We will write to you again to confirm that the new directive has been fully implemented within the call centre.

In addition to any potential changes that NHS England may make to NHS Pathways, to ensure that there is the opportunity for national learning to take place, our patient safety team will also share the changes that we have made to our processes with their counterparts.

I hope that this letter has adequately addressed the concerns that you have raised. Should you wish to discuss these matters further, please contact , Head of Legal Services at SCAS who will be able to facilitate this.