NHS England
NHS / Health Body
Noted
NHS England acknowledges the concerns and notes that the North West Ambulance Service followed protocol, but also outlines national work taking place around Reports to Prevent Future Deaths, ensuring learnings are shared across the NHS. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Drew John Greaves- Pimblett who died on 22nd March 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th January 2026 concerning the death of Drew John Greaves-Pimblett on 22nd March
2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Drew’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Drew’s care have been listened to and reflected upon.
Your Report raised concerns that there is a gap in national pathways for call handlers. You asked for consideration to be given to further guidance and assistance for call handlers on probing questioning for fundamental aspects such as for breathing and general presentation (e.g. how best to assess how cold a body is and where to take a pulse), so that call handlers can make more informed decisions as to whether someone is breathing and if CPR is required.
Regional Response NHS England’s Regional North West Team have liaised with the North West Ambulance Service (NWAS) regarding your Report. They have advised that when Drew was found not breathing and unresponsive, a 999 call was made to NWAS. The caller stated he was blue, had swollen lips, was very cold and not breathing. The call was initially categorised as a Category 1, the highest level of ambulance response, but was then downgraded to a Category 4 following responses to further questions asked (note that one of the outcomes on NHS Pathways for a person who is clearly deceased is a Category 4 response, and where death is not expected this can be onward referred to the police). The police were notified of the unexpected death, attended within 30 minutes and stated that Drew was blue and unresponsive but was slightly warm, and therefore they started CPR – the police documented that pressing Drew’s chest was very difficult. NWAS were called again and arrived within 2 minutes of the police officer arriving at the scene. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
3 March 2026
The attending NWAS clinician completed an assessment and confirmed that Drew had passed away. He stated when asked that Drew was very cold. NWAS audited the call after the event and did find that there had been some deviation and the need for more probing before the downgrade, which resulted in the ambulance being stood down, with feedback given at the time to the NWAS call handler on this. NHS England was not a party to the inquest, but has been informed that the Coroner accepted all of the evidence and concluded that it was more likely than not that Drew had been deceased for some time before NWAS’s arrival.
National Position Background 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 the Medical Priority Dispatch System (MPDS). The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs). The North West Ambulance Service (NWAS) uses the NHS Pathways system. 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. NHS Pathways Background NHS Pathways is the Clinical Decision Support System (CDSS) used for remote clinical assessment (triage) in urgent and emergency care. In use since 2005, it underpins all NHS 111 services and more than half of England’s 999 telephony services. It is also used for self-service triage via NHS 111 online and at the front door of Emergency Departments. The product is owned by the Secretary of State for Health and Social Care and is manufactured and managed by the Transformation Directorate of NHS England. The tool also supports enhanced clinical assessments via modules such as the NHS Pathways Clinical Consultation Support (PaCCS) system. The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges (AoMRC). Alongside this independent oversight, NHS Pathways aligns its clinical content and assessment protocols with up-to-date national clinical guidance, including from NICE (the National
Institute for Health and Care Excellence), the UK Resuscitation Council and the UK Sepsis Trust, amongst others. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. NHS Pathways follows a structured clinical hierarchy. Serious and potentially life- threatening symptoms are assessed first to ensure rapid escalation - such as dispatching an ambulance or involving a clinician. The assessment then progresses through to less urgent symptoms, identifying the most appropriate level of care. Principles of Health Advisor Training In telephone settings (calls made to NHS 111 or 999), assessments are conducted by specially trained non-clinical health advisors. These advisors complete a comprehensive, structured mandatory training programme to ensure they can use the NHS Pathways algorithm safely and effectively, and they are always supported by clinicians, as a condition of the NHS Pathways licence, which NHS 111 and 999 providers must enter into in order to use the system. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. The NHS Pathways licence states that clinical supervision and escalation support must be available 24/7, and immediately accessible to health advisors during live calls. This clinical availability is a core system control. Following the initial core role preparation training, health advisors and clinicians are required to update their training every 12 weeks. They are also able to access a comprehensive library of additional training courses and educational resources such as ‘Hot Topics’, case studies and e-learning packages. NHS Pathways Assessment of Consciousness and Breathing Based on the information provided regarding this particular case, in respect of the NHS Pathways triage system we can confirm the following:
• If a cardiac arrest is not suspected at the onset of the call, the system seeks to quickly establish whether there is an immediate threat to life. If the patient is not fitting or choking, supporting information is provided to the health advisor to assist them to establish whether the patient is conscious or not. Unconsciousness is classed as when the individual cannot be woken or is difficult to wake up.
• If the patient is confirmed to be unconscious, the next question presented seeks to establish whether a normal breathing pattern is present.
