NHS England
NHS / Health Body
Action Planned
NHS Digital has reviewed the NHS Pathways script and will work with stakeholders to explore options for improvements. They have committed to reviewing the NHS Pathways training materials to ensure that the importance of encouraging callers to seek support is reinforced. (AI summary)
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Dear Ms. Anna Loxton Inquest into the death of Karl James Bolam
I am writing in response to the Regulation 28 report received from HM Assistant Coroner, dated 14th January 2021. This follows the death of Karl James Bolam who sadly died on the 17th August
2018. This was followed by an investigation and inquest which concluded on 8th October 2020. We would like to express our sincerest condolences to the family of Karl James Bolam. Unfortunately, NHS Digital was not informed that this inquest was occurring, and it is disappointing that we did not have the opportunity to provide information and address your concerns directly. NHS Pathways is the clinical decision support software used by all 111 service providers, and some 999 ambulance service providers including South East Coast Ambulance Service NHS Foundation Trust (SECAmb). For information, I have included a short summary of the functions that NHS Pathways performs and the governance that underpins it (containing background information on NHS Pathways) in Annex A. I also enclose the HM Coroner’s Information Pack (containing background information on NHS Pathways), please see Annex B. HM Coroner has raised the following matters of concern with regards to NHS Pathways:
1. The script currently used by NHS Pathways in respect of emergency callers does not positively persuade callers to call someone to be with them, particularly in circumstances where paramedic attendance is delayed due to demands on the service. Consideration should be given to whether any steps can be taken to address the above concerns.
enquiries@nhsdigital.nhs.uk
NHS DIGITAL’S RESPONSE
For all calls that go through NHS Pathways, care advice and closing instructions are provided at the end of each call by the health advisor or clinician. This advice instructs the patient how to manage themselves either whilst waiting for an ambulance to arrive or another health care professional to contact them. All callers are given specific worsening instructions to call back if they have any new symptoms, or if the condition gets worse, changes or they have any other concerns. In addition to closing care advice and worsening instructions, disposition advice is provided to inform the caller of the next steps, for example that an emergency ambulance is being arranged. For NHS Pathways release 17 which was deployed from 5th May 2019, health advisors were provided with an optional script to advise callers that an ambulance aims to be with you, within eight or eighteen minutes or within one or two hours depending on the disposition reached. This was introduced at the request of ambulance services to assist in managing patients' expectations regarding the ambulance arrival. Exact times of the arrival of an ambulance response cannot be given by NHS Pathways as this information can only be provided by the 999 provider and is dependent on operational demands at the time of the call. NHS Pathways Script for a Category 2 ambulance response:
In both 999 and 111 (when using NHS Pathways) when an ambulance disposition is reached, callers are advised to keep their contact number free in case the ambulance service needs to call the patient back (for example to confirm the address or any special requirements like entry information). This is especially important in calls generated from 111 as these are automatically sent through to the ambulance service and the service that has received the case may need to call back. This script forms part of the closing instructions and is agreed nationally with all ambulance services using NHS Pathways. This wording was reviewed in 2016 by NHS Pathways and the 6 ambulance service trusts using NHS Pathways at the time. The agreement was for this instruction to remain. Mr Bolam’s call was received on the 14th August 2018 and reached a Category 2 ambulance response (aim to attend within 18 minutes). SECAmb has advised NHS Pathways they were using release 16.0.1 at this time. Accordingly the instruction "Once this call is finished don't ring anyone else in case we need to call you back" would have been given before the worsening advice.
enquiries@nhsdigital.nhs.uk
The wording was further reviewed in 2019 (details below) and in Release 19, deployed January 2020, amended to: "If you do need to contact somebody do so now then try and keep the line free as we may need to call you back". This change was applied to all closing instructions across the system, as per the example below:
Previous Version:
Changes applied from release 19:
All providers can, and are encouraged, to submit feedback, information, and requests to NHS Pathways via the clinical or training issue log, or via a monitored mailbox. The 2019 review was based on a request for change made to NHS Pathways by SECAmb on the 25th February 2019 suggesting inclusion of an instruction for patients who were alone to call someone. The request for change was discussed at the 999 User Group. This group is formed by representatives from all 999 providers using NHS Pathways to enable discussion of requests for change, areas of good practice and other relevant topics. NHS Pathways are invited and members of the clinical, training and implementation team attend.
enquiries@nhsdigital.nhs.uk
The proposed changes were presented at the 999 User Group on 17th July 2019. South East Coast, South Central, North East and West Midlands Ambulance Services were represented by clinical and training leads. There was not a majority consensus regarding instructing a 1st party caller to phone someone due to concerns listed below.
