North West Ambulance Service NHS Trust
NHS / Health Body
Action Taken
North West Ambulance Service (NWAS) acknowledges that Miss Williams' call was incorrectly transferred to Cumbria Health On Call (CHOC) due to suicide risk. Since the inquest, NWAS's Mental Health Liaison Lead contacted CHOC to collectively review the incident, confirming their shared commitment to learning and service improvement. (AI summary)
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[Page 1] LADYBRIDGE HALL Mr Andrew Cousins His Majesty’s Assistant Coroner 399 Chorley New Road BCuym Ebmraiai lC Oonrolyn e rs Court Bolton BL1 5DD nwas.nhs.uk 14 May 2026 DReeagru Mlart iCoonu 2si8n Rs eport – Inquest Touching the Death of Jardine Williams th I write further to your Prevention of Future Deaths Report dated 16 March 2026, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Miss Jardine Williams. I am aware that you will share my response with Miss Williams’ family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. Within this letter, I will address tChoonscee cronn 1ce: rYnosu r afoisuendd a sth faart a“tsh Ie a fmlo awb loef. information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation”. You were concerned that full and accurate information was therefore not passing between NWAS and CHOC. As acknowledged by the NWAS Service Delivery Manager during the inquest, and reiterated here for the purposes of this response, the initial transfer of Ms Williams’ call by NWAS to Cumbria Health On Call (CHOC) should not have occurred as the NHS pathways triage indicated a risk of suicide, which is an exclusion to CHOC triaging the call. th The call was made by Ms Williams to NWAS at 17:16hrs on 24 March 2025. The call was passed to CHOC, albeit in error, at 17:40hrs via the Interoperability Toolkit (ITK), which is a method of electronic referral. The transfer of information via ITK relies on the NWAS clinician selecting what they consider relevant for the receiving provider. As a result, it does not enable full transfer of the assessment or all associated information. It is acknowledged that additional details were recorded during the call which, if shared, would have provided further clarity and context. However, ITK does not support the transmission of complete clinical notes from the 999 call. Booking and Referral Standard (BaRS) is an alternative software solution which offers this functionality and is used between NWAS and the Greater Manchester Clinical Assessment Service (GMCAS). Headquarters: Delivering the right care, at the right time, Ladybridge Hall, 399 Chorley New Road, Bolton BL1 5DD in the right place; every time.
[Page 2] The BaRS connection between NWAS and the GMCAS was implemented as part of a user case and test of change for NHS England, however, BaRS is not yet universally standardised across all providers. ITK remains the current national interoperability standard. BaRS is expected to replace ITK as the national standard; however, this transition is being directed at a national level, and there is no confirmed implementation date at this time. As such, all systems continue to operate under the existing ITK requirements until formal national instruction Ciso insscueerdn. 2: You state “thereafter between 18:14 and 18:54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19:48hrs, NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18:25hrs”. You considered that the flow of information between CHOC and NWAS appeared to have confused the issue. The call from Ms Williams to NWAS was correctly categorised as a Category 3 at 17:20 and reviewed by a senior clinician at 17:32, within the 15-minute target time for clinical review. Although erroneously transferred, the agreement in place between NWAS and CHOC states that upon receipt of a referral, CHOC are to contact the patient to conduct their own triage. Should the patient not answer the telephone, a further two attempts should be made, following which the call should be passed back to NWAS. In line with our respective responsibilities, NWAS called CHOC for an update at 19:45 and were informed by the CHOC call handler that only two attempts had been made to contact Miss Williams and a third attempt would be made prior to CHOC passing the incident back to NWAS. CHOC confirmed in their evidence, dealt with at inquest under Rule 23 of the Coroners (Inquests) Rules 2013, that between 18:14 and 18:54 hours, they had made four attempts to contact Ms Williams, each without success. The information provided to NWAS on this occasion was therefore incorrect. At 20:43, NWAS chased CHOC again and were informed a third call had been made with no answer and the CHOC clinician requested a Category 3 ambulance. The ambulance arrived on scene at 20:58, and after obtaining access with the assistance of the fire