NHS England
NHS / Health Body
Noted
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Hollie Elizabeth Loraine who died on 30th August 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st April 2026 concerning the death of Hollie Elizabeth Loraine on 30th August 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Hollie’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Hollie’s care have been listened to and reflected upon.
Your report raises concerns that the national NHS pathways telephone triage system does not provide guidance to health advisors dealing with calls with patients who are expressing suicidal ideation and whether the advisor ought to maintain telephone contact with them and how to ameliorate the risk of that patient ending their own life.
Background of NHS Pathways Clinical Decision Support System 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 systems. The tool also supports online triage, in-person and 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. Alongside this external scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including NICE (National Institute for Health and Care Excellence), Resuscitation Council UK and UK Sepsis Trust. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
14th May 2026
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 to less urgent symptoms, identifying the most appropriate level of care. The tool is not diagnostic. Instead, it works by systematically ruling out more serious causes of symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically necessary to minimise triage time while maintaining safety. In telephone settings, assessments are conducted by trained non-clinical Health Advisors. These advisors complete a rigorous training programme and are always supported by clinicians. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. It is therefore a condition of the NHS Pathways licence is that clinical supervision and escalation support must be available 24/7.
Clinical alignment of Ambulance Response Codes between systems
The NHS Pathways system is developed and maintained by the Transformation Directorate of NHS England. The ambulance responses (dispositions) are ratified by the National Ambulance Services Medical Directors (NASMeD). This is an advisory group to Association of Ambulance Chief Executives (AACE), comprising the Medical Directors of ambulance services in England, Wales, Scotland and Northern Ireland. This group endorses the categorisation of ambulance codes across both AMPDS and NHS Pathways, and these codes are further ratified by the Emergency Call Prioritisation Advisory Group (ECPAG). The purpose of the ECPAG is to advise NHS England and the, Department of Health & Social Care (DHSC) on issues of ambulance call prioritisation. Its principal remit is to recommend which disposition codes should be mapped to which ambulance responses. The Group membership consists of AACE, NHS England, NASMeD, ambulance Heads of Control and representatives of the principle triage systems. NHS England has led several national discussions regarding the management of suicidal callers. The NHS Pathways system has been adjusted to accommodate changes and the introduction of a national process. In this process, ambulance and NHS 111 providers facilitate an urgent clinical review for cases flagged as ‘Risk of Suicide’, which is further described below. These changes acknowledge that risks relating to suicidal intent are complex and may be multifactorial. Although non-clinical health advisers receive significant, structured training to use the NHS Pathways system, this system is organised to triage cases for further clinical input or assessment in most cases.
In the NHS Pathways triage system, where the patient or caller reports either a suicide attempt or active suicidal intent, the lowest disposition that may be reached is a Category 3 emergency ambulance response. A higher category of ambulance response would be reached where other relevant symptoms/conditions, such as loss of consciousness or difficulty breathing, are present at the time of assessment. These
align to the Ambulance Response standards set by the Ambulance Response Programme (ARP).
In early 2019, NHS England, with endorsement of NASMeD and other associated groups, instructed ambulance and NHS 111 providers that any suicide-related cases reaching a Category 3 ambulance outcome should receive an urgent remote clinical review facilitated by a clinician working with the 999 ambulance control room. This enables a prioritised clinical assessment, considering the individual circumstances of each case. Such assessments should determine the appropriate level of response, which could include upgrading the response to a Category 1 or 2 emergency ambulance response.
To facilitate this, a new disposition code was developed in the NHS Pathways product in April 2019. ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category
3)’ enables clearer visibility of such cases in the Computer Assisted Dispatch (CAD) system used by staff in ambulance services, supporting them to readily identify the cases requiring prioritised review due to suicide attempt.
In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled ‘Category 3/999 Overdose and Suicidal Ideation Calls: Initial Assessment of Lethality/Toxicity Principles Document’. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes to ensure suicidal patients receive the correct clinical response. This review was also the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above.
In November 2023, the 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document, which was issued in April 2021, was reissued following a review by the ECPAG and NASMeD. The process outlined in that document appears to have been followed within this particular case.
NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions, including training around the sensitive management of calls with a mental health element. This training is included in Core Module One which all Health Advisors must complete. Core Module One includes mandatory assessments which must be passed.
The training around sensitive management of calls with a mental health element explains that the manner of communication is just as important as the words said. This includes being warm, empathetic and sensitive in approach. Tone of voice is also important.
The training references the importance of active listening and how to respond to the patient sensitively, and explains that there may be situations when the Health Advisor needs to stay on the phone with the patient.
Individual service providers develop their own policies for managing patients who are alone, allowing organisations to make local decisions based on continually changing operational constraints.
Health Advisors are taught to listen carefully to what a caller says and to pick up on not just the answer to a clinical question, but to everything that is said or referred to. If a Health Advisor has any concerns about a patient being alone in a life-threatening or urgent situation, they should seek clinical support or transfer the call to a clinician via the system functionality of ‘early exit’. NHS Pathways has not been privy to the call recording of this case and therefore are unable to follow the exact route taken during the call in question. However, from the information available and following review of the possible route in NHS Pathways, it can be confirmed from a system perspective, there is a question that asks about the immediacy of the potential suicide scenario.
Following this, if the caller is alone the Health Advisor is presented with the following care advice at the end of the call:
However, it is overall an operational decision for each ambulance service whether a health advisor should stay on the line with any caller. Ambulance services have access to their real time demand levels which NHS Pathways does not.
Regional response
North East and Yorkshire colleagues have advised that the Integrated Care Board (ICB) are overseeing the North East Ambulance Service review of this case and have shared the Investigation Conclusion Report with us. The Report found that all clinicians acted appropriately. The report also notes that a separate review of NEAS dispatch processes confirmed that although there was a delay before an ambulance was able to attend to Hollie, there were no opportunities at that time to reach Hollie sooner. The ambulance crew who attended had noted in the electronic patient record an issue with the Zoll, which is a device used by paramedics and other ambulance practitioners in the management of cardiac arrests. When the pads were in place, CPR mode would not activate on the Zoll. A clinical audit found that the care at the scene was carried out in line with Advanced Life Support guidelines. Although Hollie’s ECG rhythm was displaying correctly, it was non-shockable, meaning that the issue with the Zoll and the need to change the defibrillator pads did not affect the crew’s resuscitation efforts. The team continued appropriate life-saving interventions throughout. The Zoll pads were replaced within two minutes of error identification, and the crew raised a separate safety incident regarding the error. The Zoll device has been sent back to Zoll by our equipment team for further investigation.
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 Hollie,
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 1st April 2026 concerning the death of Hollie Elizabeth Loraine on 30th August 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Hollie’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Hollie’s care have been listened to and reflected upon.
Your report raises concerns that the national NHS pathways telephone triage system does not provide guidance to health advisors dealing with calls with patients who are expressing suicidal ideation and whether the advisor ought to maintain telephone contact with them and how to ameliorate the risk of that patient ending their own life.
Background of NHS Pathways Clinical Decision Support System 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 systems. The tool also supports online triage, in-person and 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. Alongside this external scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including NICE (National Institute for Health and Care Excellence), Resuscitation Council UK and UK Sepsis Trust. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
14th May 2026
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 to less urgent symptoms, identifying the most appropriate level of care. The tool is not diagnostic. Instead, it works by systematically ruling out more serious causes of symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically necessary to minimise triage time while maintaining safety. In telephone settings, assessments are conducted by trained non-clinical Health Advisors. These advisors complete a rigorous training programme and are always supported by clinicians. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. It is therefore a condition of the NHS Pathways licence is that clinical supervision and escalation support must be available 24/7.
Clinical alignment of Ambulance Response Codes between systems
The NHS Pathways system is developed and maintained by the Transformation Directorate of NHS England. The ambulance responses (dispositions) are ratified by the National Ambulance Services Medical Directors (NASMeD). This is an advisory group to Association of Ambulance Chief Executives (AACE), comprising the Medical Directors of ambulance services in England, Wales, Scotland and Northern Ireland. This group endorses the categorisation of ambulance codes across both AMPDS and NHS Pathways, and these codes are further ratified by the Emergency Call Prioritisation Advisory Group (ECPAG). The purpose of the ECPAG is to advise NHS England and the, Department of Health & Social Care (DHSC) on issues of ambulance call prioritisation. Its principal remit is to recommend which disposition codes should be mapped to which ambulance responses. The Group membership consists of AACE, NHS England, NASMeD, ambulance Heads of Control and representatives of the principle triage systems. NHS England has led several national discussions regarding the management of suicidal callers. The NHS Pathways system has been adjusted to accommodate changes and the introduction of a national process. In this process, ambulance and NHS 111 providers facilitate an urgent clinical review for cases flagged as ‘Risk of Suicide’, which is further described below. These changes acknowledge that risks relating to suicidal intent are complex and may be multifactorial. Although non-clinical health advisers receive significant, structured training to use the NHS Pathways system, this system is organised to triage cases for further clinical input or assessment in most cases.
