NHS England
AI-generated response summary
• South East Coast Ambulance Service (SECAmb) has implemented clearer rules for staff to involve clinicians earlier when patients present with multiple or unclear symptoms. • SECAmb has implemented the Intelligent Clinical Queue to help identify higher-risk patients and prioritise them for clinical review. • SECAmb has strengthened staff training and support to help staff recognise when concerns should be escalated and to foster a culture where raising concerns is encouraged.
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Dear Dr Henderson, Re: Regulation 28 Report to Prevent Future Deaths – Oliver Charles Major Shelley who died on 22nd July 2024. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11th May 2026 concerning the death of Oliver Charles Major Shelley on 22nd July 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Oliver’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Oliver’s care have been listened to and reflected upon. Your Report raised the following concerns:
1. There is a lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls
2. That Emergency Medical Advisors (EMA’s), generally have no qualifications in medicine or nursing and the use of this title to describe their role raises a concern they are misleading the public. Background of NHS Pathways Clinical Decision Support System The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that is used to support Urgent and Emergency Care (UEC) in England. The product is owned by the Secretary of State for Health and Social Care and is manufactured and managed by the Transformation Directorate of NHS England. It is embedded within host systems in NHS 111 and 999 ambulance providers where it interacts with other technology products to support the assessment, sorting and onward management of calls received by those services. The NHS 111 and 999 providers are required to enter into a licence governing their use of NHS Pathways and the training materials. 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
[Page 2] scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including NICE (National Institute for Health and Care Excellence), UK Resuscitation Council and UK Sepsis Trust. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. 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. The term “Health Advisor” is set by the NHS 111 service specification. 999 services can determine this per service. Though non-clinical, these advisors complete a rigorous structured training programme, which includes classroom learning, assessments and preceptorship, to ensure they can use the NHS Pathways algorithm safely and effectively. Once working independently, health advisors must be supervised by clinical staff, to whom they must always have access to for guidance and support. It is therefore a condition of the NHS Pathways licence that clinical supervision and escalation support must be available 24/7. Health advisors using the NHS Pathways system are trained to use probing questions to better understand caller responses. A fundamental component of training is learning how to manage complex calls. The "complex call process" provides a clear protocol for health advisors to seek assistance or transfer a complex call to a clinician. This process should be followed in situations involving declared medications, medical procedures, terminology that complicates triage or any other situation when the advisor feels they have reached the limits of their knowledge or understanding. Additionally, it should be used if the call includes three “not sure” answers, or information is incomplete, ambiguous, or difficult to interpret. In such circumstances health advisors are expected to seek immediate clinical input from an experienced NHS Pathways trained clinician. This approach is reinforced by the principle: “If in doubt, shout.” NHS Pathways recognise there may be operational delays which must be managed locally. NHS Pathways is not able to take account of these as they and the local management of them can vary, and thus NHS Pathway’s expectations are based on what should happen in absence of such delays. 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
[Page 3] addition, they have access to a comprehensive suite of ongoing learning resources, including ‘Hot Topics’ (a “Hot Topic” is a short, focused NHS Pathways training resource used to reinforce key areas of triage practice across Providers), case studies and e-learning packages, which support continuous professional development and dissemination of learning. Sepsis and meningitis are specifically addressed within core training, including pre- module learning, scenario training, and ongoing learning resources such as a sepsis training toolkit and ‘Hot Topics’, ensuring that users are familiar with the recognition and escalation of these time-critical conditions. 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. Audit findings are intended to be used to provide structured feedback, targeted coaching, and, where required, retraining to ensure ongoing competence and safe application of the system. 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. Sepsis algorithm pathway Upon review of the calls, it is apparent that Oliver was seriously unwell and there were concerns expressed regarding Oliver's level of consciousness. Unconscious callers are triaged to a level no lower than a category 2 emergency ambulance. NHS Pathways acknowledges that, although multiple symptoms were present concurrently, had the health advisor selected any of the declared symptoms as the main problem, including ‘Behaviour Change’, ‘Rash’, ‘Vomiting’ or ‘Headache’ pathway, the triage system would have presented a question to assess whether the patient was able to carry out normal everyday activities (functional impairment assessment). In this case it appeared that Oliver was functionally impaired, which in all of these Pathways would have led to a further question about a non-blanching rash, resulting in the dispatch of a Category 2 ambulance. The assessment of a 'non blanching' rash accompanied by being unable to carry out normal activities appears in over 100 different clinical triage pathways as NHS Pathways acknowledges the multiple different ways that symptoms of Meningococcal Septicaemia may present. It is noted that the health advisor sought advice from a Senior Non-Clinician as they wanted to know if there was a specific Pathway for meningitis before then passing the case to the clinical queue for inability to prioritise a main symptom. It is important to highlight that as NHS Pathways is a non-diagnostic clinical assessment tool 'Meningitis' (or any other condition) would not present as a pathway option, however, questions regarding septicaemia and meningitis are covered in a variety of symptom- based pathways and when answered positively result in an ambulance dispatch. In essence, rather than one ‘sepsis algorithm’ pathway, NHS Pathways has embedded a ‘sepsis’ algorithm into a wide range of symptom-based pathways where sepsis could
[Page 4] present. In this way, even if the caller does not recognise potential symptoms of sepsis, the NHS Pathways algorithm would screen for potential sepsis in a wide range of symptom pathways. NHS Pathways training explicitly recognises that presentations involving multiple symptoms increase the complexity of triage and are associated with higher clinical risk. To mitigate this risk, NHS Pathways includes a structured and safety-focused approach to assessing patients with multiple symptoms. This is embedded within both system design and user training. Health advisors are trained to:
• Prioritise the rapid exclusion of immediately life-threatening conditions through structured questioning in the first section of NHS Pathways (known as Module 0). This includes an assessment of consciousness.
