Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Glyn Ackerley who died on 4 September 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27 November 2023 concerning the death of Glyn Ackerley on 4 September 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Glyn’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Glyn’s care have been listened to and reflected upon.

I apologise for the delay in responding to the coroner and for any anguish this delay may have caused Glyn’s family. Due to the initial email containing the Report being misdirected, the relevant team at NHS England only became aware of the Report on 8 February 2024. I realise that Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

In your Report you raised the concern that the current NHS Pathways process does not differentiate between a high risk and low risk overdose, categorising all such calls without additional symptoms, as Category 3. You also raised that it was unclear whether NHS Pathways would be making changes to their existing processes following the inquest into Glyn’s care.

NHS Pathways is owned by DHSC. However, the Transformation Directorate within NHS England have overall management and responsibility for the clinical governance of NHS Pathways, and it has therefore been agreed with the DHSC that NHS England will respond to your Report directly.

Background on NHS Pathways System

NHS Pathways is an interlinked series of algorithms, or pathways, that link questions and care advice to clinical endpoints known as “dispositions”. The system presents a series of questions to arrive at the most appropriate disposition, based on the National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

6 March 2024

presenting symptoms. The disposition will determine the response skill set and time frame that a patient requires.

NHS Pathways uses a clinical hierarchy, to ensure that life-threatening symptoms are assessed at the start of any call, and progressing through to less urgent symptoms which require a less urgent response. NHS Pathways is not diagnostic, but instead works on the basis of 'ruling out'.

Overdoses and ambulance categorisation

Where an overdose has occurred, and in the absence of signs or symptoms indicating an immediate life-threat (reduced conscious level, breathlessness, or shock, for example), the lowest disposition that can be reached is a Category 3 ambulance response. A quicker response will be actioned where there are symptoms indicating an immediate life threat.

In 2019, NHS Pathways developed a new disposition code ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’. This code facilitates improved visibility of overdose and suicide attempt cases within the ambulance dispatch queue.

In April 2021, NHS England and Improvement, in collaboration with the Association of Ambulance Chief Executives (AACE) published a new operational procedure1 for all ambulance services in England which sets out that, where an overdose is declared, a further clinical intervention should take place within 30 minutes, and/or the case will be automatically upgraded to a Category 2 ambulance response if this does not occur within 40 minutes. 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 is done without delay.

In October 2023 a review of this document was completed by the Emergency Call Prioritisation Advisory Group (ECPAG, NHS England) and the National Ambulance Service Medical Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remains fit for purpose.

Assessing “high risk” vs “low risk” substances

The further clinical assessment referenced above involves gathering clinical information about the substance(s) ingested and their quantities. It is recommended that health advisors use TOXBASE® to support this assessment. TOXBASE is the clinical toxicology database of the UK National Poisons Information Service that clinicians have access to, to help support clinical decision making when excess medications have been ingested.

Health advisors are not clinicians, and their training therefore ensures an understanding of where they should seek supervisory, or clinical, support. This includes instances where medical information, such as medication names, are

1 Entitled ‘Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document’

volunteered during the assessment where they are not expected to understand or identify the medication names or drug classifications.

NHS Pathways also provides a telephone consultation tool called Pathways Clinical Consultation Support System (PaCCS). This is for use by experienced clinicians and lends itself more to a consultation-led assessment rather than triage. Within each clinical template there is additional supporting information and links to approved websites that can be viewed if required.

Should national guidance or standards be amended such that toxic substances, where identified, impact on ambulance categorisation or disposition, NHS England would align the NHS Pathways system accordingly.

Further information

The specific details of this case were not shared with NHS Pathways. However, the NHS Pathways team has discussed this case with North West Ambulance Service (NWAS) in response to their concerns regarding overdoses and suicidal ideation cases.

On 6th April 2023, NHS Pathways discussed with NWAS:
• The background to decisions made.
• Understanding competing pressures in ambulance queue management.
• The requirement to not inappropriately increase risk in category 2 responses.
• Recommendation that concerns and proposals for change should be raised with the Clinical Coding Review Group (CCRG) and ECPAG.
• That any changes to categorisation defined by these groups would be enacted into the NHS Pathways system, reflecting changes in national standards.
• Category 3 / 999 overdose and suicidal ideation calls.
• Initial assessment of lethality/toxicity principles document that the Association of Ambulance Chief Executives issued in April 2021 was also re-shared.

Governance of NHS Pathways

The safety of the clinical triage process endpoints resulting from a 111 or 999 assessment using NHS Pathways, is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate group hosted by the Academy of Medical Royal Colleges. This group is made up of representatives from Medical Royal Colleges and other clinical professional bodies and groups. Senior clinicians from these organisations provide independent oversight and scrutiny of the NHS Pathways clinical content. The group considers all aspects of the triage process, including the impact on services, as well as the evidence base for changes to the clinical content. All changes to, and development of, the core telephone system and other platforms, are formally documented and presented for a critique in accordance with agreed processes endorsed by NCAG.

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.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.