• Health advisors can use the supporting information provided to advise the caller to check whether the chest is rising and falling regularly and/or whether regular breaths can be heard or felt coming from the nose of mouth. If there is doubt, they are prompted to ask the caller to ‘look, listen and feel’ for breathing.
• If the patient is not breathing normally, the supporting information advises that there may be no or very little attempt being made by the individual to breathe. They are advised that there may be occasional gasps or breaths with possible long pauses in between. The supporting information also advises here that the
skin may appear grey or blue, and where to check for this on the body, and where to check when skin tones may be darker.
• If the patient is not breathing or not breathing sufficiently, this results in a Category 1 ambulance outcome, on the basis that a cardiac arrest is likely. This was the outcome reached in this case based on the information provided.
• Once it has been established that the scene is safe, the NHS Pathways system seeks to establish whether the caller is within easy reach of the patient. If no specific scenarios where specialist instructions are required (such as hanging, drowning, choking etc) are present, information on how to give basic life support (BLS), and whether a defibrillator can be located, presents itself for the health advisor. The only reasons that a health advisor should advise BLS to cease are if the ambulance crew arrive and take over, if the patient regains consciousness, or if the person performing BLS is for some reason unable to continue. NHS Pathways does not ask the caller to try to ascertain if there is a pulse present. For the ordinary lay person, the identification of a pulse can prove challenging, thus potentially wasting valuable time in terms of dispatching an ambulance. All pathways relating to instructional information regarding resuscitation have been approved and ratified by Resuscitation Council UK. Also, of relevance to this particular case, in terms of additional training regarding the assessment of consciousness and breathing, health advisors utilising NHS Pathways who have completed the core training are provided with ‘CPR Toolkit Training’. This encompasses what is called the ‘No, No, Go’ approach where, if the patient is not conscious or not breathing (either normally or at all), health advisors are trained to proceed immediately to the initiation of cardiopulmonary resuscitation (CPR) as presented by the system. This additional training seeks to ensure that health advisors are supported to proceed quickly to the required life supporting advice. The CPR Toolkit training explains that evidence from multiple studies indicates that performing CPR on a patient who is not in cardiac arrest is unlikely to cause harm. Health advisors are therefore trained that, where there is any uncertainty regarding whether a patient’s breathing is normal, or if the patient is not breathing at all, they should initiate telephone-guided CPR. NHS Pathways Management of Expected or Unexpected Death A ‘triage not possible’ route exists within the NHS Pathways system for the management of an expected or unexpected death. From the limited information provided regarding this case, it is not possible to comment on whether or not the health advisor should have selected the option for ‘discovery of a stone cold or stiff dead body’. Even if the health advisor in this case had thought that Drew was already deceased and this route was selected, the option of ‘Sudden Unexpected Death’ would have likely been chosen. This route follows the consciousness/breathing assessment as described above, whereby BLS instructions are presented as the system in this
scenario assumes that CPR should be performed as the exact moment of cardiac arrest is not known. NHS Pathways Additional Health Advisor Support Almost every question in the NHS Pathways triage system has ‘supporting information’, shown under the question text, enabling the health advisor to ask probing questions. This supports health advisors to ensure the caller’s responses match the answer selection. ‘Probing’ is extensively trained in the health advisors’ mandatory training, and the facility is a fundamental aspect of the NHS Pathways system and how it differs from fixed-script based systems. The supporting information provided to support the identification of an immediate threat to life is extensive as, in circumstances whereby a patient may not be conscious or breathing, this is recognised as an exceptionally stressful situation for all involved including the health advisor. The Medical Priority Dispatch System (MPDS) In addition to the NHS Pathways response detailed above and whilst this falls outside of NHS England’s direct remit, for completeness, NHS England has discussed the concerns in your Report with the provider of the MPDS triage system. The MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED). PDC has advised that:
• Upon the report of a patient found on the floor ‘unresponsive and not breathing’, with no other indication of trauma or cause of injury, the 999 call handler will utilise the MPDS instructions to provide CPR advice to the caller.
• CPR advice will not be discontinued until a responder is at scene to take over, unless there is definite evidence that the patient is no longer in cardiac arrest.
• In the event that a caller provides additional information that indicates a patient may be beyond help, the call handler will continue to provide CPR instructions unless a specific set of individual ambulance service Medical Director approved identifiers are mentioned, which include the patient being cold and stiff in a warm environment, or if the patient’s condition is incompatible with life.
• If any of the identifiers are confirmed, the MPDS will direct the call handler to ask an additional safety question to confirm the detail and ensure the caller is clear that the patient cannot be resuscitated. Only in this instance would the call handler cease advice and clear the line. This obvious death information is only addressed if volunteered by the caller.
