Hannah Royle

Dr Karen Henderson 
HM Assistant Coroner for West Sussex 
Centenary House 
Durrington Lane 
Worthing 
BN13 2PQ 

7 and 8 Wellington Place 
Leeds 
West Yorkshire 
LS1 4AP 

7th December 2021 

Dear Dr Henderson 

NHS  Digital  Response  to  Regulation  28  Report  –  inquest  touching  the  death  of  Hannah 
Royle 

I am writing in response to the Regulation 28 Prevention of Future Deaths (“PFD”) report received 
from HM Assistant Coroner dated 4th October 2021. This follows the death of Hannah Royle who 
sadly  passed  away  on  1st  July  2020.  This  was  followed  by  an  investigation  and  inquest  which 
concluded on 29th July 2021. I am Dr 
 and am writing in my capacity as Chief Clinical 
Officer, NHS Pathways, NHS Digital.  

NHS Pathways is the clinical decision support software (CDSS) used by all 111 service providers, 
and some 999 ambulance trusts in England.  For information, we 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 would like to reiterate my sincerest condolences to 

. 

I  have  had  the  opportunity  to  discuss  the  Regulation  28  report  with  representatives  from  NHS 
England,  South  East  Coast  Ambulance  Service  (SECAmb)  and  Health  Education  England  to 
ensure that all aspects are responded to by the relevant party.  

In response to the matters of concern outlined in the report: 

1. Both calls to the 111 service were significantly non-compliant; the call handlers did not

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 correctly  complete  the  algorithm,  they  did  not  take  into  consideration  Hannah’s 
disabilities and inability to verbalise, they failed to recognise Hannah as a complex case 
requiring transfer to a more senior member of the 111 service despite Hannah’s parents 
providing sufficient information for that to be the case 

SECAmb have agreed to respond to this matter.  

2.  The 111 service does not have a sufficiently robust system to manage members of the 
public  with  underlying  disabilities  in  that  no  accommodation  is  given  for  it  in  the 
completion of the algorithm 

As set out in my witness statement to HM Assistant Coroner dated 22 July 2021, NHS Pathways is 
a comprehensive decision support system,  which assesses symptoms presented at the time of a 
call  and  signposts  to  next  level  of  care.    Therefore  medical  history  (including  disabilities)  is  not 
routinely enquired about as it could delay assessment of life-threatening symptoms, and it would 
not be clinically safe for non-clinical Health Advisors to assess the impact of a patient’s medical 
history. It would also not be safe or appropriate to apply blanket rules based on the presence of 
learning  disabilities.  However,  where  a  certain  medical  history  is  relevant  to  a  specific  clinical 
problem, then NHS Pathways will present relevant questions to be asked. For example, within the 
chest pain pathway, the caller is asked if they have ever been diagnosed with a heart condition.  

There  are  functions  within  NHS  Pathways  that  have  been  designed  to  support  those  who  have 
learning  or  developmental  needs,  and  to  support  Health  Advisors  to  respond  to  declarations  of 
medical history, principally through the complex calls and early exit functionality as detailed below. 

A key element of healthcare delivery is recognising when one is at the limit of one’s knowledge or 
understanding  and  escalating  the  matter  appropriately.  An  important  safety  feature  within  NHS 
Pathways is the identification of a ‘complex call’. A complex call is defined as ‘any call which isn’t 
straightforward and where the Health Advisor determines that they are working at or beyond the 
limits  of  their  knowledge’.  In  addition  to  this  broad  definition  of  a  ‘complex  call’,  the  following 
situations would also be classed as ‘complex’:  

a. Difficulty in obtaining adequate information;  
b. The caller being unable to prioritise a main symptom;  
c. Declared past medical history; and  
d. A call that relates to medication or a medical procedure 

Health  Advisors  are  taught,  as  part  of  their  core  training  by  providers,  about  the  definition  of 
complex calls, the rationale for why these should be managed by a clinician, and how to transfer 
these using the system. They also spend time practising this through role play scenarios using the 
system. NHS Pathways has developed training materials and led sessions to support providers to 
manage complex calls.  

The NHS Pathways system provides a route for Health Advisors to take in the event of a complex 
call, and if they are unable to get sufficient information to complete a safe and thorough triage. 
This is called ‘Early Exit’. Early Exit results in a transfer to a clinician. The importance of utilising 
Early Exit is covered during NHS Pathways Core Training and embodied within the competencies 
that staff are audited against. 