• 1st party callers ringing someone else may block the line and prevent the ambulance service contacting the patient.
• A mandated instruction may invite dialogue regarding having no one to phone, no credit, who to phone, which can increase call length.
• Family or friends could arrive after the ambulance which could lead to further calls into 999.
• Operational standard operating procedures (SOP’s) manage calls where there is a delay in dispatch of an ambulance, including no contact welfare calls, therefore it is not for NHS Pathways to mandate. The group discussed the above risks, and possible options of: i) giving an instruction; ii) giving advice; and iii) not changing the content. The group agreed that encouraging 1st party callers waiting for an ambulance to ring family or friends if they wished to, and to do so straight away, was safe and should be included. The wording above was agreed by the group and added to Release
19. NHS Pathways responded to SECAmb’s request for change, noting the agreed outcome from the 999 User Group and did not receive any further communication from SECAmb. In circumstances where paramedic attendance is delayed due to demands on the service. Whilst using NHS Pathways, the health advisor may not be aware of delays within the 999 service. This information is held on the 999 providers host system and does not influence the NHS Pathways triage. Once an ambulance disposition is reached, the disposition script can be amended by a provider or local SOP to require health advisors to give further information depending on the circumstances. Demand management is maintained and managed within each 111 and 999 providers; therefore NHS Pathways is unable to mandate a script to persuade callers to call someone to be with them if the ambulance is delayed. Disposition Script:
NHS Pathways is currently reviewing if there is a need for the question “is the patient alone” to be embedded within the NHS Pathways triage as an ‘information only’ tick box. This question is asked by some providers during the collection of demographic information, primarily to assist with safeguarding concerns, and to inform any onward provider of care post disposition that the patient is alone. It is not proposed that it would alter dispositions reached within NHS Pathways. The proposal is being discussed with users and providers to collate feedback.
enquiries@nhsdigital.nhs.uk
If HM Coroner requires any further clarification in relation to any points, please do not hesitate to contact us and we can assist further.
I am writing in response to the Regulation 28 report received from HM Assistant Coroner, dated 14th January 2021. This follows the death of Karl James Bolam who sadly died on the 17th August
2018. This was followed by an investigation and inquest which concluded on 8th October 2020. We would like to express our sincerest condolences to the family of Karl James Bolam. Unfortunately, NHS Digital was not informed that this inquest was occurring, and it is disappointing that we did not have the opportunity to provide information and address your concerns directly. NHS Pathways is the clinical decision support software used by all 111 service providers, and some 999 ambulance service providers including South East Coast Ambulance Service NHS Foundation Trust (SECAmb). For information, I have included a short summary of the functions that NHS Pathways performs and the governance that underpins it (containing background information on NHS Pathways) in Annex A. I also enclose the HM Coroner’s Information Pack (containing background information on NHS Pathways), please see Annex B. HM Coroner has raised the following matters of concern with regards to NHS Pathways:
1. The script currently used by NHS Pathways in respect of emergency callers does not positively persuade callers to call someone to be with them, particularly in circumstances where paramedic attendance is delayed due to demands on the service. Consideration should be given to whether any steps can be taken to address the above concerns.
