Alf Rewin

1 Trevelyan Square 

Boar Lane  Leeds LS1 6AE 

0113 397 3614 

December 2nd 2019 

Mr Crispin Butler 
Senior Coroner for Buckinghamshire 
Coroner’s Office 
29 Windsor End 
Beaconsfield 
Buckinghamshire 
HP9 2JJ 

Our Reference LT02365 

Via email to: coroners@buckscc.gov.uk 

Dear Mr. Butler  

Inquest into the death of Alf Rewin 

I am writing in response to the Regulation 28 report received from HM Senior Coroner dated 7th October 
2019.  This follows the death of Alf Rewin who sadly passed away on 22nd November 2018. This was 
followed by an investigation and inquest which concluded on 25th September 2019.  Firstly, we would like 
to express our sincerest condolences to the family of Mr. Rewin. 

Unfortunately, NHS Digital was not informed that this inquest was occurring, and it is disappointing that we 
did not have the opportunity to provide information and address your concerns directly at the inquest.   

Pathways  is  the  clinical  decision  support  software  used  by  all  111  service  providers,  and  some  999 
ambulance service providers including South Central Ambulance service. I am Darren Worwood RGN, 
RSCN, BSc, SPQ and am writing in my capacity as Deputy Clinical Director, NHS Pathways, NHS Digital. 

We have included the updated Coroner’s Information Pack (containing background information on NHS 
Pathways). 

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

1.  The  National  Ambulance  Call  Categories  prescribed  by  NHS  Pathways  to  ambulance 
services, including South Central Ambulance Service, who were the attending service in 
relation to Alf Rewin’s death, indicate that an individual contacting emergency services 
himself  or  herself,  having  taken  an  overdose  may  be  triaged  through  the  national  call 
handling pathway to a Category 3 Urgent call. This category currently prescribes a target 
attendance within 120 minutes. 

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

 
 
 
 
 2.  There  is  a  concern  that  in  cases  of  overdose,  the  patient  is  at  risk  of  becoming 
unconscious or having a cardiac arrest or other potentially fatal event and will be unable 
to contact emergency services or be contacted by them subsequently, such that his or 
her call should at that stage then be regraded as Category 1 (with a 7 minute response 
time) or a Category 2 (with an 18 minute response time). 

3.  In Alf Rewin’s case, there existed a local policy to override the Category 3 120-minute 
response in overdose cases to provide a specific triage which could lead to a Category 2 
18-minute response (although the 18-minute response was not, in fact, implemented at 
the  outset  in  Alf  Rewin’s  case  and  he  was  initially  allocated  the  national  Category  3 
response). 

4.  It is understood that the national categorisation of overdose cases is under review. Whilst 
the  Category  3  120-minute  target  may  be  the  standard,  subject  to  local  variation,  in 
relation to overdose cases where the patient is conscious, the risk of deaths arising during 
this  period  remains  where  the  circumstances  of  the  overdose  might  enable  some 
counteractive treatment to be given, or successful resuscitation measures to be carried 
out, if there were to be earlier attendance and /or earlier hospitalisation. 

BACKGROUND INFORMATION 

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  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. 

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 NGCC. 

Alongside 
this  independent  oversight,  NHS  Pathways  ensures  its  clinical  content  and 
assessment protocols are concordant with the latest advice from respected bodies  that  provide 
evidence  and guidance  for medical practice in the UK.  In  particular,  we are  concordant with 
the latest guidelines  from: 

• 

NICE  (National  Institute  for Health  and Clinical  Excellence) 

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

 
 
 • 
• 

The UK Resuscitation Council 
The UK Sepsis Trust 

NHS Pathways currently available version is Release 18.  Widescale deployment of Release 
18  to  all  providers  of  NHS111  and  all  ambulance  services  in  England  that  use  the  NHS 
Pathways system began on 7th October 2019, with services then having an 8 week period to 
update their staff and deploy in their systems.   

To specifically address the concerns raised: 

NHS DIGITAL’S RESPONSE 

1)  The National Ambulance Call Categories prescribed by NHS Pathways to ambulance 
services, including South Central Ambulance Service, who were the attending service 
in  relation  to  Alf  Rewin’s  death,  indicate  that  an  individual  contacting  emergency 
services  himself  or  herself,  having  taken  an  overdose  may  be  triaged  through  the 
national  call  handling pathway  to  a  Category  3  Urgent call. This  category  currently 
prescribes a target attendance within 120 minutes. 

We have broken down our response to the concerns raised and details of measures in place and 
actions taken and ongoing in this area as detailed below: 

A)  Triage of symptoms  

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.  

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 by 
asking about breathing, conscious level, fitting and choking, and heavy bleeding. Specific questions 
about  the  many  individual  conditions  that  could  lead  to  such  symptoms,  including  substance 
ingestion and suicidal intent, are not included in the very early questions as NHS Pathways focuses 
on triggering a suitable disposition) (e.g. Category 1 emergency ambulance dispatch) based on the 
severity of the symptoms themselves.  