In the NHS Pathways triage system, where the patient or caller reports either a suicide attempt or active suicidal intent, the lowest disposition that may be reached is a Category 3 emergency ambulance response. A higher category of ambulance response would be reached where other relevant symptoms/conditions, such as loss of consciousness or difficulty breathing, are present at the time of assessment. These
align to the Ambulance Response standards set by the Ambulance Response Programme (ARP).
In early 2019, NHS England, with endorsement of NASMeD and other associated groups, instructed ambulance and NHS 111 providers that any suicide-related cases reaching a Category 3 ambulance outcome should receive an urgent remote clinical review facilitated by a clinician working with the 999 ambulance control room. This enables a prioritised clinical assessment, considering the individual circumstances of each case. Such assessments should determine the appropriate level of response, which could include upgrading the response to a Category 1 or 2 emergency ambulance response.
To facilitate this, a new disposition code was developed in the NHS Pathways product in April 2019. ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category
3)’ enables clearer visibility of such cases in the Computer Assisted Dispatch (CAD) system used by staff in ambulance services, supporting them to readily identify the cases requiring prioritised review due to suicide attempt.
In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled ‘Category 3/999 Overdose and Suicidal Ideation Calls: Initial Assessment of Lethality/Toxicity Principles Document’. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes to ensure suicidal patients receive the correct clinical response. This review was also the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above.
In November 2023, the 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document, which was issued in April 2021, was reissued following a review by the ECPAG and NASMeD. The process outlined in that document appears to have been followed within this particular case.
NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions, including training around the sensitive management of calls with a mental health element. This training is included in Core Module One which all Health Advisors must complete. Core Module One includes mandatory assessments which must be passed.
The training around sensitive management of calls with a mental health element explains that the manner of communication is just as important as the words said. This includes being warm, empathetic and sensitive in approach. Tone of voice is also important.
The training references the importance of active listening and how to respond to the patient sensitively, and explains that there may be situations when the Health Advisor needs to stay on the phone with the patient.
Individual service providers develop their own policies for managing patients who are alone, allowing organisations to make local decisions based on continually changing operational constraints.
Health Advisors are taught to listen carefully to what a caller says and to pick up on not just the answer to a clinical question, but to everything that is said or referred to. If a Health Advisor has any concerns about a patient being alone in a life-threatening or urgent situation, they should seek clinical support or transfer the call to a clinician via the system functionality of ‘early exit’. NHS Pathways has not been privy to the call recording of this case and therefore are unable to follow the exact route taken during the call in question. However, from the information available and following review of the possible route in NHS Pathways, it can be confirmed from a system perspective, there is a question that asks about the immediacy of the potential suicide scenario.
Following this, if the caller is alone the Health Advisor is presented with the following care advice at the end of the call:
However, it is overall an operational decision for each ambulance service whether a health advisor should stay on the line with any caller. Ambulance services have access to their real time demand levels which NHS Pathways does not.
Regional response
North East and Yorkshire colleagues have advised that the Integrated Care Board (ICB) are overseeing the North East Ambulance Service review of this case and have shared the Investigation Conclusion Report with us. The Report found that all clinicians acted appropriately. The report also notes that a separate review of NEAS dispatch processes confirmed that although there was a delay before an ambulance was able to attend to Hollie, there were no opportunities at that time to reach Hollie sooner. The ambulance crew who attended had noted in the electronic patient record an issue with the Zoll, which is a device used by paramedics and other ambulance practitioners in the management of cardiac arrests. When the pads were in place, CPR mode would not activate on the Zoll. A clinical audit found that the care at the scene was carried out in line with Advanced Life Support guidelines. Although Hollie’s ECG rhythm was displaying correctly, it was non-shockable, meaning that the issue with the Zoll and the need to change the defibrillator pads did not affect the crew’s resuscitation efforts. The team continued appropriate life-saving interventions throughout. The Zoll pads were replaced within two minutes of error identification, and the crew raised a separate safety incident regarding the error. The Zoll device has been sent back to Zoll by our equipment team for further investigation.
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 Hollie,
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.