Probing is also a vital skill throughout calls, which Health Advisors are trained on. It is often needed 

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 at the outset to establish the reason for the call, or the presence of any life-threatening problems. 
It is needed during the symptom assessment and it may be needed once a disposition has been 
conveyed,  if  there  seems  to  be  resistance  to  the  outcome.  It  is  also  essential  to  realise  when 
probing  is  not  needed.  This  includes  situations  where  ample  information  has  been  provided  or 
situations where it is clear that even an endless amount of probing would not get a clear answer 
to  a  question.  In  these  situations,  Health  Advisors  must  consider  the  safest  alternative  which, 
depending on the situation, may be to transfer to a clinician via the Early Exit function. 

At  the  time  of  Miss  Royle’s  inquest  The  NHS  Pathways  Training  Team  were  in  the  process  of 
developing  additional  learning  content  for all  users  of  the  system.  This  has  subsequently  been 
released and the content of this new material focuses on:  

a) The difference between a learning disability and a learning difficulty  
b) The causes of learning disabilities  
c)  The  health  inequalities  and  healthcare  access  difficulties  experienced  by  some  people 
with a learning disability  
d) Strategies to aid communication over the phone with a person with a learning disability.  

This  learning  material  was  released  on  7th  September  2021  and  is  included  in  updated  core 
mandatory training for new Health Advisors and Clinicians within NHS111 and 999. Similar material 
has also been developed and released for all existing staff, which will be delivered by providers.  

3.  The skill and expertise of the ‘clinical advisor’ was wholly inadequate for her position 
as  she  had  no  contemporaneous  or  relevant  experience  in  working  in  an  emergency 
department  as  a  nurse.  She  was  also  insufficiently  robust  in  her  assessment  and 
understanding of Hannah’s condition when the call handler contacted her for advice. 

Safe and appropriate use of NHS Pathways by NHS care providers is governed by way of a ‘Licence 
to Use’. The ‘Licence to Use’ is managed by NHS Digital and all providers using NHS Pathways 
must enter into and comply with it. It defines the type of Clinician that can potentially receive training 
to use NHS Pathways in a clinical capacity as follows: 

"Clinician" means either: 

(a)          a registered nurse; or 
(b)          a registered paramedic; or 
(c)          any other personnel with an appropriate recognised clinical qualification as 
authorised and notified to End Users by the Authority from time to time, and which is selected 
by the End User to receive the necessary training to enable them to perform the role detailed 
in schedules 1 and 2; 

The criteria for employment is managed by the provider (in this case SECAmb) to ensure that the 
Clinicians employed have the appropriate qualifications, skills and experience. The provider is also 
responsible  for  the  ongoing  audit  and  performance  management  of  Clinicians,  which  is  also 
mandated through the Licence to Use. To this end the Licence to Use states: 

The End User is responsible for ensuring on an ongoing basis that each Clinician is at all 
times  able  to  demonstrate  the  underpinning  education,  skill,  experience  and  professional 
scope of practice to enable them to: 

•  undertake autonomous holistic physical health and mental health assessments, 

which includes differential diagnosis; 

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 •  direct an appropriate clinical management plan; and 
• 

refer  or  discharge  patients  with  unscheduled  and  emergency  health  and  social 
care needs. 

4.  Members of the public who contact the 111 are ill-informed with a real risk they are being 
misled  over  the  role  and  capability  of  the  111  service.  There  is  little  clarity  or 
understanding by the public that it is based on following and completing an algorithm 
by individuals who have no need for any qualification in health care and who will only 
receive a short training programme after they are employed. Hannah’s parents indicated 
that if they knew this, they would have opted to ring 999 and the outcome would have 
been different. 

NHS England have agreed to respond to this matter.  

5.  The 111 service is not a ‘diagnostic’ service yet the ‘call handlers’ have been renamed 
‘health  advisors’.  This  is  misleading  to  the  public  as  it  implies  Regulation  28  –  After 
Inquest Document Template Updated 30/07/2021 professionalism which is untrue given 
their  underlying  skills  and  unsubstantiated  given  it  is  their  role  to  complete  an 
algorithm.  

NHS England have agreed to respond to this matter.  

6.  The  NHS  pathway  for  ‘Abdominal  Pain’  is  insufficiently  robust  or  sufficiently 
discriminatory to effectively deal with the myriad of potential symptoms associated with 
this complaint. 

NHS Digital has a well-established procedure, the “clinical enquiries log”, for providers to submit 
issues and for these to be reviewed and responded to by NHS Pathways.  The investigation carried 
out by NHS Pathways, following the enquiry by SECAmb, concluded that for such a non-verbal 
patient with learning needs, both of the calls from Hannah’s parents should have been considered 
as “complex calls” (as per Health Advisor training) and transferred to a Clinician for assessment, 
rather than following the pathway for abdominal pain.  

NHS Pathways subsequently undertook a review of the abdominal pain pathway with particular 
reference to abdominal emergencies, including intestinal obstruction as experienced by Hannah. 
The questions within NHS Pathways, which relate to symptoms of potential obstruction include:  

•  Questions  relation  to  features  of  life-threatening  illness,  which  include  questions  about 

respiratory distress or shock.  