Once  immediately  life-threatening  symptoms  have  been  ruled  out  NHS  Pathways  continues  to 
assess symptoms in a hierarchical manner and reach appropriate dispositions.   

B)  Disposition codes and ambulance categorisation 

National ambulance call categories are not prescribed by NHS Pathways to ambulance services. 

NHS  Pathways  dispositions  are  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 being dispatched this is then ‘mapped’ to the clinically appropriate ambulance response 
standard.  These  are  set  by  NHS  England  (not  NHS  Digital  /  NHS  Pathways)  and  this  process 
results in the specific disposition code indicating the category of ambulance.  

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

 
 
 Ambulance  response  standards  and  ambulance  quality  indicators  are  the  nationally  agreed 
timeframes  for  ambulances  to  arrive  at  the  patient’s  location  following  a  call  passed  to  the 
ambulance service.  The response time standards vary according to the urgency of the call.  These 
are set by NHS England and further information can be found at:  
https://www.england.nhs.uk/urgent-emergency-care/arp. 

All of NHS Pathways ambulance response disposition codes are ratified by the National Ambulance 
Services  Medical  Directors  (NASMED).    NASMeD  is  an  advisory  group  consisting  of  medical 
director  representatives  from  all  ambulance  services  in  England,  Wales,  Scotland  and  Northern 
Ireland who endorse the categorisation of ambulance codes.   

Ambulance codes are further ratified by the Emergency Call Prioritisation Advisory Group (ECPAG).  
The purpose of the ECPAG is to advise NHS England, NHS Improvement and Department of Health 
& Social Care (DHSC) on issues of ambulance call prioritisation.  Its principal remit is to recommend 
which disposition codes should be mapped to which ambulance responses.  The group consists of 
membership from Association of Ambulance Chief Executives (AACE), College of Paramedics, NHS 
England, DHSC, NHS Pathways, AMPDS, National Ambulance Commissioning Network (NACN), 
NASMeD and ambulance Heads of Control. 

Category 3 ambulances do not have an average response target, but a 90th percentile response 
target of 120 minutes, meaning these types of calls will be responded to at least 9 out of 10 times 
before 120 minutes. However, there is a 60-minute response indicator which is collected nationally 
by the ambulance quality indicators.  

C)  Categorisation of, and safeguards relating to, overdose cases 

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.  

Due to this complexity, the lowest disposition that can be reached by a patient where self-harm or 
suicidal intent is present (even if asymptomatic) is a Category 3 (Dx012) emergency ambulance 
response  (with  more  severe  symptoms  generating  a  higher  disposition).    As  of  Release  18  this 
disposition would specifically be Dx0124(following the changes detailed below in paragraph 2C).  

Mr Rewin was assessed in this manner and a suicide attempt was recorded which resulted in the 
disposition of a Category 3 emergency ambulance response.  If more severe symptoms had been 
recorded this would have generated a higher disposition. 

Where no  self  harm  or suicidal intent  is present  a patient  who  has  taken an  overdose would  be 
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).    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,  assess  using  Toxbase  and  allocate  the 

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

 
 
 
 appropriate response based on that assessment.  

The  Ambulance  Response  Programme  in  December  2018  discussed  categorisation  of  suicidal 
cases as detailed in paragraph 4A) below. 

2) There  is  a  concern  that  in  cases  of  overdose  the  patient  is  at  risk  of  becoming 
unconscious  or  having  a  cardiac  arrest  or  other  potentially  fatal  event  and  will  be 
unable  to  contact  emergency  services  or  be  contacted  by  them  subsequently,  such 
that his or her call should at that stage be regarded as a Category 1 or Category 2.  

We have broken down our response to the concerns raised and details of measures in place and 
actions taken and ongoing in this area as detailed below: 

A)  Assessment of drugs 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. 

Within  NHS  Pathways  when  an  emergency  ambulance  disposition/outcome  is  reached  for 
suicide attempt a question is asked, “what was the method of the suicide attempt”. The answers; 
overdose of medication, swallowing something harmful, breathing in poisonous fumes, and other 
all have a free-text ‘specify’ box for documenting further details.  

Within  the  accidental  poisoning/inhalation  pathway  a  positive  answer  to  “Do  you  know  what, 
when and how much was taken?” also has a free text ‘specify’ box to document further details.  

This  information  is  transferred  into  the  call  report  and  call  summary.  These  reports  are  then 
visible  to  clinicians  working  within  the  999  or  111  services  when  reviewing  cases  to  assess 
whether they are required to be upgraded based on the medication taken. 

