Susan Longden

Dr Peter Harrowing 
HM Assistant Coroner 
The Coroner’s Court 
Old Weston Road 
Flax Bourton 
Bristol 
BS48 1UL 

Sent by email to: avoncoronersteam@bristol.gcsx.gov.uk 

Our ref: LT01844 
Your ref: 9458 

Dear Dr Harrowing 

1 Trevelyan Square 
Boar Lane 
Leeds LS1 6AE 

0300 303 5678 

19 February 2019 

Re Regulation 28 (Report to Prevent Future Deaths) sent in connection  with the inquest into the death 
of Mrs Susan Longden 

Thank you for your letter dated 19th December 2018. 

I am writing on behalf of NHS Digital, in response to your Regulation 28 Report to Prevent Future Deaths.  This 
follows the death of Mrs Susan Longden who sadly passed away on 1st February 2018. This was followed by 
an  investigation  and  inquest  which  concluded  on  28th  November  2018.  Please  allow  us  to  express  our 
condolences to Mrs Longden’s family at this late stage. 

NHS  Pathways  is  the  clinical  decision  support  software  used  by  all  111  service  providers,  and  some  999 
ambulance  service  providers.  I  am 
,  MD,  FRCEM,  MRCS(Glasgow),  MBChB  and  am 
writing in my capacity as Senior Clinical Lead for Urgent and Emergency Care at NHS Digital. 

The Report to Prevent Future Deaths has raised the following matters of concern: 

1.  The  NHS  Pathways  algorithm  does  not  include  a  question  with  regard  to  recent  surgical  or 
interventional  procedures  where  a  patient  is  reporting  abdominal  pain.    The  close  association  in  time 
between  such  a  procedure  and  the  onset  of  symptoms  may  well  be  significant  in  ensuring  prompt 
action is taken to investigate the cause of symptoms: and  

2.  Where the caller to NHS 111 is not the patient then the Health Advisor continues to follow the algorithm 
obtaining information for the caller and not the patient.  There should be greater emphasis on tying to 
speak  with  the  patient  and  the  reason(s)  why  the  patient  cannot  come  to  the  telephone.    The 
information is provided may well affect the outcome of the triage: and 

3.  Previous  concerns  have  been  raised  by 

,  the  Medical  Lead  for  SW111,  Care 

UK, under case references P130273, P132849 and P133040.   

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Background: 

NHS DIGITAL’S RESPONSE 

For information, I have provided below a short summary of the functions that NHS Pathways performs and the 
governance that underpins it. 

Function of NHS Pathways 

NHS Pathways is a programme providing the Clinical Decision Support System (CDSS) used in NHS 111 and 
half of English ambulance services. This triage system supports the remote assessment of over 15 million calls 
per  year.  These  calls  are  managed  by  trained,  non-clinical  call  handlers  who  refer  the  patient  into  suitable 
services  based  on  the  patient’s  health  needs  at  the  time  of  the  call.  These  call  handlers  are  supported  by 
clinicians  who can  provide advice  and guidance  or  who can take over the call  if the situation requires  it. The 
system is built around a clinical hierarchy, meaning that life-threatening problems assessed at the start of the 
call  trigger  ambulance  responses,  progressing  through  to  less  urgent  conditions  which  require  a  less  urgent 
response (or disposition) in other settings. 

Governance of NHS Pathways 

The  safety  of  the  clinical  triage  process  endpoints  resulting  from  a  111  or  999  assessment  using  NHS 
Pathways,  is  overseen  by  the  National  Clinical  Governance  Group,  hosted  by  the  Royal  College  of  General 
Practitioners.  This  group  is  made  up  of  representatives  from  the  relevant  Medical  Royal  Colleges.  Senior 
clinicians from the Colleges provide independent oversight and scrutiny of the NHS Pathways clinical content. 
Alongside this independent oversight, NHS Pathways ensures its clinical content and assessment protocols are 
consistent with the latest advice from respected bodies that provide evidence and guidance for medical practice 
in the UK.  In particular, we are consistent with the latest guidelines from 

  NICE  (National  Institute  for Health  and Clinical  Excellence) 

  The UK Resuscitation Council 

  The UK Sepsis Trust 

To specifically answer the concerns raised: 

1.  The  NHS  Pathways  algorithm  does  not  include  a  question  with  regard  to  recent  surgical  or 
interventional procedures where a patient is  reporting abdominal pain.  The  close association  in 
time  between  such  a  procedure  and  the  onset  of  symptoms  may  well  be  significant  in  ensuring 
prompt action is taken to investigate the cause of symptoms: 

NHS  Pathways  is  built  on  a  clinical  hierarchy  of  symptoms,  meaning  that  life-threatening  symptoms  are 
prioritised and assessed through our initial set of questions (known as module 0). 

