Allan Davies

James Bennett 
Area Coroner Birmingham and Solihull 
The Coroner's Court 
50 Newton Street 
Birmingham 
B4 6NE 

By Email: 
Our reference: LT02223 

Dear Mr Bennett 

Inquest into the death of Allan Davies 

1 Trevelyan 
Square 
Boar Lane  Leeds 
LS1 6AE 

0113 397 3614 

5th September 2019  

I am writing  in response to the Regulation 28 report received from HM Senior Coroner, dated 9th 
July 2019. This follows the death  of Allan Davies who sadly passed away  on 7th February 2019. 
This  was followed  by an  investigation  and  inquest  which  concluded on 26th June 2019.  NHS 
Pathways is the clinical decision  support software  used  by  all  111  service  providers,  and 
some 999 ambulance service providers including West Midlands Ambulance Service. 
I am 
, RGN, RSCN, BSc, SPQ and am writing in my capacity as Deputy Clinical 
Director, NHS Pathways, NHS Digital. 

HM Coroner  has raised the following matters of concern with regards to NHS Pathways: 

1.  NHSP triaging of overdoes cases is too generic, namely it fails to have regard to the 
type of drug(s) taken and the potential for sudden collapse in certain patients: and 
2.  Not  all  NHS  trusts/ambulance  services  that  utilise  NHSP  are  aware  of  the  apparent 

deficiency.  

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.   

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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  16.7 million  calls per annum. These calls are managed by non-clinical 
specially  trained  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  are  able  to  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. 

Please note that where an NHS Pathways question is answered in such a manner as to prompt 
the  asking  of  a  further  question  along  the  same  pathway  this  is  referred  to  as  a  ‘negative’ 
answer.  Where a response (in most cases indicative of more serious clinical symptoms) to a 
question or string of questions is such that it prompts different questions or a clinical endpoint 
specifying the level of care and time frame that a patient needs (‘disposition’) being reached 
this is generally referred to as a ‘positive’ answer.   

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.  Changes to the NHS Pathways clinical content 
cannot be made unless there is a majority agreement at NCGG. 
this  independent  oversight,  NHS  Pathways  ensures  its  clinical  content  and 
Alongside 
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 address the concerns raised: 

1)  NHSP triaging of overdoes cases is too generic, namely it fails to have regard to the 

type of drug(s) taken and the potential for sudden collapse in certain patients. 

NHS Digital (along with NHS England and NHS Improvement as detailed below) is aware of 
issues associated with the unpredictability of deterioration in overdose cases and ensuring care 
is provided when needed. 

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

 
 
 
 
 
 
 
 
 
 
 
 Our  response  to  the  specific  concerns  raised  and  details  of  measures  in  place  and  actions 
taken and ongoing in this area are detailed below.   

1)  Drugs  taken  by  a  patient  is  not  a  determinative  factor  in  NHS  Pathways  reaching  a 

disposition 

NHS Pathways triages symptoms presenting at the time of the call and directs patients to the 
most appropriate services based on these symptoms rather than making a diagnosis. 

Overdose  cases  (whether  with  suicidal  intent  or  not)  are  very  complex  to  assess  within 
telephone  triage  due  to  different  methods,  lethality  and  social  circumstances.  In  overdose 
cases the capacity of any drug to cause harm is dependent on multiple factors; for example, 
quantity of drug taken, interactions of other medication, the patient’s medical history and time 
of overdose, as well as the patient’s understanding of what exactly has been taken.   

NHS  Pathways  previously  considered  whether  there  was  a  way  of  identifying  higher  risk 
overdose patients automatically within the system based on drugs taken.  Our assessment was 
that this is not possible given that NHS Pathways is a computer-based system operated by 
non-clinical call handlers.   There are too many variables to address this in multiple choice / 
closed type questions.   NHS Pathways does not rely on non-clinical call handlers being able 
to recognise particular conditions or the likely consequences of factors such as drugs taken, 
as: i) this requires knowledge and discretion that non-clinical call handlers are not expected to 
have, and that a training programme for individuals who are not medical professionals could 
not deliver; and ii) therefore to do so may introduce further risks if relied upon to determine a 
disposition.   

2)  Information about drugs taken is recorded by NHS Pathways 

Within the Accidental Poisoning/ Inhalation pathway there is a specific question which allows 
the call handler to document (if known, from information given by the patient or caller) ‘what, 
when and how much was taken’ in a free text box. When there is suicidal attempt, after reaching 
the emergency ambulance disposition/outcome, “what was the method of the suicide attempt” 
is  asked,  each  of  the  answers,  overdose  of  medication,  swallowing  something  harmful, 
breathing in poisonous fumes, and other has a free-text ‘specify’ box for documenting further 
details.   