B)  Potential for worsening and advice given 

NHS  Pathways  operates  on  the  basis  of  directing  a  patient  to  the  most  appropriate  service  for  their 
symptoms and situation at the time of a call. It does not diagnose any condition, suggest any prognosis 
or direct to a service based on what might happen next. Therefore the risks associated with any given 
symptoms  or  situation  (including  attempted  suicide)  are  taken  account  of  in  the  disposition  but 
speculation about possible worsening is not, as the assessment of any such associated risks must be 
undertaken as part of a review by a clinician who can use their knowledge and discretion.    

However,  for  all  calls  that  go  through  NHS  Pathways,  care  advice  and  closing  instructions  are 
provided at the end of each call by the call handlers. All calls end with worsening advice, in cases 
where an ambulance has already been dispatched this advises callers to call back to 999 if there 
are any new symptoms, or if the condition gets worse, changes or the caller has any other concerns.  

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

 
 
 If  a  caller  calls  back  with  worsening  symptoms,  they  would  be  re-triaged,  and  an  appropriate 
response sent.  

Care advice instructs the patient how to look after themselves, either whilst waiting for an ambulance 
to arrive or another health care professional to contact them. 

Release  16  (2018)  introduced  a  new  piece  of  care  advice  created  to  assist  the  call  handler 
supporting a caller following a suicide attempt. Following the ambulance dispatch the care advice 
is  to  keep  the  patient  talking  and  follow  local  policy  to  encourage  additional  support  until  the 
ambulance arrival. 

Current Care advice screen shot: 

C)  Closing  instructions  have  been  amended  for  deployment  in  Release  19  following 
consultation with the 999 ambulance review group in July 2019, to encourage 1st party 
callers, whilst waiting for the ambulance, to contact someone at the end of the call. This 
is displayed as “If you do need to contact somebody do so now, then try to keep the line 
free as we may need to call you back”.   

Release 18 changes: 

Release  18  includes  the  addition  of  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.    This  new  disposition 
code  will  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 began on 7th October 2019, with services then having an 8 
week period to update their staff and deploy in their systems. 

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

 
 
 
 D)  Further planned changes 

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.  

3)  In  Alf  Rewin’s  case,  there  existed  a  local  policy  to  override  the  Category  3  120-
minute response in overdose cases to provide a specific triage which could lead to 
a Category 2 18-minute response (although the 18-minute response was not, in fact, 
implemented  at  the  outset  in  Alf  Rewin’s  case  and  he  was  initially  allocated  the 
national Category 3 response). 

We cannot comment on the operation of local policy.  

4)  It is understood that the national categorisation of overdose cases is under review. 
While  the  Category  3  120  minute  target  may  be  the  standard,  subject  to  local 
variation, in relation to overdose cases where the patient is conscious, the risk of 
deaths arising during this period remains where the circumstances of the overdose 
might enable some counteractive treatment to be given, or successful resuscitation 
measures  to  be  carried out,  if there  were  to  be  earlier attendance  and /or  earlier 
hospitalisation.  

We have broken down our response to the concerns raised and details of measures in place and 
actions taken and ongoing in this area as detailed below.  Relevant to this concern are points relating 
to assessment of drugs taken, potential for worsening and advice given and the new dispositions 
as covered above in paragraph 2.   

A)  Ambulance Response Programme discussions 

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 

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

 
 
 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. 

B) National communications from NHS England 

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. 

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. 

I, or an appropriate member of my team, are happy to answer any further enquiries  from HM 
Coroner. 

Yours sincerely 

Darren Worwood 
Deputy Clinical Director 
NHS Pathways 

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

 
 
 
 
 
 Appendix A 

21st January 2019  

 Dear Ambulance Service CEO / Medical Director    

 RE: Management of 999 patients who have self-harmed (including overdose) and/or who are at risk 
of suicide   

The ambulance service plays a pivotal role in managing patients in acute mental health crisis, especially those 
individuals who have self-harmed and/or those who are at risk of suicide. The initial call to the ambulance service is 
often complex and difficult to manage. Many ambulance services have various models in place for managing these 
patients. It is clear from Coroners’ Preventing Future Deaths (PFD) reports and internal feedback from ambulance 
trusts that patient outcome and experience is dependent on the quality of the ambulance response. It is imperative 
that these patients are managed safely through the Emergency Operations Centre (EOC) and provided with 
appropriate clinical input and support at an early stage.   

 At the meeting of the Ambulance Response Programme (ARP) Implementation Group on 18th December 2018, it 
was noted that many ambulance trusts are managing these patients differently. It was agreed 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.   

 I am therefore writing to request that ambulance trusts review their internal assurance processes 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. 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.  

There are several examples of good practice already in use, and we can signpost these. Similarly, if the central 
ambulance team can assist with this review in any way please do not hesitate to get in touch.  

Yours faithfully,  

Professor Jonathan Benger,  

National Clinical Director for Urgent and Emergency Care.   

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