service, Ms Williams was sadly found to be deceased at 21:25. Since this inquest, NWAS’ Mental Health Liaison Lead contacted CHOC to review the incident collectively. This review was undertaken with CHOC’s Medical Director and Digital Operations/Programme Manager. CHOC have acknowledged the evidence already provided by NWAS that the incident should not have been transferred to CHOC due to the identified risk of suicide and that the information provided on this occasion ought to have contained more context. It was also acknowledged by CHOC that, as the incident was categorised as a Category 3 response, it should have been returned by CHOC following the third unsuccessful attempt to make contact, which did not occur. NWAS and CHOC work closely in partnership and place significant emphasis on effective communication between our organisations. Call pathways and incidents are routinely reviewed to maintain a strong governance framework and to support ongoing service improvement. The continued collaborative communication and incident review processes between NWAS and CHOC demonstrates our shared commitment to delivering the highest standards of care and to learning from all available opportunities. I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact the Trust’s Deputy Director of Corporate Affairs, Emma Shiner.
[Page 2] The BaRS connection between NWAS and the GMCAS was implemented as part of a user case and test of change for NHS England, however, BaRS is not yet universally standardised across all providers. ITK remains the current national interoperability standard. BaRS is expected to replace ITK as the national standard; however, this transition is being directed at a national level, and there is no confirmed implementation date at this time. As such, all systems continue to operate under the existing ITK requirements until formal national instruction Ciso insscueerdn. 2: You state “thereafter between 18:14 and 18:54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19:48hrs, NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18:25hrs”. You considered that the flow of information between CHOC and NWAS appeared to have confused the issue. The call from Ms Williams to NWAS was correctly categorised as a Category 3 at 17:20 and reviewed by a senior clinician at 17:32, within the 15-minute target time for clinical review. Although erroneously transferred, the agreement in place between NWAS and CHOC states that upon receipt of a referral, CHOC are to contact the patient to conduct their own triage. Should the patient not answer the telephone, a further two attempts should be made, following which the call should be passed back to NWAS. In line with our respective responsibilities, NWAS called CHOC for an update at 19:45 and were informed by the CHOC call handler that only two attempts had been made to contact Miss Williams and a third attempt would be made prior to CHOC passing the incident back to NWAS. CHOC confirmed in their evidence, dealt with at inquest under Rule 23 of the Coroners (Inquests) Rules 2013, that between 18:14 and 18:54 hours, they had made four attempts to contact Ms Williams, each without success. The information provided to NWAS on this occasion was therefore incorrect. At 20:43, NWAS chased CHOC again and were informed a third call had been made with no answer and the CHOC clinician requested a Category 3 ambulance. The ambulance arrived on scene at 20:58, and after obtaining access with the assistance of the fire service, Ms Williams was sadly found to be deceased at 21:25. Since this inquest, NWAS’ Mental Health Liaison Lead contacted CHOC to review the incident collectively. This review was undertaken with CHOC’s Medical Director and Digital Operations/Programme Manager. CHOC have acknowledged the evidence already provided by NWAS that the incident should not have been transferred to CHOC due to the identified risk of suicide and that the information provided on this occasion ought to have contained more context. It was also acknowledged by CHOC that, as the incident was categorised as a Category 3 response, it should have been returned by CHOC following the third unsuccessful attempt to make contact, which did not occur. NWAS and CHOC work closely in partnership and place significant emphasis on effective communication between our organisations. Call pathways and incidents are routinely reviewed to maintain a strong governance framework and to support ongoing service improvement. The continued collaborative communication and incident review processes between NWAS and CHOC demonstrates our shared commitment to delivering the highest standards of care and to learning from all available opportunities. I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact the Trust’s Deputy Director of Corporate Affairs, Emma Shiner.