This information is not taken account of in reaching a disposition (due to the risks of non-clinical 
call handlers being unable to accurately analyse and record the relevant information as above) 
but it is transferred into the call report and call summary. These reports are visible to clinicians 
working within the 999 or 111 services when reviewing cases and for any onward health care 
professionals to see (including any clinician to whom the call is transferred). 

3)  Safeguards in respect of the potential for sudden collapse in certain overdose patients 

Mr  Davies  was  assessed  using  the  Accidental  Poisoning  /  Inhalation  pathway.    Due  to  the 
complex nature of accidental poisoning cases, the lowest disposition that can be reached by a 
patient  presenting  with  any  symptoms  is  a  Category  3  (Dx012)  emergency  ambulance 
response (with more severe symptoms generating a higher disposition/outcome).   

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

 
 
 
 
 
 
 
 
 
 
 (Dx012  is  a  generic  ambulance  disposition  within  NHS  Pathways  associated  with  urgent  / 
emergency calls but not immediately life-threatening symptoms.) 

If asymptomatic the outcome reached is “speak to a clinician from our service immediately – 
toxic ingestion/inhalation”. This outcome is to allow immediate transfer to a clinician to clinically 
assess the risk to life, apply their expertise to information about drugs taken or other relevant 
factors  and  triage  to  an  appropriate  level  of  response.   Mr  Davies  had  symptoms  of 
breathlessness which resulted in a Category 3 (Dx012) ambulance response.  

If self-harm, or suicidal intent is present, even if asymptomatic, the lowest disposition is an 
emergency ambulance response (Dx012 /Category 3).   

NHS Pathways dispositions have unique codes, for example Dx012 is the disposition code for 
a Category 3 emergency ambulance response.  Where symptoms require a disposition related 
to an ambulance needing to be dispatched this is then ‘mapped’ to the clinically appropriate 
ambulance  standards  which  are  set  by  NHS  England  and  results  in  the  specific  disposition 
code  indicating  the  category  of  ambulance.  NHS  Pathways  does  not  set  the  Ambulance 
response  standards  or  the  Ambulance  Quality  Indicators  and  these  can  be  found  at 
https://www.england.nhs.uk/urgent-emergency-care/arp 

4)  Use of disposition Dx012 /Category 3 ambulance response 

The  Ambulance  Response  Programme  in  December  2018  discussed  and  agreed  that  re-
categorisation of all suicidal cases  from Dx012 (Category 3 ambulance) responses to Category 
2 ambulance responses without first differentiating the clinical risks of  the method, toxicity and 
social  circumstance  of  the  case  is  unlikely  to  offer benefits  of  a  faster  response  due  to  the 
volume  of  patients involved  and  would  likely  introduce  new  clinical  risks  across  the  wider 
emergency care system.  This approach is also in line with the other national triage system in 
use in 999 services. 

It is important that the presumed illness/risk posed to a patient following triage is accurate in 
NHS  Pathways,  not  only  to  ensure  that  patients  receive  the  appropriate  level  of  care  when 
seriously ill, but also to ensure that patients are not over-referred.  When the questions within 
NHS  Pathways  are  created,  the  clinical  team  must  ensure  that  a  careful  balance  between 
'sensitivity' and 'specificity' is struck. By way of brief summary, the ‘sensitivity of a test’ is the 
ability  to  correctly  identify  those  with  a  disease  or  condition  (true  positive  rate),  whereas 
‘specificity’ is the ability to correctly identify those without the disease (true negative rate). More 
than 16.7 million calls are triaged every year using NHS Pathways, so it is critically important 
that the content of the system has an appropriate and safe balance between sensitivity and 
specifically, since an imbalance in either direction carries significant risks.   

5)  Changes implemented to disposition Dx012 

NHS Pathways has however continued to review the category of response for suicidal patient 
groups  alongside the recommendation as documented in the letter in Appendix A where the 
Ambulance Response Programme requested that  “all services should review the identification 
and management of these patients to ensure they are receiving the correct type of response 
and timely clinical assessment”.   

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

 
 
 
 
 
 
 
 
 
 
 
 To  support  this  recommendation  NHS  Pathways  have  introduced  a  new disposition  code 
(Dx0124),  ratified  by  the  NHS  Pathways  National  Clinical  Governance  Group  (NCGG)  in 
February 2019.  This new code, ‘Dx0124 Emergency Ambulance Response for Risk of Suicide 
(Category  3)’  is  designed  to facilitate  the early identification  of  higher  risk suicidal  patients 
either following an intentional toxic overdose or persons who intend to end their life by violent 
means, so that they can undergo early clinical review within 111 and 999 call-handling centres.  

The purpose of this new disposition code is to raise the visibility of higher risk suicide cases 
within the larger Dx012 Emergency Ambulance Response (Category 3) cohort so they can be 
targeted by clinicians in the control rooms for urgent remote clinical assessment of the risk to 
life, using their expertise to clinically re-triage to alternative levels of response if required, e.g. 
a higher Category 2 ambulance response if appropriate. 

This new disposition code to support further clinical assessment was finalised and included in 
Release 18 of NHS Pathways content.  Beta testing occurred in August 2019 and widescale 
deployment of Release 18 to all providers of NHS111 and all ambulance services in England 
that use the NHS Pathways system begins on 7th October 2019, with services then having an 
8 week period to update their staff and deploy in their systems. 

6)  Future changes to disposition Dx012 

NHS Pathways has also recognised that those patients who have overdosed without suicidal 
intent and have symptoms (and so receive a Dx012 disposition and  Category 3 ambulance) 
would benefit from having the same visibility within the Category 3 cohort as those with suicidal 
intent,  so  they  can  also  be  easily  identified  by  clinicians  working  within  ambulance  control 
rooms  for  urgent  remote  clinical  assessment  of  the  risk  to  life.    Further  work  by  the  NHS 
Pathways  team  is  commencing  in  this  area  and,  subject  to  review  by  the  National  Clinical 
Governance Group, a new disposition code will be introduced  (similar to Dx0124) to enable 
this  to  occur.    The  Ambulance  Response  Programme  will  be  made  aware  of  this  proposed 
change. 

We are happy to provide an update on the progress of this work if required.   

2)  Not all NHS trusts/ambulance services that utilise NHSP are aware of the apparent 

deficiency. 

NHS England and NHS Improvement, through the Ambulance Response Programme and Joint 
Ambulance  Improvement  Programme  Board,  are  aware  of  issues  associated  with  the 
unpredictability of deterioration in overdose and suicide cases and ensuring care is provided 
when needed and have sought to address this with NHS Trusts and Ambulance Services.  
The National Clinical Director for Urgent and Emergency Care, NHS England issued a letter as 
outlined  in  Appendix  A,  to  all  Ambulance  Service  Chief  Executives  and  Ambulance  Service 
Medical  Directors  in  England  on  21st  January  2019  following  a  meeting  of  the  Ambulance 
Response programme (ARP) implementation group on 18th December 2018 to request Trusts 
review how they monitor self-harm and suicidal patients.  The ARP group is attended by all 999 
Ambulance trusts. 

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

 
 
 
 
 
 
 
 
 
 
 On 2nd April 2019 the National Clinical Director for Urgent and Emergency Care NHS England 
wrote  a  further  letter  to  all  Ambulance  Service  Chief  Executives  and  Ambulance  Service 
Medical Directors in England to again highlight these issues and ask them to: 

"ensure they have robust clinical oversight in place in control rooms to monitor 
• 
self-harm and suicidal patients safely and effectively, particularly those who have been 
allocated a Category 3 or 4 response initially”.  
And stated that “Consideration should be given, at the point of call, to the type of 
• 
overdose and quantity taken (where relevant), and to the intent to end life, all of which 
will determine the necessary response including the need to upgrade a call for clinical 
reasons...".  

This  letter  also  offered  to  promote  and  share  good  practice  in  this  regard,  which  several 
ambulance services have done.  

Through our standard deployment process all users of NHS Pathways are aware of the new 
disposition code Dx0124 coming in Release 18. 

We trust that this addresses your concerns but please let us know if we can answer any further 
enquiries from HM Coroner. 

Yours sincerely 

Deputy Clinical Director  
NHS Pathways 

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

Mr James Bennett, Coroner for 
Birmingham and Solihull 
Coroner's Court 
50 Newton Street 
Birmingham 
B4 6NE 

                                     Professor Stephen Powis 
                                      National Medical Director 
                                                      Skipton House 
                                                   80 London Road 
                                                               SE1 6LH 

                                               30th August 2019 

Dear Mr Bennett,  

Re: Regulation 28 Report to Prevent Future Deaths – Allan Davies 

Thank you for your Regulation 28 Report (hereinafter the ‘report’) dated 9th July 2019 
concerning  the  death  of  Mr  Allan  Davies  on  7th  February  2019.  Firstly  before 
responding  to  your  concerns,  I  would  like  to  express  my  deep  condolences  to  Mr 
Davies’ family.  

I note that your recent inquest into the death of Mr Davies concluded that his death 
was drug related and more specifically as a result of heroin overdose. 

Following the conclusion of the inquest you raise the following concerns in your report 
for NHS England to consider:  

(1) NHS Pathways (NHSP) triaging of overdose cases is too generic, namely it fails 
to have regard to the type of drug(s) taken and the potential for sudden collapse 
in certain patients; 

(2) Not  all  NHS  trusts/ambulance  services  that  utilise  NHSP  are  aware  of  this 

apparent deficiency. 

In  response  I  can  confirm  that  NHS  England  and  NHS  Improvement,  through  the 
Ambulance  Response  Programme  and  Joint  Ambulance  Improvement  Programme 
Board, are aware of this issue, and have taken steps to address it. On 2nd April 2019 
Professor Jonathan Benger, the National Clinical Director for Urgent and Emergency 
Care  at  NHS  England,  wrote  to  all  Ambulance  Service  Chief  Executives  and 
Ambulance Service Medical Directors in England to highlight this issue and ask them 
to: 

• 

"ensure they have robust clinical oversight in place in control rooms to monitor 
self-harm  and  suicidal  patients  safely  and  effectively,  particularly  those  who 
have been allocated a Category 3 or 4 response initially”.  

And stated that: 

• 

“consideration should be given, at the point of call, to the type of overdose and 
quantity taken (where relevant), and to the intent to end life, all of which will 

                                            NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                         
 determine  the  necessary  response  including  the  need  to  upgrade  a  call  for 
clinical reasons...".  

This  letter  also  offered  to  promote  and  share  good  practice  in  this  regard,  which 
 followed 
several  ambulance  services  have  done.  This  letter from 
earlier  work  to  examine  whether  there  might  be  a  way  of  identifying  higher  risk 
overdose  patients  automatically,  given  that  NHS  Pathways  is  a  computer-based 
system operated by non-clinical call handlers. However unfortunately no such system 
exists at present, not least because patients who have taken an overdose may not be 
able to identify accurately the substance or quantity that they have taken, and for this 
reason active clinical oversight within ambulance control rooms was recommended. 

NHSP, within NHS Digital, is also aware of the issue, and has taken steps to address 
it  in  coordination  with  the  initiatives  described  above.  In  February  2019  NHSP’s 
National  Clinical  Governance  Group  (NCGG)  ratified  the  decision  of  the  clinical 
authoring team to introduce a new disposition code (Dx). I can confirm the purpose of 
this  additional  code    is  to  raise  the  visibility  of  higher  risk  cases  within  the  larger 
Emergency  Ambulance  Response  (Category  3)  cohort  (Dx012),  so  they  can  be 
targeted  for  urgent  clinical  assessment  of  the  risk  to  life  and  clinical  re-triaging  to 
alternative levels of response if required, e.g. a Category 2 ambulance response.    

This  new  code,  Dx0124  (Emergency  Ambulance  Response  for  Risk  of  Suicide 
(Category  3),  is  designed  to  facilitate  the  early  identification  of  higher  risk  suicidal 
patients following an intentional toxic overdose, or persons who intend to end their life 
by  violent  means.  It  is  anticipated  that  the  introduction  of  the  new  code  will  ensure 
these  patients  can  undergo  earlier  clinical  review  within  both  the  111  and  999  call-
handling centres.  

I can confirm the new Dx0124 code is currently being introduced as a component of 
the  ‘NHS  Pathways  Release  18’  which  is  due  to  be  beta  tested  in  August  2019. 
Widescale deployment of Release 18 to all providers of NHS111 and all ambulance 
services in England that use the NHS Pathways system will then occur on 7th October 
2019 following  the  period  of testing,  with  services  then  having  an 8  week  period  to 
update their staff and systems.  

Unfortunately it is acknowledged that suicide attempts are complex to assess within 
telephone triage systems.  Different methods, lethality and social circumstances make 
it  challenging  for  non-clinical  call  handlers  and  to  try  and  ask  them  to  capture  this 
information  is  likely  to  introduce  further  risks.  Due  to  the  difficulties  involved  the 
introduction of a new Dx code, to raise visibility to clinicians, was considered the safest 
and best option for this specific group of patients.  

to  a  Category  2  ambulance  response,  without 

I  can  confirm  that  the  re-categorisation  of  all  such  cases  from  Dx012  (Category  3 
first 
ambulance)  responses 
differentiating the clinical risks of method, toxicity and social circumstance, was also 
considered. However given the large volume of low risk patients that would be included 
in  such  a  change  this  would  also  introduce  new  clinical  risks  across  the  wider 
emergency  care  system  and  delay  the  ambulance  response  to  other  patients  with 
greater need. Therefore again the introduction of a new code was felt to be the safest 
and best option. 

                                            NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 Thank you for bringing this important patient safety issue to my attention and I hope 
the above has explained the steps that have been taken to deal with and tackle the 
recognised issue. If however you require any further information please do not hesitate 
to contact me by return. 

Yours sincerely, 

Professor Stephen Powis 
National Medical Director   
NHS England and NHS Improvement  

                                            NHS England and NHS Improvement