• Where a patient is unconscious and not breathing, CPR advice will be delivered and no other interruption to the guidance for the caller will occur. Should the Coroner require any further information relevant to the MPDS, we would advise that you contact PDC directly.
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 Drew, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th January 2026 concerning the death of Drew John Greaves-Pimblett on 22nd March
2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Drew’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Drew’s care have been listened to and reflected upon.
Your Report raised concerns that there is a gap in national pathways for call handlers. You asked for consideration to be given to further guidance and assistance for call handlers on probing questioning for fundamental aspects such as for breathing and general presentation (e.g. how best to assess how cold a body is and where to take a pulse), so that call handlers can make more informed decisions as to whether someone is breathing and if CPR is required.
Regional Response NHS England’s Regional North West Team have liaised with the North West Ambulance Service (NWAS) regarding your Report. They have advised that when Drew was found not breathing and unresponsive, a 999 call was made to NWAS. The caller stated he was blue, had swollen lips, was very cold and not breathing. The call was initially categorised as a Category 1, the highest level of ambulance response, but was then downgraded to a Category 4 following responses to further questions asked (note that one of the outcomes on NHS Pathways for a person who is clearly deceased is a Category 4 response, and where death is not expected this can be onward referred to the police). The police were notified of the unexpected death, attended within 30 minutes and stated that Drew was blue and unresponsive but was slightly warm, and therefore they started CPR – the police documented that pressing Drew’s chest was very difficult. NWAS were called again and arrived within 2 minutes of the police officer arriving at the scene. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
3 March 2026
The attending NWAS clinician completed an assessment and confirmed that Drew had passed away. He stated when asked that Drew was very cold. NWAS audited the call after the event and did find that there had been some deviation and the need for more probing before the downgrade, which resulted in the ambulance being stood down, with feedback given at the time to the NWAS call handler on this. NHS England was not a party to the inquest, but has been informed that the Coroner accepted all of the evidence and concluded that it was more likely than not that Drew had been deceased for some time before NWAS’s arrival.
National Position Background 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 the Medical Priority Dispatch System (MPDS). The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs). The North West Ambulance Service (NWAS) uses the NHS Pathways system. 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. NHS Pathways Background NHS Pathways is the Clinical Decision Support System (CDSS) used for remote clinical assessment (triage) in urgent and emergency care. In use since 2005, it underpins all NHS 111 services and more than half of England’s 999 telephony services. It is also used for self-service triage via NHS 111 online and at the front door of Emergency Departments. The product is owned by the Secretary of State for Health and Social Care and is manufactured and managed by the Transformation Directorate of NHS England. The tool also supports enhanced clinical assessments via modules such as the NHS Pathways Clinical Consultation Support (PaCCS) system. The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges (AoMRC). Alongside this independent oversight, NHS Pathways aligns its clinical content and assessment protocols with up-to-date national clinical guidance, including from NICE (the National
Institute for Health and Care Excellence), the UK Resuscitation Council and the UK Sepsis Trust, amongst others. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. NHS Pathways follows a structured clinical hierarchy. Serious and potentially life- threatening symptoms are assessed first to ensure rapid escalation - such as dispatching an ambulance or involving a clinician. The assessment then progresses through to less urgent symptoms, identifying the most appropriate level of care. Principles of Health Advisor Training In telephone settings (calls made to NHS 111 or 999), assessments are conducted by specially trained non-clinical health advisors. These advisors complete a comprehensive, structured mandatory training programme to ensure they can use the NHS Pathways algorithm safely and effectively, and they are always supported by clinicians, as a condition of the NHS Pathways licence, which NHS 111 and 999 providers must enter into in order to use the system. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. The NHS Pathways licence states that clinical supervision and escalation support must be available 24/7, and immediately accessible to health advisors during live calls. This clinical availability is a core system control. Following the initial core role preparation training, health advisors and clinicians are required to update their training every 12 weeks. They are also able to access a comprehensive library of additional training courses and educational resources such as ‘Hot Topics’, case studies and e-learning packages. NHS Pathways Assessment of Consciousness and Breathing Based on the information provided regarding this particular case, in respect of the NHS Pathways triage system we can confirm the following:
• If a cardiac arrest is not suspected at the onset of the call, the system seeks to quickly establish whether there is an immediate threat to life. If the patient is not fitting or choking, supporting information is provided to the health advisor to assist them to establish whether the patient is conscious or not. Unconsciousness is classed as when the individual cannot be woken or is difficult to wake up.
• If the patient is confirmed to be unconscious, the next question presented seeks to establish whether a normal breathing pattern is present.
• Health advisors can use the supporting information provided to advise the caller to check whether the chest is rising and falling regularly and/or whether regular breaths can be heard or felt coming from the nose of mouth. If there is doubt, they are prompted to ask the caller to ‘look, listen and feel’ for breathing.
