Robert Hogg

From the Lord Prior of Brampton

RGR Parliamentary Under Secretary of State for NHS Productivity (Lords)
Department
of Health
Mr C. Butler Richmond House
Assistant Coroner 79 Whitehall
. London
Coroners Service SW1A 2NS
29 Windsor End
Beaconsfield Tel: 0207210 4850
Buckinghamshire
HP9 24) 9 Oder RAS

L, Bowe,

Thank you for your letter of 10 August 2015 to Dr Felicity Harvey
following the inquest into the death of Robert Hogg. I am responding as
the Minister responsible for this policy area. I was extremely sorry to hear
of Robert’s death and wish to extend my sincerest condolences to his
family.

Your concerns in this case arise from the handling of an emergency call
that was made by Robert’s mother to the NHS 111 service provided by the
South Central Ambulance Service (SCAS) on the 21 April, following a
deterioration in Robert’s health.

Following Robert’s death, an investigation report, prepared by Suzanne
Solera for SCAS, revealed the following area of concern:

"NHS Pathways toddler/child Pathways are not necessarily
highlighting/picking up very sick children. This is not the first event
relating to incidents involving toddlers/children and this has been
highlighted through our own Pathways Lead to NHS Pathways for
investigation".

Evidence at the inquest showed that no changes had been made to the
toddler/child pathways and you are therefore concerned that this issue is a
continuing risk.

As in the majority of NHS 111 services, SCAS uses NHS Pathways
Clinical Decision Support System (CDSS) to support safe assessment of
calls received by the service. This system allows for sorting, or triage, of
calls such that they may receive an appropriate response.

The Health and Social Care Information Centre (HSCIC) is the national
provider of information, data and IT systems for commissioners, analysts
and clinicians in health and social care. HSCIC is an executive non-
departmental public body and is responsible for the NHS Pathways
system, NHS Pathways has provided a response which I am enclosing.

I am grateful to you for bringing the circumstances of Robert’s death to
my attention and hope that you find this reply helpful.

Ja v ;
Jol

DAVID PRIOR .

Regulation 28 Report to prevent future deaths – Robert Gordon John Hogg 

NHS Pathways Response 

NHS Pathways Overview 

NHS Pathways is the provider of the Clinical Decision Support System (CDSS) 
for six of the ten ambulance providers in England. In addition to this it is used 
in all NHS 111 sites. Use of this system is wrapped around by a comprehensive 
package of training and continuous quality assessments.  

NHS Pathways clinical content, which comprises the hierarchical algorithmic 
questions presented to call takers, is continuously subject to review. Where 
there are grounds to amend the content NHS Pathways undertakes to make such 
amendments in good time and without increasing risk to patient assessment. It 
encourages sites to submit issues where they consider improvement could be 
made to the system. The NHS Pathways Clinical Author Team investigates 
these issues and makes any necessary changes. The changes within any 
particular timeframe are included in a single release. There are usually two 
releases per annum. This is because of the safety issues related to making patch 
updates without adequate testing or training.  

Sequence of events 

This case relates to calls handled by SCAS - the sequence of events is as 
follows: 

 
 
 
 
 
 
 
 
 
 
 
 The Incident Report and its Claims 

The incident report referred to in the Coroner’s ruling (IR 4865) states:  

“The Call Handler did a thorough assessment using the NHS Pathways and 
came to an appropriate disposition for what symptoms were being described.” 

It is difficult to understand, therefore, any basis for the later statement: 

“NHS Pathways toddler/child Pathways are not necessarily 
highlighting/picking up very sick children.” 

Furthermore, the statement:  

“This is not the first event relating to incidents involving toddlers/children and 
this has been highlighted through our own Pathways Lead to NHS Pathways for 
investigation.” 

is in fact incorrect as no similar cases in this age category, toddler/child1 have 
been highlighted to NHS Pathways for investigation by SCAS. 

NHS Pathways Safety Record 

NHS  Pathways  takes  patient  safety  extremely  seriously.  The  system  supports 
the  safe  triage  of  approximately  1  million  calls  per  month  in  the  NHS  111 
environment.  There  are  a  handful  of  cases,  across  all  ages,  where  there  have 
been  adverse  incidents.  Indeed  an  internal  NHS  England  document,  Learning 
from NHS 111 Related Serious Incidents – Childhood Sepsis, states: 

“The  rate  of  reporting  of  clinical  Serious  Incidents  is  approximately  1  in 
250,000 calls answered.” 

A search on the records by NHS 111 relating to childhood sepsis identified a 
total of twelve incidents in the 13 month period between March 2013 and May 
2014, in a total of over 12 million calls assessed. The majority of these were 
related to operational matters outside of NHS Pathways clinical assessment of 
the child. 

However as a learning system, and as a consequence of this document, NHS 
Pathways did amend the system, and is continuing to review the clinical content 
and architecture in regards to safe identification of cases of paediatric sepsis. 

1 Toddler encompasses ages 1 to 5 years, Child refers to patients aged 5 to 16 years. 

 
 
 
 
 
 
 
 
 
 
 
 
                                                 
 Specifically, NHS Pathways added advice to regularly check on un-well 
children overnight and enhanced the training materials. 

Assessment and Sorting in this Case 

From the timeline above, and as is detailed in Suzanne Solera’s report (IR 4865) 
the case was appropriately assessed at the time of the initial triage.  

There was a failure to follow correct procedure in the later call logged at 
11:42. This error is referred to in the report. Had the call been triaged, a 
different (higher) outcome may well have been reached if the patient had 
clinically deteriorated. 

Speak to GP within 1 hour is an urgent primary care disposition in the NHS 
Pathways system. The reason for a “Speak to” rather than a “Contact” 
disposition is that the system determines that a high level of clinical expertise is 
required to determine the correct skill-set and timeframe required to respond to 
the patient’s needs at the time of the call. 

Allegations 

1.  NHS Pathways toddler/child pathways are not necessarily 

highlighting/picking up very sick children. 

There are no grounds for this claim either within the Incident Report 
submitted to the court, or by the weight of evidence of 12 cases, mainly 
associated with issues outside of the decision support system, in 
approximately 12 million calls handled in 2013-14.  

2.  This is not the first event relating to incidents involving 

toddlers/children and this has been highlighted through our own 
Pathways Lead to NHS Pathways for investigation. 

No similar related cases have been notified to NHS Pathways by SCAS.  

Further Actions 

1.  Matters to be struck from the record 

It should be considered that the allegations made be struck from the 
record as they are misleading and not an accurate representation of the 
facts as found by the investigation at site. 

 
 
 
 
 
 
 
 
 
 
 
 
 2.  Seeking adjournment 

NHS Pathways would seek that in similar cases, where NHS Pathways 
CDSS is alleged to be attributable, that they have adequate opportunity to 
be held accountable and answer directly to the Court. In this case we 
consider it a grave error if the patient’s family have been led to believe 
that the NHS Pathways system is in any way attributable for this, or any 
other similar death. Since the NHS Pathways system is publically owned, 
it is incumbent upon us to hold its leaders to account when required, but 
also to uphold its reputation where necessary. 

3.  Working with SCAS 

NHS Pathways are liaising directly with SCAS to better understand why 
these allegations may have been made. From initial enquiries, it seems 
that the views expressed in court are not consistent with those of the 
senior clinical leadership of SCAS.