• Progress systematically into the next section of questions (known as Module
1) to identify the most clinically significant presenting problem, supported by Key Points within the system. Key points assist the health advisor to select the most appropriate pathway by providing details on when to use each pathway.
• Recognise that where symptoms suggest potential compromise to airway, breathing, circulation or a reduced level of consciousness, these must take priority regardless of how they are described by the caller.
• Use targeted probing to clarify symptoms and reduce ambiguity. Importantly, training emphasises that where a caller is unable to identify a main symptom, or where the presentation remains unclear or complex, this should be treated as an indicator of increased risk. In these situations, call handlers are instructed to:
• Seek immediate clinical support, or
• Undertake an Early Exit and transfer the call to a clinician This reflects a deliberate safety principle within NHS Pathways: that it is appropriate and expected for non-clinical users to escalate to a clinician when the limits of system- supported decision-making are reached. This structured approach is reinforced through initial training, ongoing learning, and monthly audit. This approach is designed to ensure that complex or unclear presentations, such as those involving multiple symptoms potentially consistent with serious infection, are identified early and managed with appropriate clinical input. The sequence described in the inquest, including the duration of the call and the timing of subsequent contact, reflects a situation that would have been deeply worrying for any family in those circumstances. While NHS Pathways does not oversee local service delivery or response times, this case emphasises the importance of early clinical input when presentations are
[Page 5] complex, where severity is unclear, or where it has not been possible to prioritise a primary symptom of concern. It is NHS Pathway's view that given the family clearly expressed concern that Oliver may have been suffering from meningitis, and recognising that Health Advisors receive training in the identification and escalation of serious infection including sepsis and meningitis, this further reinforces the importance of early clinical involvement if there is uncertainty about which route to take through the system. Emergency Medical Advisors The terminology used to describe call-takers using the NHS Pathways system is described in the background and training section above. For clarity, the term Health Advisor is set by the NHS 111 service specification. 999 services can determine this per service. In ambulance service settings, local services may choose to adopt alternative role titles, such as “Emergency Medical Advisor (EMA)”. The selection and use of these titles is determined locally by provider organisations. Regardless of job title, when undertaking the Health Advisor role using NHS Pathways, individuals are operating within a structured clinical decision support system, supported by training, defined principles and access to clinical supervision. It is a requirement of the NHS Pathways licence that appropriately trained clinicians are available at all times to provide immediate advice and to take over calls where needed. NHS Pathways training and system design emphasise the importance of recognising the limits of non-clinical roles and escalating to clinical support where there is uncertainty or complexity. Regional Response NHS England's South East Regional Team have liaised with South East Coast Ambulance Service regarding this PFD. Following a full investigation into Oliver's death, SECAmb identified learning relating to the way the service responded when patients presented with multiple or unclear symptoms. In these situations, it can be harder to recognise the seriousness of a patient's condition and delays can occur in escalation to clinical review. The Trust has acknowledged the impact this had on Oliver and his family and has implemented a number of improvements in response to the learning identified. These include:
[Page 6]
• Clearer rules for escalation: Staff are now clearly instructed that when a patient has multiple or unclear symptoms, they must involve a clinician earlier rather than trying to manage the call alone.
• Faster access to clinicians: The Trust has removed any ambiguity around seeking clinical support and staff are actively encouraged to obtain clinical advice promptly.