• If the patient is not breathing normally, the supporting information advises that there may be no or very little attempt being made by the individual to breathe. They are advised that there may be occasional gasps or breaths with possible long pauses in between. The supporting information also advises here that the
skin may appear grey or blue, and where to check for this on the body, and where to check when skin tones may be darker.
• If the patient is not breathing or not breathing sufficiently, this results in a Category 1 ambulance outcome, on the basis that a cardiac arrest is likely. This was the outcome reached in this case based on the information provided.
• Once it has been established that the scene is safe, the NHS Pathways system seeks to establish whether the caller is within easy reach of the patient. If no specific scenarios where specialist instructions are required (such as hanging, drowning, choking etc) are present, information on how to give basic life support (BLS), and whether a defibrillator can be located, presents itself for the health advisor. The only reasons that a health advisor should advise BLS to cease are if the ambulance crew arrive and take over, if the patient regains consciousness, or if the person performing BLS is for some reason unable to continue. NHS Pathways does not ask the caller to try to ascertain if there is a pulse present. For the ordinary lay person, the identification of a pulse can prove challenging, thus potentially wasting valuable time in terms of dispatching an ambulance. All pathways relating to instructional information regarding resuscitation have been approved and ratified by Resuscitation Council UK. Also, of relevance to this particular case, in terms of additional training regarding the assessment of consciousness and breathing, health advisors utilising NHS Pathways who have completed the core training are provided with ‘CPR Toolkit Training’. This encompasses what is called the ‘No, No, Go’ approach where, if the patient is not conscious or not breathing (either normally or at all), health advisors are trained to proceed immediately to the initiation of cardiopulmonary resuscitation (CPR) as presented by the system. This additional training seeks to ensure that health advisors are supported to proceed quickly to the required life supporting advice. The CPR Toolkit training explains that evidence from multiple studies indicates that performing CPR on a patient who is not in cardiac arrest is unlikely to cause harm. Health advisors are therefore trained that, where there is any uncertainty regarding whether a patient’s breathing is normal, or if the patient is not breathing at all, they should initiate telephone-guided CPR. NHS Pathways Management of Expected or Unexpected Death A ‘triage not possible’ route exists within the NHS Pathways system for the management of an expected or unexpected death. From the limited information provided regarding this case, it is not possible to comment on whether or not the health advisor should have selected the option for ‘discovery of a stone cold or stiff dead body’. Even if the health advisor in this case had thought that Drew was already deceased and this route was selected, the option of ‘Sudden Unexpected Death’ would have likely been chosen. This route follows the consciousness/breathing assessment as described above, whereby BLS instructions are presented as the system in this
scenario assumes that CPR should be performed as the exact moment of cardiac arrest is not known. NHS Pathways Additional Health Advisor Support Almost every question in the NHS Pathways triage system has ‘supporting information’, shown under the question text, enabling the health advisor to ask probing questions. This supports health advisors to ensure the caller’s responses match the answer selection. ‘Probing’ is extensively trained in the health advisors’ mandatory training, and the facility is a fundamental aspect of the NHS Pathways system and how it differs from fixed-script based systems. The supporting information provided to support the identification of an immediate threat to life is extensive as, in circumstances whereby a patient may not be conscious or breathing, this is recognised as an exceptionally stressful situation for all involved including the health advisor. The Medical Priority Dispatch System (MPDS) In addition to the NHS Pathways response detailed above and whilst this falls outside of NHS England’s direct remit, for completeness, NHS England has discussed the concerns in your Report with the provider of the MPDS triage system. The MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED). PDC has advised that:
• Upon the report of a patient found on the floor ‘unresponsive and not breathing’, with no other indication of trauma or cause of injury, the 999 call handler will utilise the MPDS instructions to provide CPR advice to the caller.
• CPR advice will not be discontinued until a responder is at scene to take over, unless there is definite evidence that the patient is no longer in cardiac arrest.
• In the event that a caller provides additional information that indicates a patient may be beyond help, the call handler will continue to provide CPR instructions unless a specific set of individual ambulance service Medical Director approved identifiers are mentioned, which include the patient being cold and stiff in a warm environment, or if the patient’s condition is incompatible with life.
• If any of the identifiers are confirmed, the MPDS will direct the call handler to ask an additional safety question to confirm the detail and ensure the caller is clear that the patient cannot be resuscitated. Only in this instance would the call handler cease advice and clear the line. This obvious death information is only addressed if volunteered by the caller.
• Where a patient is unconscious and not breathing, CPR advice will be delivered and no other interruption to the guidance for the caller will occur. Should the Coroner require any further information relevant to the MPDS, we would advise that you contact PDC directly.
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 Drew, 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.