Within  these  algorithms  we  specifically  look  to  identify  the  symptoms  and  signs  of  life-threatening  conditions, 
including  bleeding,  by  asking  about  conscious  level,  fitting  and  choking,  breathlessness,  cool,  cold,  clammy 
skin  and  pallor.  Specific  questions  about  the  many  individual  conditions  that  could  lead  to  such  symptoms, 
including post-procedure complications, are not included at this stage as NHS Pathways focuses on triggering 
a suitable response (e.g. ambulance dispatch) based on the severity of the symptoms themselves. 

On ruling out the described immediately life-threatening symptoms, the abdominal pain pathways are used for 
those with abdominal pain as their main symptom.  Within these pathways there are further questions to identify 
or  exclude  potentially  life-threatening  symptoms,  including  vomiting  or  passing  blood  rectally  which  could  be 
linked to post procedural complications.  If any of these were present, further assessment would be made and 
an emergency ambulance would be likely to be dispatched. 

A  question  about  a  recent  surgical  procedure  or  intervention  is  specifically  asked  within  the  abdominal  pain 
pathway where the pain is described as moderate or mild in nature. This results in a referral to primary care for 
a direct clinical assessment after all life-threatening symptoms and severe illness have been excluded. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We acknowledge that we do not specifically include a question about recent procedures within the sub-section 
of  the  abdominal  pain  algorithm  where  callers  describe  severe  pain.  This  is  because,  at  present,  any  patient 
describing  severe  pain  will,  as  a  minimal  response,  be  referred  to  primary  care  urgently  regardless  of  such 
background. Before this backstop is reached, other questions are asked, looking to identify key symptoms that 
warrant prompt action to investigate their cause, including ambulance dispatch. 

In  the  case  of  Mrs.  Longden,  the  NHS  Pathways  algorithm  recommended  an  emergency  (Category  3) 
ambulance.  Pursuant to a local service process the call was then passed to a clinician to validate dispatch of 
an  ambulance,  and  the  ambulance  was  downgraded  to  ‘contact  primary  care  within  2  hours’.    This  step  and 
decision are not a part of NHS Pathways procedures.   

At the time of the call to 111, Care UK  was using release 14.0.2 of NHS  Pathways. Since then,  questions to 
better  identify critical illness symptoms have been  added  into many pathways (including abdominal  pain).  On 
reviewing the call made in this case against our new algorithms, please be reassured that a caller with similar 
symptoms would still receive the same emergency ambulance disposition from NHS Pathways. 

NHS  Pathways  regularly  review  the  algorithms  and  our  abdominal  pain  pathways  are  currently  undergoing  a 
review with our external subject matter experts from the Royal Colleges.  This review will include the severe pain 
section specifically, and inclusion of a question asking about a recent surgical procedure or intervention 
has specifically been requested for review as part of this work.  I can further reassure HM Coroner  that this 
comprehensive  review  of  our  abdominal  pain  algorithms  will  be  concluded  by  1st  May  2019,  and  that  any 
changes to NHS Pathways will be implemented later this year, pending successful safety testing.   

2.  Where the caller to NHS 111 is not the patient then the Health Advisor continues to follow the 
algorithm  obtaining  information  for  the  caller  and  not  the  patient.    There  should  be  greater 
emphasis on tying to speak with the patient and the reason(s) why the patient cannot come to 
the telephone.  The information is provided may well affect the outcome of the triage: 

Within  initial  NHS  Pathways  training,  which  both  call  handlers  and  clinicians  must  complete  as  part  of 
initial training, there is great emphasis placed on the importance of speaking to a patient, where possible 
and  appropriate.  The  training  programme  for  staff  is  competency  based  and  as  such  is  mapped  to  the 
NHS  Pathways  Competencies  (See  Appendix  1).  These  competencies  stress  the  importance  of  talking 
directly to a patient wherever it is safe and appropriate to do so.  

The  section  below  outlines  how  the  NHS  Pathways  Competencies  refer  to  the  need  to  speak 
directly to the patient: 

“Makes efforts to speak directly to patient 
Triage is often more effective when it is carried out directly with the patient. This is because introducing a 
3rd party often creates a “lost in translation” effect. Talking with the patient also enables the call handler to 
evaluate for themselves important factors such as the nature of the person’s breathing, speech patterns, 
comprehension and so on. With 1st party calls certain questions don’t need to be asked such as whether 
the person is too breathless to speak more than a few words. Thus, 1st party triage is often more accurate 
and quicker. 

It is crucial to remember that there are situations where speaking to the patient is appropriate and others 
where  it  is  not.  It  would  not  be  appropriate  to  ask  to  speak  to  someone  who  is  in  an  obviously  life-
threatening  situation,  for  example  someone  experiencing  arterial  blood  loss.  Neither  would  it  be 
appropriate  to  conduct  an  assessment  with  someone  who  is  confused  or  a  very  young  child.  The  call 
handler needs to exercise judgement as to how strenuously they pursue talking to the patient rather than 
the caller. Every call is different and requires skilled judgement on the part of the person handling it.” 