enquiries@nhsdigital.nhs.uk
NHS DIGITAL’S RESPONSE
For all calls that go through NHS Pathways, care advice and closing instructions are provided at the end of each call by the health advisor or clinician. This advice instructs the patient how to manage themselves either whilst waiting for an ambulance to arrive or another health care professional to contact them. All callers are given specific worsening instructions to call back if they have any new symptoms, or if the condition gets worse, changes or they have any other concerns. In addition to closing care advice and worsening instructions, disposition advice is provided to inform the caller of the next steps, for example that an emergency ambulance is being arranged. For NHS Pathways release 17 which was deployed from 5th May 2019, health advisors were provided with an optional script to advise callers that an ambulance aims to be with you, within eight or eighteen minutes or within one or two hours depending on the disposition reached. This was introduced at the request of ambulance services to assist in managing patients' expectations regarding the ambulance arrival. Exact times of the arrival of an ambulance response cannot be given by NHS Pathways as this information can only be provided by the 999 provider and is dependent on operational demands at the time of the call. NHS Pathways Script for a Category 2 ambulance response:
In both 999 and 111 (when using NHS Pathways) when an ambulance disposition is reached, callers are advised to keep their contact number free in case the ambulance service needs to call the patient back (for example to confirm the address or any special requirements like entry information). This is especially important in calls generated from 111 as these are automatically sent through to the ambulance service and the service that has received the case may need to call back. This script forms part of the closing instructions and is agreed nationally with all ambulance services using NHS Pathways. This wording was reviewed in 2016 by NHS Pathways and the 6 ambulance service trusts using NHS Pathways at the time. The agreement was for this instruction to remain. Mr Bolam’s call was received on the 14th August 2018 and reached a Category 2 ambulance response (aim to attend within 18 minutes). SECAmb has advised NHS Pathways they were using release 16.0.1 at this time. Accordingly the instruction "Once this call is finished don't ring anyone else in case we need to call you back" would have been given before the worsening advice.
enquiries@nhsdigital.nhs.uk
The wording was further reviewed in 2019 (details below) and in Release 19, deployed January 2020, amended to: "If you do need to contact somebody do so now then try and keep the line free as we may need to call you back". This change was applied to all closing instructions across the system, as per the example below:
Previous Version:
Changes applied from release 19:
All providers can, and are encouraged, to submit feedback, information, and requests to NHS Pathways via the clinical or training issue log, or via a monitored mailbox. The 2019 review was based on a request for change made to NHS Pathways by SECAmb on the 25th February 2019 suggesting inclusion of an instruction for patients who were alone to call someone. The request for change was discussed at the 999 User Group. This group is formed by representatives from all 999 providers using NHS Pathways to enable discussion of requests for change, areas of good practice and other relevant topics. NHS Pathways are invited and members of the clinical, training and implementation team attend.
enquiries@nhsdigital.nhs.uk
The proposed changes were presented at the 999 User Group on 17th July 2019. South East Coast, South Central, North East and West Midlands Ambulance Services were represented by clinical and training leads. There was not a majority consensus regarding instructing a 1st party caller to phone someone due to concerns listed below.
• 1st party callers ringing someone else may block the line and prevent the ambulance service contacting the patient.
• A mandated instruction may invite dialogue regarding having no one to phone, no credit, who to phone, which can increase call length.
• Family or friends could arrive after the ambulance which could lead to further calls into 999.
• Operational standard operating procedures (SOP’s) manage calls where there is a delay in dispatch of an ambulance, including no contact welfare calls, therefore it is not for NHS Pathways to mandate. The group discussed the above risks, and possible options of: i) giving an instruction; ii) giving advice; and iii) not changing the content. The group agreed that encouraging 1st party callers waiting for an ambulance to ring family or friends if they wished to, and to do so straight away, was safe and should be included. The wording above was agreed by the group and added to Release
19. NHS Pathways responded to SECAmb’s request for change, noting the agreed outcome from the 999 User Group and did not receive any further communication from SECAmb. In circumstances where paramedic attendance is delayed due to demands on the service. Whilst using NHS Pathways, the health advisor may not be aware of delays within the 999 service. This information is held on the 999 providers host system and does not influence the NHS Pathways triage. Once an ambulance disposition is reached, the disposition script can be amended by a provider or local SOP to require health advisors to give further information depending on the circumstances. Demand management is maintained and managed within each 111 and 999 providers; therefore NHS Pathways is unable to mandate a script to persuade callers to call someone to be with them if the ambulance is delayed. Disposition Script:
NHS Pathways is currently reviewing if there is a need for the question “is the patient alone” to be embedded within the NHS Pathways triage as an ‘information only’ tick box. This question is asked by some providers during the collection of demographic information, primarily to assist with safeguarding concerns, and to inform any onward provider of care post disposition that the patient is alone. It is not proposed that it would alter dispositions reached within NHS Pathways. The proposal is being discussed with users and providers to collate feedback.
enquiries@nhsdigital.nhs.uk
If HM Coroner requires any further clarification in relation to any points, please do not hesitate to contact us and we can assist further.