•  A question about the presence of abdominal pain in the diarrhoea and vomiting pathways.  
•  Critical  illness  questions  including  functional  impairment  (unable  to  carry  out  usual 

activities), being confused or being breathless.  

•  Questions on severity of pain – either keeping still because of the pain or writhing/ rolling 

around because of pain.  

•  A question about feculent vomiting.  

The review, which concluded in July 2021, was carried out in conjunction with the Royal College 
of Surgeons (Scotland) and Royal College of Emergency Medicine and concluded that the current 

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 questioning within NHS Pathways was robust in triaging symptoms that could relate to obstruction 
of the bowel.  

In  addition,  NHS  Pathways  invited  comment  regarding  this  particular  case  and  the  associated 
presentation  of  symptoms  from  Royal  College  of  Surgeons  (Scotland)  and  Royal  College  of 
Emergency Medicine, who recommended no further changes were required to the abdominal pain 
pathway.  

The  NHS  Pathways  content  is  continually  under  review  to  take  account  of  clinical  issues,  user 
feedback,  the  latest  available  data  and  evidence,  guidelines  from  Royal  Colleges  and  other 
respected  bodies  and  Coroner  feedback.      Any  changes  to  NHS  Pathways  clinical  content  are 
overseen by the National Clinical Governance Group (NCGG) and Coroner referrals are submitted 
to NCGG as a standing agenda item.  

NHS Digital takes its role in such inquiries and any PFD report received very seriously. NHS Digital 
wish to reassure the Coroner that it fully investigates and responds to PFD Reports accordingly. If 
I can be of any further assistance, please let me know. 

Yours sincerely 

Dr 
Chief Clinical Officer, NHS Pathways 
NHS Digital 

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 Appendix A 

Function of NHS  Pathways 

BACKGROUND INFORMATION 

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  1 8   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 problems 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. 

this  independent  oversight,  NHS  Pathways  ensures  its  clinical  content  and 
Alongside 
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) 
The UK Resuscitation Council 
The UK Sepsis Trust 

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Dr Karen Henderson 
HM Assistant Coroner for West Sussex 

29 November 2021 

Dear Madam Coroner 

Hannah Royle deceased 

I write in response to your Regulation 28 Prevention of Future Deaths report dated 4 October 
2021. 

I was very much saddened to read of Hannah’s death and I would like to express my personal 
condolences to 

Senior members of the 111-service management team have met to discuss the concerns you 
raised and how best to address them.  We have also liaised with NHS England and NHS Digital in 
order to ensure that all parts of your report are answered by the most appropriate organisation. 

Addressing your concerns as numbered in your report: 

1 & 2 – failure to recognise a complex case and transfer to a more senior member of staff 

Our 111-service management team agree that this was a complex case and should have been 
transferred to a clinician.  In order to ensure that call handlers fully understand the need to 
identify and refer such cases, the following actions have been taken: 

1. Work has been undertaken on a focused area of learning known as a “Hot Topic” which was
issued to all call handling staff in the 111 service in October 2021.  A copy is attached. NHS
Pathways has been designed to triage a symptom in an otherwise well, non-complex patient
i.e. with no medical history and no medication issues. It will be noted that whilst there is no
defined list of calls that are to be classified as complex, a wide range of circumstances could
lead to the call being considered complex, including any patients with complex medical
history or multiple unrelated symptoms, patients unable to prioritise a main symptom and
patients who are unable to verbalise the answer to triage questions, for example those who
are non-verbal.

 
 
 2.  Key skills is the name given to core training delivered to all members of staff quarterly.  The 
content varies according to job role and is based upon required system updates, clinical 
updates and learning from incidents and events.  The next key skills for Health Advisors and 
Emergency Medical Advisors will include a section on dealing with calls from or about 
patients who have a learning disability. A copy of the relevant part of the key skills course 
content is attached.  

3.  Health Advisors and Emergency Medical Advisors have a period of mentoring following their 
initial training and also if any concerns are recognised during routine or requested audits. In 
order to pass the mentoring process, they have to demonstrate that they have passed all key 
competencies. This is achieved by a mentor witnessing the mentee undertake all of the 
required elements from within the mentoring pack to the required standard. The mentor will 
then sign off on the individual elements once competency is achieved. The handling of 
complex calls has been added to those core competencies and as such new Health Advisors 
and Emergency Medical Advisors will be required to demonstrate this as a competency 
moving forwards. 