• New technology to prioritise risk: The Intelligent Clinical Queue has been implemented to help identify higher-risk patients and prioritise them for clinical review.
• Improved staff training and culture: Training and support have been strengthened to help staff recognise when concerns should be escalated and to foster a culture where raising concerns is encouraged. The Trust continues to review its systems, listen to staff and families, and implement further improvements to reduce the risk of similar incidents occurring in the future. 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 Oliver, 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.
1. There is a lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls
2. That Emergency Medical Advisors (EMA’s), generally have no qualifications in medicine or nursing and the use of this title to describe their role raises a concern they are misleading the public. Background of NHS Pathways Clinical Decision Support System The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that is used to support Urgent and Emergency Care (UEC) in England. The product is owned by the Secretary of State for Health and Social Care and is manufactured and managed by the Transformation Directorate of NHS England. It is embedded within host systems in NHS 111 and 999 ambulance providers where it interacts with other technology products to support the assessment, sorting and onward management of calls received by those services. The NHS 111 and 999 providers are required to enter into a licence governing their use of NHS Pathways and the training materials. 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
[Page 2] scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including NICE (National Institute for Health and Care Excellence), UK Resuscitation Council and UK Sepsis Trust. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. 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. The term “Health Advisor” is set by the NHS 111 service specification. 999 services can determine this per service. Though non-clinical, these advisors complete a rigorous structured training programme, which includes classroom learning, assessments and preceptorship, to ensure they can use the NHS Pathways algorithm safely and effectively. Once working independently, health advisors must be supervised by clinical staff, to whom they must always have access to for guidance and support. It is therefore a condition of the NHS Pathways licence that clinical supervision and escalation support must be available 24/7. Health advisors using the NHS Pathways system are trained to use probing questions to better understand caller responses. A fundamental component of training is learning how to manage complex calls. The "complex call process" provides a clear protocol for health advisors to seek assistance or transfer a complex call to a clinician. This process should be followed in situations involving declared medications, medical procedures, terminology that complicates triage or any other situation when the advisor feels they have reached the limits of their knowledge or understanding. Additionally, it should be used if the call includes three “not sure” answers, or information is incomplete, ambiguous, or difficult to interpret. In such circumstances health advisors are expected to seek immediate clinical input from an experienced NHS Pathways trained clinician. This approach is reinforced by the principle: “If in doubt, shout.” NHS Pathways recognise there may be operational delays which must be managed locally. NHS Pathways is not able to take account of these as they and the local management of them can vary, and thus NHS Pathway’s expectations are based on what should happen in absence of such delays. 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
[Page 3] addition, they have access to a comprehensive suite of ongoing learning resources, including ‘Hot Topics’ (a “Hot Topic” is a short, focused NHS Pathways training resource used to reinforce key areas of triage practice across Providers), case studies and e-learning packages, which support continuous professional development and dissemination of learning. Sepsis and meningitis are specifically addressed within core training, including pre- module learning, scenario training, and ongoing learning resources such as a sepsis training toolkit and ‘Hot Topics’, ensuring that users are familiar with the recognition and escalation of these time-critical conditions. 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. Audit findings are intended to be used to provide structured feedback, targeted coaching, and, where required, retraining to ensure ongoing competence and safe application of the system. 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. Sepsis algorithm pathway Upon review of the calls, it is apparent that Oliver was seriously unwell and there were concerns expressed regarding Oliver's level of consciousness. Unconscious callers are triaged to a level no lower than a category 2 emergency ambulance. NHS Pathways acknowledges that, although multiple symptoms were present concurrently, had the health advisor selected any of the declared symptoms as the main problem, including ‘Behaviour Change’, ‘Rash’, ‘Vomiting’ or ‘Headache’ pathway, the triage system would have presented a question to assess whether the patient was able to carry out normal everyday activities (functional impairment assessment). In this case it appeared that Oliver was functionally impaired, which in all of these Pathways would have led to a further question about a non-blanching rash, resulting in the dispatch of a Category 2 ambulance. The assessment of a 'non blanching' rash accompanied by being unable to carry out normal activities appears in over 100 different clinical triage pathways as NHS Pathways acknowledges the multiple different ways that symptoms of Meningococcal Septicaemia may present. It is noted that the health advisor sought advice from a Senior Non-Clinician as they wanted to know if there was a specific Pathway for meningitis before then passing the case to the clinical queue for inability to prioritise a main symptom. It is important to highlight that as NHS Pathways is a non-diagnostic clinical assessment tool 'Meningitis' (or any other condition) would not present as a pathway option, however, questions regarding septicaemia and meningitis are covered in a variety of symptom- based pathways and when answered positively result in an ambulance dispatch. In essence, rather than one ‘sepsis algorithm’ pathway, NHS Pathways has embedded a ‘sepsis’ algorithm into a wide range of symptom-based pathways where sepsis could
[Page 4] present. In this way, even if the caller does not recognise potential symptoms of sepsis, the NHS Pathways algorithm would screen for potential sepsis in a wide range of symptom pathways. NHS Pathways training explicitly recognises that presentations involving multiple symptoms increase the complexity of triage and are associated with higher clinical risk. To mitigate this risk, NHS Pathways includes a structured and safety-focused approach to assessing patients with multiple symptoms. This is embedded within both system design and user training. Health advisors are trained to:
• Prioritise the rapid exclusion of immediately life-threatening conditions through structured questioning in the first section of NHS Pathways (known as Module 0). This includes an assessment of consciousness.
