Levi Alleyne

4 January 2023

BY EMAIL:

Katy Thorne KC
Assistant Coroner
Berkshire Coroner’s Office

Association of Ambulance Chief Executives
25 Farringdon Street
London
EC4A 4AB

E:

T:  020 7118 0977

W: www.aace.org.uk

Dear Katy Thorne KC

PREVENTING FUTURE DEATHS:  LEVI LOUIS ALLEYNE

The Association of Ambulance Chief Executives (AACE) has recently received the above PFD,
following the investigation and inquest in relation to the death of Levi Louis Alleyne who died on
16 November 2020.

Please note, AACE is a membership organisation, subscribed to by all UK NHS ambulance
services, and as such can offer guidance, encourage collaboration across services, and represent
sector views, but cannot mandate action.

I can confirm that actions taken by South Central Ambulance Service NHS Trust, to update their
Standard Operating Procedures (SOPs) following the inquest, have been shared across all NHS
ambulance services, including a map and the appropriate contact details for each of the electricity
Distribution Network Operators.  In addition, to reinforce the required steps, the matter is being
discussed with all Heads of Emergency Operations Centres at their meeting in January 2023.

We hope very much that this will improve the response to these types of incidents and prevent
any delay in patients receiving necessary treatment on scene.

I hope this provides sufficient information for you in response to the PFD report.

On behalf of AACE, I would like to extend our sincere condolences to the family of Levi Alleyne.

Yours sincerely

Managing Director

cc

, HM Inspector of Health & Safety

Chairman:

Managing Director:

8 December 2022 

Ms Katy Thorne KC 
Coroner's Office  
Reading Borough Council 
Reading Town Hall 
Blagrave Street 
Reading  
RG1 1QH 

Dear Ms Thorne, 

This letter is the response from Energy Networks Association (‘ENA’) to your Regulation 28: 
Report to prevent future deaths, dated 4th November 2022. 

We would like to begin by sharing that we are deeply saddened by the tragic death of  
Levi Louis Alleyne and want to express our deepest sympathies and extend our condolences 
to his family and friends. 

ENA was not represented (and did not participate) in the inquest which you held in this case, 
but we are happy to try to address the concerns you have identified. 

ENA  represents  the  companies  which  operate  the  electricity  wires,  gas  pipes  and  energy 
system  in  the  UK  and  Ireland.  We  help  our  members  meet  the  challenge  of  delivering 
electricity and gas to communities across the UK and Ireland safely, sustainably, and reliably. 
Our members’ duties are enshrined in many legislative provisions and in regulatory licence 
conditions issued by Ofgem, the industry regulator. 

Our members include every major electricity and gas distribution network operator in England 
and  Wales  including  some  independent  network  operators  and  National  Grid  Electricity 
Transmission. For the purpose of this response, we are focussing on the electricity Distribution 
Network Operators (DNO) and Transmission Network Operators (TNO) in England and Wales.  

ENA has considered your concerns as expressed within your report and we wish to share with 
you the actions ENA and its members are implementing with an aim to prevent similar future 
events from occurring. 

As  a  result  of  the  immediate  actions  undertaken  by  SSEN  and  South-Central  Ambulance 
Service (SCAS) as documented within your report, on 8th November 2022 ENA met with all 
DNO and TNO member companies.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 Ms Katy Thorne KC   

8 December 2022 

-2- 

ENA  has  asked  each  DNO  and  TNO  to  check  and  confirm  that  suitable  and  effective 
arrangements are in place to regularly communicate on an annual basis, their overall network 
boundaries at a regional level or equivalent with their local emergency services.  
This will help maintain awareness of the appropriate DNO and TNO to be contacted in the 
event of an emergency involving overhead powerlines (OHPLs).   

I can confirm that this review will be completed as soon as reasonably practicable and, in any 
event, no later than 31st January 2023. I will write to you again to confirm when this has been 
done. 

ENA continues to promote awareness of the dangers associated with electricity networks with 
third parties and members  of the  public through its  Public  Safety  Committee  (‘PSC’)  which 
includes the Health and Safety Executive (‘HSE’). This includes promoting: 

-  best practice guidance such as ENA’s ‘Look Out, Look Up’ campaign material.  
-  HSE’s Guidance Note GS6 Avoiding danger from overhead power lines and the need 
for third parties to undertake a risk assessment when working in the vicinity of OHPLs.  
the industry’s 105 number (for reporting or gaining information relating to power cuts 
and to report safety concerns with electricity network assets) as another route for third 
parties to report safety incidents and receive advice. 

- 

o 

It is relevant to note that 105 is a simple number to remember which enables 
anybody, based on phone number matching with location of telecommunication 
masts, to automatically be put through to the local network operator (DNO) who 
can give relevant help and support. However, it does not and should not replace 
999  as  the  primary  route  for  reporting  emergencies  in  which  there  is  an 
immediate risk to life. 

ENA has great respect for the work of the HSE and our relationship is a constructive one borne 
from shared goals. We will open dialogue with the HSE to see whether we can support them 
to  further  enhance  contractor/site  manager  awareness  through  the  HSE’s  guidance 
publications to industry and increase industry awareness of the emergency 105 number. 

Referencing the concerns set out in your report, ENA will also review and update accordingly 
its  safety  leaflet  entitled  -  Safety  advice  for  the  Emergency  Services.    Again,  this  will  be 
completed by 31st January 2023 at the latest and I will write to let you know when it has been 
done.  

Finally, we will also undertake an assessment of any changes or improvements that can be 
made  to  how  we  communicate  with  the  public  to  promote  the  awareness  of  the  dangers 
associated with electricity assets in the public domain.  

We hope that you find this response provides a level of reassurance that ENA and its members 
have considered your concerns and we intend to take proactive steps to address the concerns 
you have identified in your Regulation 28 Report. 

Yours sincerely 

Chief Executive

Katy Thorne KC 
Assistant Coroner  
Berkshire Area  

By email: 

Date 12 January 2023  

Health and Safety 

   Executive 

Engagement and Policy Division 
Operational Strategy Branch 

Transportation and Public 
Services Unit  

19 Ridgeway 
Quinton Business Park 
Quinton 
Birmingham 
B32 1AL 

www.hse.gov.uk 

Deputy Director 

Dear Katy Thorne KC, 

Re: Prevention of future deaths report - Levi Louis Alleyne 

Thank you for your Regulation 28 report to prevent future deaths issued following the inquest into the 
death of Levi Louis Alleyne.  

In this report, you highlighted that the potential for future deaths was two-fold: 

1.  Unnecessary delay to life-saving treatment being given due to the fear that overhead power 

lines (OHPL) are still live, and 

2.  Potentially by-standers or emergency services putting their lives at risk by approaching patients 

near electrical hazards where OHPLs remain live.  

In relation to the first concern, in England the Care Quality Commission (CQC) is the lead inspection 
and enforcement body for safety and quality of treatment and care matters involving patients and 
service users in receipt of a health or adult social care service from a provider registered with CQC. The 
Memorandum of Understanding between CQC and HSE explains the respective roles and 
responsibilities of each organisation with regard to health and safety incidents.   

This means that delays to life-saving treatment for patients provided by the ambulance service in 
England would fall within the remit of CQC and not HSE. We have therefore shared this report with 
CQC to consider.  

In Wales, the Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of 
healthcare. HIW’s core role is to review and inspect NHS and independent healthcare organisations in 
Wales to check that patients, the public, and others are receiving safe and effective care which meets 
recognised standards. The Memorandum of Understanding between HIW and HSE sets out our roles 
and responsibilities in further detail. As this would fall within HIW’s remit, we have shared this report 
with them.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In relation to the second concern, the Association of Ambulance Chief Executives (AACE) have advised 
that actions taken by South Central Ambulance Service NHS Trust following the inquest, including to 
update their Standard Operating Procedures (SOPs), have been shared across all NHS ambulance 
services. This includes a map and the appropriate contact details for each of the Distribution Network 
Operators (DNOs). This matter is due to be discussed further with all Heads of Emergency Operations 
Centres at their meeting in January 2023.  

HSE has also shared these concerns with the Association of Police Health and Safety Advisors 
(APHSA), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and 
Safety Committee to ensure all emergency services are aware and check they have suitable 
procedures in place to deal with incidents involving equipment on the electricity network. 

We have contacted the Energy Networks Association (ENA), who have advised that DNOs and 
Transmission Network Operators (TNO) have suitable and effective arrangements in place with their 
local emergency services providers. This includes ensuring that emergency services have suitable 
emergency contact details for their DNO and that they know how to respond to an incident involving 
equipment on the electricity network. In future, the ENA has requested that DNOs and TNOs check 
their arrangements with the emergency services on an annual basis.   

The ENA are currently reviewing their information leaflet on Safety Advice for the Emergency Services. 
HSE has commented on the draft document and the review is due to be completed by the end of 
January 2023.    

I hope this clarifies the situation but please let me know if you need anything further. 

Yours sincerely 

Head of Transportation and Public Services Unit 

2

Katy Thorne KC 
Assistant Coroner, Berkshire 

By Email: 
Our reference: 

 and 

7&8 Wellington 
Place 
Leeds 
West Yorkshire 
LS1 4AP 

0300 303 5678 

14th December 2022 

Dear Ms Thorne 

NHS  Digital  Response  to  Prevention  of  Future  Deaths  Report  -  Inquest  touching  the 
death of Levi Louis Alleyne 

I am writing  in response to the Prevention of Future Deaths Report received from HM Coroner, 
dated 4th November 2022. This follows the death  of Levi Louis Alleyne who sadly passed away 
on 16 November 2020. This  was followed  by an  investigation  and inquest which concluded 
on 3rd October 2022.  NHS Digital were not aware that this inquest was occurring, and therefore 
we did not have the opportunity to provide information to assist your inquiry. 

Firstly, I would like to offer my sincerest condolences to the family of Levi Alleyne. 

I am 
Digital. 

 and am writing in my capacity as Clinical Director, NHS Pathways, NHS 

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. 

HM Coroner  has raised a number of matters of concern in the Regulation 28 Report.  None of 
these directly reference NHS Pathways, but we believe concerns 4 and 5 are the most applicable.  
We have set out below relevant information about NHS Pathways, and NHS Digital’s role. 

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

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 1)  Standard operating procedures and DNO contact numbers 

NHS Pathways remit does not extend to preparing or overseeing local or national standard operating 
procedures or providing national oversight of 111 or 999 operations.  Standard operating procedures 
relating  to  a  range  of  operational  requirements  are  locally  set  by  111  and  999  providers.    NHS 
Pathways is a clinical decision support system and more operationally focused content such as how 
to contact a utility provider sits outside the remit of the NHS Pathways system.     

2)  NHS Pathways assessment of electrocution, including where there are scene safety 

concerns  

NHS  Pathways  is  a  clinical  triage  system  which  provides  the  means  to  assess  a  patient's 
clinical presentation at the time of the call and signposts to the care skill set and time frame 
that a patient requires at that point in time.  There are 2 main routes within the NHS Pathways 
system where electrocution from a non-domestic hazard (such as overhead power lines) can 
be identified: 

1)  following identification of cardiac arrest, which leads straight to a Category 1 ambulance 
disposition  being  reached,  the  system  seeks  to  establish  if  the  scene  is  safe.    If  a 
negative (‘no’) response is given the ‘unsafe’ route asks whether an electrical hazard is 
present.   

2)  via  the  major  trauma  route  in  Module  0,  if  it  has  been  identified  that  the  patient  is 
conscious  (as  occurred  initially  with  the  deceased  in  this  case).    The  route  asks 
questions about the nature of the trauma and if the option for ‘electrical injury’ is selected 
the  NHS  Pathways  system  asks  whether  the  shock  was  caused  by  a  non-domestic 
supply.  If so this generates a Category 2 ambulance.   

Following either of the above routes being followed the NHS Pathways system makes a further 
assessment of scene safety.  If ‘the scene is unsafe’ is selected, this prompts identification of 
an electrical hazard. There is further questioning about whether the electrical hazard has been 
made safe. In the case of a non-domestic electrical hazard that hasn’t been made safe, further 
advice presents where the caller is advised; 

•  Not to put themselves at risk 

•  Not to go closer than 20 yards as high voltage electricity can jump 

•  Keep away from liquid spills, wet floors and puddles due to the conduction of electricity 

in water. 

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

 
 
 
 
 
 
 
 
 
 
 
 
 There are also system prompts for the Health Advisor to consider whether the situation also 
requires the attendance of other emergency services for any type of electrical hazard that has 
the potential to make the scene ‘unsafe’. Although such tragic incidents are rare, NHS Pathways 
are fully supportive of identifying any further learning from this case and are currently reviewing the 
scene  safety  elements  within  the  triage  system.  The  initial  discovery  has  commenced,  and  any 
identified changes would be subject to review and sign off from the National Clinical Assurance Group 
and, if relevant, from the Emergency Call Prioritisation Advisory Group (ECPAG).  The purpose of the 
ECPAG is to advise NHS England 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 Digital, 
AMPDS, National Ambulance Commissioning Network (NACN), NASMeD and ambulance Heads of 
Control. 

Conclusion 

•  NHS Pathways assesses symptoms presented at the time of the call and signposts to 
the  care  skill  set  and  time  frame  that  a  patient  requires  at  that  point  in  time.      NHS 
Pathways identifies electrical hazards and advises callers on scene safety. 

•  NHS Pathways remit does not extend to preparing or overseeing local or national standard 

operating procedures or providing national oversight of 111 or 999 operations.   

•  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  Assurance  Group  and  Coroner 
referrals are submitted to the National Clinical Assurance Group as a standing agenda 
item. 

NHS  Digital  takes  its  role  in  such  enquiries  and  any  Prevention  of  Future  Deaths  Reports 
received very seriously.  I would like to take this opportunity again to offer my sincere condolence 
to Levi Alleyne’s family. If I can be of any further assistance, please contact me. 

Yours sincerely 

Clinical Director 
NHS Digital 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 Function of NHS  Pathways 

Appendix A 

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  20 
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.    

Calls using NHS Pathways are managed by non-clinical specially trained ‘Health Advisors’ who refer 
the patient into suitable services based on the patient’s health needs 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 system 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 response (or disposition) in other settings. NHS Pathways is not a diagnostic 
system and only assesses symptoms presented at the time of the call and signposts to next level of 
care.  

NHS Pathways is an interlinked series of algorithms, or pathways, that link questions and care advice 
leading to clinical endpoints known as “dispositions”. The system presents a series of questions in order 
that the most appropriate clinical response or disposition may be determined based on the answers 
given. A disposition will specify the skill set and time frame that a patient requires. The system triages 
both injury and illness presentations for all age groups (neonate, infant, toddler, child, and adult). In 
addition, special populations are included where relevant to the triage e.g., pregnancy. 

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. 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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  Assurance  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. The 
group considers all aspects of the triage process, including the impact on services, as well as 
the evidence base for changes to the clinical content. All changes to, and development of, the 
core  telephone  system  and  other  platforms,  are  formally  documented  and  presented  for  a 
critique by a group of authors. This includes both purely clinical elements, but also an appraisal 
of the operational impacts on NHS Pathways users and on providers’ services. 

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 clinical practice in the UK. This includes latest guidelines from: 

a. NICE (National Institute for Health and Clinical Excellence); 

b. The UK Resuscitation Council; and 

c. The UK Sepsis Trust. 

Safe and appropriate use of NHS Pathways by NHS care providers is governed by way of a 
‘Licence to Use’. 

NHS Pathways welcomes user feedback to help improve the system. The License to Use details 
how serious incidents, near misses, requests for change, suggestions for enhancements and 
inquests or Prevention of Future Deaths Reports relevant to NHS Pathways should be reported 
to NHS Digital via the NHS Pathways authoring tool (in redacted form). Such clinical enquiries 
are given a priority grade and reviewed and responded to accordingly. All providers have access 
to the log and can see all enquiries raised. 

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