In addition to the actions already undertaken, the following is planned: 

4.  A “shared learning” is an anonymised real case example circulated to all relevant staff to 

demonstrate an issue in practice and to reinforce theoretical learning.  Experience has shown 
that real cases can be more powerful and thus are more readily retained than theory of a 
particular process or procedure.  Our Head of Governance for 111 plans to publish a shared 
learning based on Hannah’s family’s contacts with the 111 service before the end of January 
2022. 

It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with 
underlying disabilities. 

3 - The skill and experience of the clinical advisor 

The NHS Pathways licence contains a definition of a Clinician who may give clinical advice as part 
of the NHS Pathways system as follows: 

"Clinician" means either: 
(a)          a registered nurse; or 
(b)          a registered paramedic; or 
(c)          any other personnel with an appropriate recognised clinical qualification as authorised and 
notified to End Users by the Authority from time to time,  
and which is selected by the End User to receive the necessary training to enable them to perform 
the role detailed in schedules 1 and 2; 

As (in most cases) it is SECAmb who employs the clinician, we remain responsible for setting criteria 
for employment by way of a Job Description, for setting standards of skill, experience and 
qualification for recruitment and for ensuring that clinicians are trained in the use of the NHS 
Pathways system. We also have a licence obligation to audit and manage the performance of the 
clinicians we employ.   

 
 
 
 
 
 
 
 
 
 
 
 
 Governing bodies such as the Nursing and Midwifery Council set requirements for their registrants 
to demonstrate, on an annual basis, that their clinical practice is up to date. 

SECAmb require applicants for the Clinical Advisor role to have at least two years’ post qualification 
or relevant experience as part of the recruitment process. SECAmb shortlists candidates in line with 
a robust set of criteria. Once candidates have been shortlisted, they are invited to 
interview/assessment.  

This consists of the following: 

•  Clinical Questions paper. These questions cover a range of conditions, complaints and 

treatments and is a pass/fail element. 

•  Clinical Scenarios. The candidate has to pass two scenario type questions, which again are 

based on a variety of different conditions and symptoms. 

•  Once the candidate passes the first two elements, they have to pass a competency-based 

interview. 

Once a candidate has been successful they must complete all the required training to be signed 
off as a Clinical Advisor. This training consists of the following: 

•  NHSP and Computer Aided Dispatch (CAD) course. This is a pass or fail course and is a 

national requirement. 

•  Each candidate must complete the call handling module to ensure that they are 

competent in using the system. 

•  Each candidate must complete ‘soft’ audits prior to being moved on to the next phase of 

training. 

•  Each candidate must then complete a period of clinical mentoring. 
•  Each candidate must complete five sign off audits before being signed off to work as a 

solo Clinical Supervisor. 

All staff using NHSP are then required to receive 3 to 5 audits a month. The number of required 
audits relate to which audit tier they are on. The tier a staff member is on is dependant on 
experience and also whether they are on any improvement plan. 

SECAmb does not specify a field of experience such as A&E or urgent care because the range of 
medical conditions and situations with which we deal on a daily basis is so wide.  Experience in a 
wide range of disciplines in our clinical workforce in the 111 service is an advantage; a broad 
spectrum of experience in different clinical settings (e.g. cardiac, stroke, paediatrics, mental 
health) helps us to accommodate the extremely diverse needs of our patients. 

In autumn 2020, SECAmb entered into a contract to provide a Clinical Assessment Service 
(“CAS”). The CAS is a national framework whereby 111 providers are required to employ a range 
of various clinical skill sets to cater for various patient needs in a virtual environment. The CAS 
incorporates clinicians from a very wide range of disciplines including GPs, midwives, registered 
Mental Health nurses, Paediatric Nurses and others; the number of clinicians and range of 
disciplines is increasing on a monthly basis. The objective of the CAS in the longer term is to  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 provide a system whereby patients are directed to the most appropriate service to 
accommodate their needs; that service may be provided by the SECAmb CAS virtually or by an 
onward care provider. This system aims to get patients the most appropriate help within the 
most appropriate time frame, with the patient only needing to make one phone call to 111. This 
all makes for a better patient journey as the service aims to meet their health care needs without 
them requiring to have multiple contacts with various services. As our complement of clinicians 
increases in both number and diversity, it is anticipated that the bespoke and specialist nature of 
the 111 service will increase accordingly. 

4 & 5 – role and understanding of the 111 service; naming of Health Advisors 

As these are matters of national policy, SECAmb defers to NHS England. 

 6 – NHS Pathway for Abdominal Pain 

We defer to NHS Digital on this matter. 

I trust that this response provides assurance that SECAmb have promptly addressed the matters 
within our remit and have plans to further enhance our staff’s understanding of and compliance 
with our complex call procedure. 

If I can be of further assistance to you or to 
me. 

, please do not hesitate to contact 

Yours faithfully 

Chief Executive Officer 
South East Coast Ambulance Service NHS Foundation Trust