Initial Call Handler and Clinician Training 
An example of where new trainees are introduced to the importance of speaking to the patient is on day 6 
of initial training in the Understanding Competencies Session.  

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 During this session, staff listen to real calls which demonstrate the importance of speaking to the patient, 
as well as highlighting the exceptions when it would not be appropriate to do this, such as if the patient is 
very young, in a life-threatening situation, or suffering from dementia.  

Additionally,  on  day  8  of  initial  training,  staff  are  involved  in  carrying  out  call  critiques  reinforcing  the 
benefits  of  speaking  to  the  patient  and  identifying  good  and  poor  practice  based  on  real  call  examples. 
The  session  also  involves  role  play  to  allow  trainees  to  practise  the  skills  of  managing  calls  effectively, 
which includes the necessity to speak to the patient where safe and appropriate to do so.  

At  the  end  of  training,  all  staff  complete  written  and  practical  assessments  before  progressing  into 
supervised practiced. They are assessed against the NHS Pathways competencies, which emphasise the 
important of avoiding a three-way conversation wherever possible.  

Ongoing Competency Assessments 

After  initial  training  has  been  completed  and  staff  have  been  signed-off  as  competent  against  the 
competencies,  monthly  call  audit  begins  as  a  way  of  quality  monitoring  the  practice  of  staff,  and  to 
highlight any additional training requirements or concerns with practice.  

The  requirement  to  carry  out  audit  is  stipulated  within  the  NHS  Pathways  Licence  to  Use  which  all 
organisations must adhere to if they wish to utilise the system. NHS Pathways mandates a robust quality 
assurance process which includes non-negotiable monthly audit.  

During  monthly  call  audit  every  member  of  staff  is  assessed  against  the  competencies.  This  is  done  by 
trained audit staff using the NHS Pathways Audit Tool. Call audit involves listening to live calls as they are 
being taken as well as recorded calls, listened to in retrospect.  

We  therefore  consider  that  the  NHS  Pathways  training  materials  and  licence  requirements  sufficiently 
address the need and importance of call handlers speaking directly to patients and recognise that 111 and 
999 providers should continue to reinforce this with the call handlers. 

3.  Previous  concerns  raised  by 

,  the  Medical  Lead  for  SW111,  Care  UK, 

with case references P130273, P132849 and P133040: 

Any  issues,  incidents  or  cases  that  a  provider  raises  are  logged  in  a  central  clinical  issues  log  (as  these 
were). For accuracy the above references should read PI30723, PI32849 and PI33040. 

PI30723  – this related to this specific case  and  was logged on the 28th June 2018  by  Care UK informing NHS 
Digital that a coroner’s case was going to be heard.  At the time of logging the issue Care UK did not raise any 
concerns.    Their  own  documentation  submitted,  including  the  local  root  cause  analysis,  did  not  raise  specific 
concerns  with  the  algorithms  and  identified  that  the  health  care  professional  downgrading  the  call  from  an 
ambulance to a call-back missed opportunities. This was prioritised by Care UK as a non-urgent change, but the 
actual change requested was not stated in the issue or documentation.   

PI32849 – logged on the 23rd September 2018 by Care UK informing NHS Digital to consider asking the type of 
medication  being  taken  when  a  patient  is  vomiting,  which  is  unrelated  to  this  specific  case  and  is  still  being 
investigated. 

PI33040 – this related to this specific case, and was logged on the 28th November 2018 by Care UK after the inquest, 
informing NHS Digital to consider asking about recent abdominal surgery / procedure in the abdominal pain pathways 
as a result of this case. This was prioritised by Care UK as an urgent change request.  As set out above in answer to 
concern 1 the  abdominal  pain  pathways  (and  the  severe  pain  section  specifically)  are  currently  undergoing  a 
review  and  inclusion  of  a  question  asking  about  a  recent  surgical  procedure  or  intervention  has 
specifically been requested  for review as part of this work.  I can  further  reassure  HM  Coroner  that this 
comprehensive  review  of  our  abdominal  pain  algorithms  will  be  concluded  by  1st  May  2019,  and  that  any 
changes to NHS Pathways will be implemented later this year, pending successful safety testing.  

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
  
  
 
 
 
 
  
 In Summary: 

  We  acknowledge  that  the  question  about  a  recent  surgical  procedure  or  operation  is  not 
specifically  asked  in  a  sub-section  of  our  abdominal  pain  pathways  and  are  reviewing  how  this 
might be included as part of a larger clinical review. This is due for completion later this year. 

  We do currently require that all users of NHS Pathways seek to talk directly with the patient where 

possible, as outlined in the training materials included. 

I  hope  that  the  above  alleviates  your  concerns,  but  I am  happy  to  answer  any  further  enquiries  from  HM 

Coroner. 

Yours sincerely 

  MD,  FRCEM,  MRCS(Glasg),  MBChB 

Senior Clinical Lead 
Urgent & Emergency Care 

0207 003 3067 | 07920 861 716 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk