Patricia Douglas

1 Trevelyan Square 
Boar Lane  Leeds 
LS1 6AE 

10th February 2021   

Dr Nicholas Shaw,  
HM Assistant Coroner for County of Cumbria  

 By email to:

Our reference:  

Dear Dr Shaw,  

Inquest touching on the death of Patricia Ann Douglas 

I am writing in response to the Regulation 28 report received from HM Senior Coroner, dated 16 December 
2020.  This follows the death of Patricia Ann Douglas who sadly died aged 76 on 28th September 2020.  We 
would like to express our sincerest condolences to the family of Patricia Ann Douglas.  

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.  We understand 
that a full hearing has not yet taken place and it is hoped this will take place early this year. We would be 
grateful if NHS Digital could be named as an interested person in this inquest going forwards.   

NHS Pathways is the Clinical Decision Support Software (CDSS) used by all NHS 111 service providers, 
and some 999 ambulance service providers including North West Ambulance Service in their 111 service. 
For information, I have included a short summary of the functions that NHS Pathways performs and the 
governance that underpins it (containing background information on NHS Pathways) in Appendix A. 

I also enclose the HM Coroner’s Information Pack (containing background information on NHS Pathways), 
please see Appendix B 

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

1.  The initial assessment by the NHS 111 call handler led her down a pathway leading to a referral to 
the Covid service and does not seem to have given weight to the history of anaemia and transfusion. 
Could the pathway be improved to give better guidance to health advisors? 

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

                              
 
 
 
 
 
 
 
 
 
 
    
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 NHS DIGITAL’S RESPONSE 

To specifically address the concerns raised:  

The call was taken on NHS Pathways release 21.1.1.  

NHS Pathways assesses symptoms presented at the time of the call, and identifies the appropriate next 
level of care. It therefore does not seek to be diagnostic.  NHS Pathways triage is built around a clinical 
hierarchy,  meaning  that  life-threatening  symptoms  are  assessed  at  the  start  of  the  call,  triggering 
ambulance responses as necessary and progressing through to less urgent symptoms that require a less 
urgent clinical endpoint (or disposition).  

At  the  time  of  the  call,  due  to  the  increased  pressures  on  NHS  111  services  nationally  arising  from  the 
COVID-19 pandemic, those patients with symptoms of breathlessness that did not require an ambulance 
response or referral to an Emergency Department / Urgent Treatment Centre were referred to the COVID 
Clinical  Assessment  Service.  A  clinician  would  then  assess  the  patient,  in  this  case  within  a  one-hour 
timeframe,  considering  potential  causes  of  breathlessness  (COVID-19  or  otherwise)  and  other  relevant 
factors such as medical history in order to make an appropriate management plan.  

Prior  to  the  pandemic,  these  symptoms  would  have  been  assessed  using  the  ‘Breathing  Problems, 
Breathlessness or Wheeze Pathway’ and the same set of symptoms would have also reached a disposition 
of  clinical  assessment  within  one  hour.  Hence,  whether  the  COVID-19  Clinical  Assessment  Service  or 
‘Breathing Problems, Breathlessness or Wheeze Pathway’ was used, the outcome for this patient would 
have been the same disposition of further clinical assessment within one hour.  

Where  information such as past  medical  history  is  declared  by  the  patient, the  health  advisor  is  able to 
document  this  within  NHS  Pathways.  However,  it  would  not  be  deemed  clinically  appropriate  for  non-
clinically trained health advisors to use discretion or make judgements in respect of  any medical history 
described. Instead, where additional medical information is declared the health advisor may exit the system 
at  an  earlier  stage  in  order  to  refer  the  patient  for  additional  clinical  assessment  within  an  appropriate 
timeframe.  Any  medical  information  recorded  is  shared  with  the  receiving  clinician  to  inform  their 
subsequent assessment and decision-making.  

Please do not hesitate to contact us if we can assist further.  

Yours sincerely, 

MMD, FRCS, DA, DCH, DipIMC, FRCEM 
Chief Medical Officer, NHS Digital 

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

 
 
 
   
 
 
 
 Appendix A 

Function of NHS Pathways  

NHS Pathways is a telephone and digital triage Clinical Decision Support System (CDSS) that has been in 
use since 2005 within the Urgent and Emergency care setting.  It is used in all NHS 111 and half of English 
ambulance  services.  This  triage  system  supports  the  remote  assessment  of  over  18.5  million  calls  per 
annum.  

NHS Digital is the Health and Social Care Information Centre (a non-department public body) as detailed 
in Part 9, Chapter 2 of the Health and Social Care Act 2012.  The NHS Pathways system is owned by the 
Department for Health and Social Care, commissioned by NHS England and developed and managed by 
NHS Digital; the NHS Pathways team is part of NHS Digital.  

The NHS Pathways triage is built around a clinical hierarchy, meaning that life-threatening symptoms are 
assessed  at  the  start  of  the  call  triggering  ambulance  responses,  progressing  through  to  less  urgent 
symptoms which require a less urgent clinical endpoint (or disposition). NHS Pathways is not diagnostic 
and only assesses symptoms presented at the time of the call and signpost to next level of care. 

The triage is based on an interlinked series of algorithms, or pathways, that link questions and care advice 
leading to dispositions. A disposition will specify the skill set and time frame that a patient requires. Triage 
for both injury and illness presentations are available for all age groups (neonate, infant, toddler, child, and 
adult). In addition, special populations are included where relevant to the triage e.g., pregnancy. 

Calls using NHS Pathways are managed by non-clinical specially trained ‘Health Advisors’ who refer the 
patient  into  suitable  services  based  on  the  disposition  at  the  time  of  the  call.  The  Health  Advisors  are 
supported by clinicians who can provide advice and guidance or who can take over the call if the situation 
requires it. 

The  NHS  Pathways  system  was  developed  and  maintained  by  a  group  of  experienced  NHS  clinicians 
(clinical authors) with an Urgent and Emergency Care background. The NHS Pathways clinical authoring 
team  come from  a  variety  of  clinical  backgrounds  and  are  either  a  paramedic,  nurse  or  doctor  who  are 
registered, licensed practitioners.  

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, an independent intercollegiate 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.  

These 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 concordant with the latest advice from respected bodies that provide evidence 
and guidance for medical practice in the UK.  

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

 
 
 
 
 
 
 Safe and appropriate use of NHS Pathways by NHS care providers is governed by way of a ‘Licence to 
Use’. One of the conditions of the licence is the provision of appropriate round the clock clinical support 
within control rooms and contact centres for 999 and 111. 

Appendix B 

HM Coroner’s Pack 

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