• Progress systematically into the next section of questions (known as Module
1) to identify the most clinically significant presenting problem, supported by Key Points within the system. Key points assist the health advisor to select the most appropriate pathway by providing details on when to use each pathway.
• Recognise that where symptoms suggest potential compromise to airway, breathing, circulation or a reduced level of consciousness, these must take priority regardless of how they are described by the caller.
• Use targeted probing to clarify symptoms and reduce ambiguity. Importantly, training emphasises that where a caller is unable to identify a main symptom, or where the presentation remains unclear or complex, this should be treated as an indicator of increased risk. In these situations, call handlers are instructed to:
• Seek immediate clinical support, or
• Undertake an Early Exit and transfer the call to a clinician This reflects a deliberate safety principle within NHS Pathways: that it is appropriate and expected for non-clinical users to escalate to a clinician when the limits of system- supported decision-making are reached. This structured approach is reinforced through initial training, ongoing learning, and monthly audit. This approach is designed to ensure that complex or unclear presentations, such as those involving multiple symptoms potentially consistent with serious infection, are identified early and managed with appropriate clinical input. The sequence described in the inquest, including the duration of the call and the timing of subsequent contact, reflects a situation that would have been deeply worrying for any family in those circumstances. While NHS Pathways does not oversee local service delivery or response times, this case emphasises the importance of early clinical input when presentations are
[Page 5] complex, where severity is unclear, or where it has not been possible to prioritise a primary symptom of concern. It is NHS Pathway's view that given the family clearly expressed concern that Oliver may have been suffering from meningitis, and recognising that Health Advisors receive training in the identification and escalation of serious infection including sepsis and meningitis, this further reinforces the importance of early clinical involvement if there is uncertainty about which route to take through the system. Emergency Medical Advisors The terminology used to describe call-takers using the NHS Pathways system is described in the background and training section above. For clarity, the term Health Advisor is set by the NHS 111 service specification. 999 services can determine this per service. In ambulance service settings, local services may choose to adopt alternative role titles, such as “Emergency Medical Advisor (EMA)”. The selection and use of these titles is determined locally by provider organisations. Regardless of job title, when undertaking the Health Advisor role using NHS Pathways, individuals are operating within a structured clinical decision support system, supported by training, defined principles and access to clinical supervision. It is a requirement of the NHS Pathways licence that appropriately trained clinicians are available at all times to provide immediate advice and to take over calls where needed. NHS Pathways training and system design emphasise the importance of recognising the limits of non-clinical roles and escalating to clinical support where there is uncertainty or complexity. Regional Response NHS England's South East Regional Team have liaised with South East Coast Ambulance Service regarding this PFD. Following a full investigation into Oliver's death, SECAmb identified learning relating to the way the service responded when patients presented with multiple or unclear symptoms. In these situations, it can be harder to recognise the seriousness of a patient's condition and delays can occur in escalation to clinical review. The Trust has acknowledged the impact this had on Oliver and his family and has implemented a number of improvements in response to the learning identified. These include:
[Page 6]
• Clearer rules for escalation: Staff are now clearly instructed that when a patient has multiple or unclear symptoms, they must involve a clinician earlier rather than trying to manage the call alone.
• Faster access to clinicians: The Trust has removed any ambiguity around seeking clinical support and staff are actively encouraged to obtain clinical advice promptly.
• New technology to prioritise risk: The Intelligent Clinical Queue has been implemented to help identify higher-risk patients and prioritise them for clinical review.
• Improved staff training and culture: Training and support have been strengthened to help staff recognise when concerns should be escalated and to foster a culture where raising concerns is encouraged. The Trust continues to review its systems, listen to staff and families, and implement further improvements to reduce the risk of similar incidents occurring in the future. 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 Oliver, 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.