Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Peter Coates who died on 14th March 2019

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23rd March 2026 concerning the death of Peter Coates on 14th March 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Peter’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Peter’s care have been listened to and reflected upon.

Your Report raises concern that there may be circumstances when a patient requires an immediate ambulance response but they are not in cardiac or respiratory distress and therefore these patients do not meet the criteria for a Category 1 response. You are concerned that there is a “gap” for patients that fall between Category 1 and 2 responses.

In 2017, following the largest clinical ambulance trials in the world, NHS England implemented new ambulance standards across the country. This was to ensure that the sickest patients get the fastest response and that all patients get the right response first time. NHS Ambulance Services are required to process 999 calls through an approved triage system. There are currently two long established systems approved in England for primary 999 triage; NHS Pathways and Medical Priority Dispatch System (MPDS). The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs). The primary purpose of triage is to quickly identify priority symptoms (e.g. unconsciousness, difficulty breathing, chest pain) and to assign an appropriate response priority. The outcome (disposition) reached based on the information provided by the caller is mapped to one of the five national categories (Categories 1 –
5) set out within the NHS Constitution and Ambulance Service 999 contracts. The development of triage question sets and instructions lies within the remit of the triage system provider. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

6th May 2026

The current ambulance categorisations ensure that all emergency responses are prioritised appropriately; Category 1 covers the most urgent, life-threatening cases, while Category 2 addresses emergency but less critical incidents. These two categories are sufficient for effective triage and timely intervention for life threatening and emergency conditions. In cases where there is risk of a patient’s condition deteriorating whilst waiting for an ambulance to arrive, the call handler could stay on the line with the patient; this is an operational decision to be made by each ambulance service. Moreover, the provision of instructions or actions to be taken in the case of worsening patients is a standard component of call exit scripts, whereby patients are advised that if their condition worsens, they should call 999 back. This provides an opportunity for a call to be re- triaged and potentially upgraded to a higher category response if this is clinically indicated. In cases where a patient is dependent on a piece of medical equipment e.g. continuous BiPAP, the accountable clinician who is responsible for overall care of the patient (e.g. their GP or hospital consultant) may wish to flag the patient to the local ambulance service to enable the ambulance service to make a note on the patient’s details within the services’ records system. This can be recorded in the urgent care plan or summary care record dependent on the local service. Then, if the patient / carer contacts 999 and is presenting with a problem relating to this equipment / medical device they can be managed rapidly to receive the appropriate care.

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 Peter, 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.