Theo Tuikubulau

Dear Ms Wiltshire, Re: Regulation 28 Report to Prevent Future Deaths - Theo Gordon Tuikubulau who died on 8th July 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6th January 2026 concerning the death of Theo Gordon Tuikubulau on 8th July 2022. Further to NHS England’s letter dated 4th September 2025, sent in response to your letter dated 24th July 2025, I would like to reiterate our condolences to Theo’s parents and loved ones.  

Your Report raises the concern that the triage and categorisation of ineffective breathing and respiratory distress is still not consistent across the two triage systems; NHS Pathways and the Medical Priority Dispatch System (MPDS). NHS England had informed you that a review would be undertaken of this, to ensure that the two triage systems are consistent and remain clinically appropriate. As you have not been informed that the review has occurred, this remains a concern.

This response is intended to update the Coroner, further to NHS England’s letter dated 4th September 2025.

NHS England’s review of the triage systems

Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.

The Coroner’s concern relates to differences in assessment and categorisation between two distinct triage systems. The MPDS is a rapid triage tool for 999 emergency calls, whereas NHS Pathways is a clinical assessment system used for both 999 and 111 services. Despite differing functions, there is generally strong national alignment in how emergency 999 calls are categorised by each. This alignment is overseen by the NHS England Emergency Call Prioritisation Advisory Group (ECPAG), supported by a clinical coding group of national experts who review outcomes and ensure consistency between systems. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2 March 2026

In our letter dated 4th September 2025, we advised that NHS England would work with the clinical coding groups and NHS Pathways to ensure consistency in the triage and categorisation of respiratory distress and ineffective breathing. Your Report has since been reviewed with the ambulance sector through the NHS Pathways Sub-Group and discussed directly with the triage system providers. Following these discussions, and the review by NHS England’s National Medical Advisor (Ambulance), we are assured that both systems ask appropriate and clinically aligned questions.

Assessment of breathing and respiratory distress

At the time of writing in September 2025, we identified variation between the two triage systems in the assessment of respiratory distress in children under five, particularly regarding the management of declared cyanosis (where a patient’s skin or lips appear blue or grey). Through our assessment, we have identified that the key difference lies in how each system gathers information about the child’s breathing. NHS Pathways assesses whether the child is “fighting desperately for every breath” and then applies an overarching set of clinical criteria, such as severe allergic reaction or asthma to determine whether a Category 1 disposition (outcome) is required. In contrast, the MPDS triage system begins with the open-ended question “is he/she breathing?” and uses a defined set of key phrases, including “fighting for air/breath,” to identify ineffective breathing.

It is essential that triage processes correctly identify those patients in immediate need of life-saving intervention. Automatically assigning all patients with any degree of cyanosis to a Category 1 ambulance response would result in an excessive number of patients being escalated, which may inadvertently delay the response to the most unwell patients. It is also important to recognise that cyanosis is a consequence of ineffective breathing rather than the cause. Although the two triage systems take different approaches to gathering clinical information, both would converge on the same outcome in a case such as Theo’s, where the child was fighting for breath and fluctuating in consciousness. Under both systems, this presentation would result in the highest clinical categorisation.

In general, NHS Pathways colleagues have confirmed that a Category 1 response would be generated where a patient is described as not fully conscious and not breathing normally. In the MPDS, descriptors such as fighting for breath or turning blue trigger an ineffective breathing protocol, also leading to a Category 1 disposition. The two triage systems use different approaches but, as set out above, in Theo’s case, both triage systems would have reached the same categorisation.

Both the MPDS and NHS Pathways use structured, scripted questioning that prioritises the most serious symptoms first. NHS Pathways also employs targeted questions for specific patient groups.

All 999 call handlers, regardless of the triage system used, are trained to recognise altered consciousness and breathing difficulties when initially establishing the reason for the call. Emergency Operations Centres have established processes to ensure the fastest possible dispatch for life-threatening conditions. Ambulance Trusts use predefined “Nature of Call” (NoC) phrases to identify immediately life-threatening

presentations before formal triage begins. NHS Pathways NoC phrases include indicators of severe breathing difficulty such as being “shocked/deathly pale” or having blue/grey lips, while the MPDS NoC phrases include triggers such as “turning blue or purple” to identify ineffective breathing. These terms are used to distinguish the difference in pallor between a patient who is critically unwell and one who is less seriously ill.

There has been a significant increase in clinical support within 999 Emergency Operations Centres, providing enhanced oversight for patients who may not initially receive a Category 1 triage outcome, but who may benefit from clinical reassessment and potential ambulance re-categorisation. This includes patients at the extremes of age and those presenting with symptoms such as severe breathing difficulty.

NHS England welcomes the feedback from HM Coroner and will continue to refine and align both systems, monitor categorisation, and strengthen clinical oversight. I hope that this further response sufficiently addresses the outstanding concern raised within your Report.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. Your Report will be discussed further at 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 Theo, 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.