NHS England
NHS / Health Body
Disputed
AI-generated response summary
• NHS England described the existing design of the NHS Pathways system, detailing how it assesses bleeding, including questions about heaviness, volume, and whether blood is soaking through dressings. • NHS England stated that the NHS Pathways system is overseen by the National Clinical Assurance Group, which has reviewed and signed off on the system's approach to clinical scenarios involving bleeding. • NHS England indicated it would liaise with Yorkshire Ambulance Service to discuss any learnings from this case.
View full response
Dear Miss Harris, Re: Regulation 28 Report to Prevent Future Deaths – Dr Kenneth Wilson Cully who died on 17 September 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 April 2026 concerning the death of Dr Kenneth Wilson Cully on 17 September 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dr Cully’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Dr Cully’s care have been listened to and reflected upon.
Your Report raised concerns regarding insufficiency of the questions in the NHS Pathways system to correctly identify the seriousness of an uncontrolled bleed (with there being no question regarding whether the bleed is controlled or not) which could lead to the categorisation of the call being incorrect and a delay in treating a catastrophic event needing immediate attention.
As you acknowledge in your report at the time of Dr Cully’s death the call was managed by Welsh Ambulance Service (WAST) who were dealing with calls on behalf of Yorkshire Ambulance Service (YAS), WAST uses Advanced Medical Priority Dispatch System (AMPDS).
NHS Ambulance Services are required to process 999 calls through an approved triage system. There are currently two long established systems approved in England for primary 999 triage; NHS Pathways and the Advanced Medical Priority Dispatch System (AMPDS). The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs).
NHS England does not manage or oversee AMPDS and we are therefore unable to provide comment on their system.
YAS’ witness statement given by , which YAS have provided to NHS Pathways as part of standard feedback and reporting processes, detailed how, in their opinion the case would have been managed if it had been dealt with by NHS Pathways.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22nd June 2026
Background on NHS Pathways
NHS Pathways is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services. The tool also supports online triage and 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 NCAG. Alongside this external scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including guidance from the National Institute for Health and Care Excellence (NICE), Resuscitation Council UK and UK Sepsis Trust.
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 to identify 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 specially trained non-clinical health advisors. These advisors complete a rigorous training programme and are supported at all times 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 license that clinical supervision and escalation support must be available 24/7.
The NHS Pathways system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings.
Principles of Health Advisor Training In telephone settings (calls made to NHS 111 or 999), assessments are conducted by specially trained non-clinical health advisors. These advisors complete a comprehensive, structured training programme to ensure they can use the NHS Pathways algorithm safely and effectively. They are always supported by clinicians, as a condition of the NHS Pathways licence, which NHS 111 and 999 providers must enter into in order to use the system. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. As above, the NHS Pathways licence states that clinical supervision and escalation support must be available 24/7, and immediately accessible to health advisors during live calls. This clinical availability is a core system control. Following initial core role training, both health advisors and clinicians are required to undertake mandatory training aligned to each new release of the NHS Pathways system, which typically occurs every 12 weeks. This ensures that staff remain up to date with any changes to clinical content, pathways, and system functionality. In addition, they have access to a comprehensive suite of ongoing learning resources, including ‘Hot Topics’, case studies and e-learning packages, which support continuous professional development and dissemination of learning.
Alongside this, providers are required to undertake regular quality assurance processes, including monthly audit of calls. These audits assess a range of core competencies, including the effective use of probing, and provide structured feedback to support ongoing development and safe practice. Within NHS Pathways, health advisors are trained and expected to actively probe to clarify and refine the information provided by the caller. This is a fundamental component of the NHS Pathways model and forms an important part of its safety design. NHS Pathways Assessment of Bleeding In respect of the NHS Pathways system, we can confirm the following occurs within the triage for all age groups:
• Immediate establishment of whether there is, or has been, any bleeding present, even if it has stopped at the time of the call;
• Whether the bleeding has been “heavy” within the last 2 hours. This establishes if there is serious, or life-threatening bleeding. The supporting information states that this may be described as “spurting, spraying, gushing or pouring, or may have made a puddle or soaked through a towel.” The system describes that this may equate to a loss of a mugful of blood in adults through to an egg cupful for younger age groups;
• The triage system then seeks information about the approximate amount of blood lost: for adults “2 mugfuls or more” progresses to asking about “bleeding from a wound or break in the skin” and whether the “blood is spraying or spurting out.” Answering ‘Yes’ to this, as from the information provided may have been the case in this incident, would result in a Category 2 ambulance disposition for Major Blood Loss. From the information submitted by YAS this confirmed that this is the same categorisation as this case was coded in the other triage system;
• The NHS Pathways system further prompts call takers to ask if the wound is covered by a dressing. If the answer to this is “Yes” the system seeks to establish if “...there is blood dripping or soaking through (the dressing)...” This further assists in establishing where bleeding is not controlled.
• In other cases where an ambulance disposition has not been reached, the system prompts questions to ascertains what the bleeding is like at the time of the call. I.e. is it “getting worse”, “about the same”, “slowing down but still bleeding”, or whether the bleeding has stopped. To summarise, a comprehensive assessment of bleeding occurs in NHS Pathways triage. This is at the beginning of the assessment, where immediate threats to life are ruled out. This assessment has been developed with oversight from the National Clinical Governance Assurance Group for NHS Pathways, who have reviewed and signed off the system relating to this type of clinical scenarios, cases and prior incidents.
From the information provided regarding Dr Cully, I would wish to convey to you that the serious nature of such bleeding would have been dealt at least as well as in the other system. And whilst the exact wording between the two systems differs. NHS Pathways does identify volumes of blood lost, nature of bleeding and picks up signs of catastrophic bleeding such as pooling or soaking through dressings, rather than asking a clinical judgement to be made by the caller as to whether bleeding is uncontrollable or dangerous. When uncontrolled bleeding is identified, as is most likely in a case presenting with the same or similar symptoms, the recommended disposition in line with up-to-date national clinical guidance is for a Category 2 ambulance for Major Blood Loss. This is the same ambulance response outcome as in this case, although tragically due to high demand, an ambulance was not available to attend Dr Cully for 1 hour and 20 minutes. NHS England is in close contact with providers using the NHS Pathways system and will liaise with Yorkshire Ambulance Service to confirm/discuss any learnings from this case.
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 Dr Cully, 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 30 April 2026 concerning the death of Dr Kenneth Wilson Cully on 17 September 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dr Cully’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Dr Cully’s care have been listened to and reflected upon.
Your Report raised concerns regarding insufficiency of the questions in the NHS Pathways system to correctly identify the seriousness of an uncontrolled bleed (with there being no question regarding whether the bleed is controlled or not) which could lead to the categorisation of the call being incorrect and a delay in treating a catastrophic event needing immediate attention.
As you acknowledge in your report at the time of Dr Cully’s death the call was managed by Welsh Ambulance Service (WAST) who were dealing with calls on behalf of Yorkshire Ambulance Service (YAS), WAST uses Advanced Medical Priority Dispatch System (AMPDS).
NHS Ambulance Services are required to process 999 calls through an approved triage system. There are currently two long established systems approved in England for primary 999 triage; NHS Pathways and the Advanced Medical Priority Dispatch System (AMPDS). The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs).
NHS England does not manage or oversee AMPDS and we are therefore unable to provide comment on their system.
YAS’ witness statement given by , which YAS have provided to NHS Pathways as part of standard feedback and reporting processes, detailed how, in their opinion the case would have been managed if it had been dealt with by NHS Pathways.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22nd June 2026
Background on NHS Pathways
NHS Pathways is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services. The tool also supports online triage and 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 NCAG. Alongside this external scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including guidance from the National Institute for Health and Care Excellence (NICE), Resuscitation Council UK and UK Sepsis Trust.
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 to identify 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 specially trained non-clinical health advisors. These advisors complete a rigorous training programme and are supported at all times 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 license that clinical supervision and escalation support must be available 24/7.
The NHS Pathways system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings.
Principles of Health Advisor Training In telephone settings (calls made to NHS 111 or 999), assessments are conducted by specially trained non-clinical health advisors. These advisors complete a comprehensive, structured training programme to ensure they can use the NHS Pathways algorithm safely and effectively. They are always supported by clinicians, as a condition of the NHS Pathways licence, which NHS 111 and 999 providers must enter into in order to use the system. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. As above, the NHS Pathways licence states that clinical supervision and escalation support must be available 24/7, and immediately accessible to health advisors during live calls. This clinical availability is a core system control. Following initial core role training, both health advisors and clinicians are required to undertake mandatory training aligned to each new release of the NHS Pathways system, which typically occurs every 12 weeks. This ensures that staff remain up to date with any changes to clinical content, pathways, and system functionality. In addition, they have access to a comprehensive suite of ongoing learning resources, including ‘Hot Topics’, case studies and e-learning packages, which support continuous professional development and dissemination of learning.
Alongside this, providers are required to undertake regular quality assurance processes, including monthly audit of calls. These audits assess a range of core competencies, including the effective use of probing, and provide structured feedback to support ongoing development and safe practice. Within NHS Pathways, health advisors are trained and expected to actively probe to clarify and refine the information provided by the caller. This is a fundamental component of the NHS Pathways model and forms an important part of its safety design. NHS Pathways Assessment of Bleeding In respect of the NHS Pathways system, we can confirm the following occurs within the triage for all age groups:
• Immediate establishment of whether there is, or has been, any bleeding present, even if it has stopped at the time of the call;
• Whether the bleeding has been “heavy” within the last 2 hours. This establishes if there is serious, or life-threatening bleeding. The supporting information states that this may be described as “spurting, spraying, gushing or pouring, or may have made a puddle or soaked through a towel.” The system describes that this may equate to a loss of a mugful of blood in adults through to an egg cupful for younger age groups;
• The triage system then seeks information about the approximate amount of blood lost: for adults “2 mugfuls or more” progresses to asking about “bleeding from a wound or break in the skin” and whether the “blood is spraying or spurting out.” Answering ‘Yes’ to this, as from the information provided may have been the case in this incident, would result in a Category 2 ambulance disposition for Major Blood Loss. From the information submitted by YAS this confirmed that this is the same categorisation as this case was coded in the other triage system;
• The NHS Pathways system further prompts call takers to ask if the wound is covered by a dressing. If the answer to this is “Yes” the system seeks to establish if “...there is blood dripping or soaking through (the dressing)...” This further assists in establishing where bleeding is not controlled.
• In other cases where an ambulance disposition has not been reached, the system prompts questions to ascertains what the bleeding is like at the time of the call. I.e. is it “getting worse”, “about the same”, “slowing down but still bleeding”, or whether the bleeding has stopped. To summarise, a comprehensive assessment of bleeding occurs in NHS Pathways triage. This is at the beginning of the assessment, where immediate threats to life are ruled out. This assessment has been developed with oversight from the National Clinical Governance Assurance Group for NHS Pathways, who have reviewed and signed off the system relating to this type of clinical scenarios, cases and prior incidents.
From the information provided regarding Dr Cully, I would wish to convey to you that the serious nature of such bleeding would have been dealt at least as well as in the other system. And whilst the exact wording between the two systems differs. NHS Pathways does identify volumes of blood lost, nature of bleeding and picks up signs of catastrophic bleeding such as pooling or soaking through dressings, rather than asking a clinical judgement to be made by the caller as to whether bleeding is uncontrollable or dangerous. When uncontrolled bleeding is identified, as is most likely in a case presenting with the same or similar symptoms, the recommended disposition in line with up-to-date national clinical guidance is for a Category 2 ambulance for Major Blood Loss. This is the same ambulance response outcome as in this case, although tragically due to high demand, an ambulance was not available to attend Dr Cully for 1 hour and 20 minutes. NHS England is in close contact with providers using the NHS Pathways system and will liaise with Yorkshire Ambulance Service to confirm/discuss any learnings from this case.
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 Dr Cully, 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.