Peter Cotter

Dear Mr Osborne

I am writing in response to a Section 28 ruling from HM Senior Coroner. This follows the tragic death of Peter Cotter who passed away on 31st January 2017. This was followed by an investigation and inquest which concluded on 22/6/2017. I am writing in my role as the Clinical Director for NHS Pathways, which is the clinical decision support software for the national NHS 111 service. I am , BA, MSc, MB ChB (Sheffield).

HM Coroner has requested that NHS Pathways review its management of patients calling with head injury symptoms to ensure they receive the correct level of clinical response.

For information I have provided below a short summary of the functions that NHS Pathways performs and the governance that underpins it.

Function of NHS Pathways

NHS Pathways is a programme providing the Clinical Decision Support System (CDSS) used in NHS 111 and half of English 999 services. This triage system supports the remote assessment of approximately 13 million calls per annum. The majority of these assessments are completed by trained call-handlers who refer the patient into suitable services based on the patient’s health needs at the time of the call. The system is hierarchical, meaning that life-threatening problems assessed at the start of the call trigger ambulance responses, progressing through to less urgent conditions which require a less urgent response (or disposition) in other settings.

Governance of NHS Pathways

The safety of the clinical triage process endpoints resulting from a 111 assessment using NHS Pathways is overseen by the National Clinical Governance Group; this is made up of representatives from the Royal Medical Colleges. Senior clinicians from the Colleges provide independent oversight and scrutiny of the CDSS. 1 Trevelyan Square Boar Lane Leeds LS1 6AE 0113 397 3614

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 medical practice in the UK. In particular we are consistent with the latest guidelines from

 NICE (National Institute for Health and Clinical Excellence)  The UK Resuscitation Council  The UK Sepsis Trust

NHS Pathways Assessment of Head Injury Symptoms

Having reviewed the case and the Coroner’s concerns I am in a position to reassure HM Coroner that NHS Pathways identifies and assesses head injuries through a detailed series of questions, and specifically identifies if callers are on anti-coagulant treatment. In this particular case we triaged the call via our head injury flow as an emergency and this resulted in an emergency department disposition via ambulance transport within 1 hour.

I can further reassure HM Coroner the series of questions used in head injury assessment is consistent with the latest NICE guidelines (issued January 2014) on the triage and early management of head injury in infants, children and adults. The 1 hour emergency department disposition reached in this particular case is also consistent with the NICE guidelines.

For reference this guidance can viewed at https://www.nice.org.uk/guidance/cg176

I am happy to answer any further enquiries from HM Coroner.

Dear Mr Osbourne Thank you for your recent letter regarding the prevention of future deaths (PFD) report issued following the inquest hearing into the sad death of Mr Peter Cotter. To confirm, your concerns are: 'During_the course of_the evidence itbecame_apparent_that Mrs Cotter had_telephoned emergency services on 27th January 2017 and reported that her _husband had had afallhittlhis head and hurt his_hip My concern is_that the clinical decision support_ software system did not appear to register _that Mr Carter had suffered a head injuny_ He_was receiving anticoagulant drugs and even a minor head_injury_could_have_had_catastrophic_results if_the_head injury_was_not_recognised_and treated believe_that_there_should be_ a review of_the_triage_system to_ensure_that alLhead injuries are recognised and treated as emergencies' To confirm the advice that you were given at the inquest hearing by our Legal Services Manager, NHS Pathways is national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves_ Our EOC Clinical Assurance & Training Manager has notified NHS Digital through their reporting portal of your concerns and that the Trust has advised you to redirect the PFD report to them: Their Clinical Lead is Dr Anil Gill and their contact details are detailed below for you: Registered Headquarters: and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR

Call 0300 303 5678 (9am to 5 pm Monday to Friday excluding bank holidays ) Email enquiries@nhsdigital nhs.uk