Glyn Ackerley

Victoria Davies  
Cheshire Coroner Area 
The West Annexe 
Town Hall  
Sankey Street 
Warrington 
Cheshire 
WA1 1UH  

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

6 March 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Glyn Ackerley who died 
on 4 September 2022 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  27 
November  2023  concerning  the  death  of  Glyn  Ackerley  on  4  September  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Glyn’s family and loved ones. NHS England are keen 
to assure the family and the coroner that the concerns raised about Glyn’s care have 
been listened to and reflected upon.  

I apologise for the delay in responding to the coroner and for any anguish this delay 
may have caused Glyn’s family. Due to the initial email containing the Report being 
misdirected, the relevant team at NHS England only became aware of the Report on 
8 February 2024. I realise that Coroner Reports can form part of the important process 
of family and friends coming to terms with what has happened to their loved ones and 
appreciate this will have been an incredibly difficult time for them.  

In your Report you raised the concern that the current NHS Pathways process does 
not differentiate between a high risk and low risk overdose, categorising all such calls 
without  additional  symptoms,  as  Category  3.  You  also  raised  that  it  was  unclear 
whether  NHS  Pathways  would  be  making  changes  to  their  existing  processes 
following the inquest into Glyn’s care.  

NHS Pathways is owned by DHSC. However, the Transformation Directorate within 
NHS England have overall management and responsibility for the clinical governance 
of NHS Pathways, and it has therefore been agreed with the DHSC that NHS England 
will respond to your Report directly.  

Background on NHS Pathways System 

NHS Pathways is an interlinked series of algorithms, or pathways, that link questions 
and care advice to clinical endpoints known as “dispositions”. The system presents a 
series  of  questions  to  arrive  at  the  most  appropriate  disposition,  based  on  the 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 presenting symptoms. The disposition will determine the response skill set and time 
frame that a patient requires.  

NHS Pathways uses a clinical hierarchy, to ensure that life-threatening symptoms are 
assessed at the start of any call, and progressing through to less urgent symptoms 
which require a less urgent response. NHS Pathways is not diagnostic, but instead 
works on the basis of 'ruling out'.  

Overdoses and ambulance categorisation 

Where an overdose has occurred, and in the absence of signs or symptoms indicating 
an  immediate  life-threat  (reduced  conscious  level,  breathlessness,  or  shock,  for 
example),  the  lowest  disposition  that  can  be  reached  is  a  Category  3  ambulance 
response. A quicker response will be actioned where there are symptoms indicating 
an immediate life threat.  

In  2019,  NHS  Pathways  developed  a  new  disposition  code  ‘Dx0124  Emergency 
Ambulance Response for Risk of Suicide (Category 3)’. This code facilitates improved 
visibility of overdose and suicide attempt cases within the ambulance dispatch queue. 

In April 2021, NHS England and Improvement, in collaboration with the Association of 
Ambulance Chief Executives (AACE) published a new operational procedure1 for all 
ambulance services in England which sets out that, where an overdose is declared, a 
further clinical intervention should take place within 30 minutes, and/or the case will 
be automatically upgraded to a Category 2 ambulance response if this does not occur 
within 40 minutes. If, on review the clinical view is that, given the individual factors of 
the  case  this  should  be  upgraded  to  a  Category  1  or  2  emergency  ambulance 
response this is done without delay.  

In  October  2023  a  review  of  this  document  was  completed  by  the  Emergency  Call 
Prioritisation  Advisory  Group  (ECPAG,  NHS  England)  and  the  National  Ambulance 
Service  Medical  Director’s  Group  (NASMeD,  Association  of  Ambulance  Chief 
Executives) to ensure it remains fit for purpose.  

Assessing “high risk” vs “low risk” substances 

The  further  clinical  assessment  referenced  above  involves  gathering  clinical 
information about the substance(s) ingested and their quantities. It is recommended 
that  health  advisors  use  TOXBASE®  to  support  this  assessment.  TOXBASE  is  the 
clinical  toxicology  database  of  the  UK  National  Poisons  Information  Service  that 
clinicians  have  access  to,  to  help  support  clinical  decision  making  when  excess 
medications have been ingested.  

Health  advisors  are  not  clinicians,  and  their  training  therefore  ensures  an 
understanding  of  where  they  should  seek  supervisory,  or  clinical,  support.  This 
includes  instances  where  medical  information,  such  as  medication  names,  are 

1 Entitled ‘Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of 
Lethality/Toxicity Principles Document’ 

 
 
 
 
 
 
 
 
 
 
 volunteered  during  the  assessment  where  they  are  not  expected  to  understand  or 
identify the medication names or drug classifications.  

NHS Pathways also provides a telephone consultation tool called Pathways Clinical 
Consultation Support System (PaCCS). This is for use by experienced clinicians and 
lends  itself  more  to  a  consultation-led  assessment  rather  than  triage.  Within  each 
clinical  template  there  is  additional  supporting  information  and  links  to  approved 
websites that can be viewed if required. 

Should national guidance or standards be amended such that toxic substances, where 
identified,  impact  on  ambulance  categorisation  or  disposition,  NHS  England  would 
align the NHS Pathways system accordingly.  

Further information 

The specific details of this case were not shared with NHS Pathways. However, the 
NHS  Pathways  team  has  discussed  this  case  with  North  West  Ambulance  Service 
(NWAS)  in  response  to  their  concerns  regarding  overdoses  and  suicidal  ideation 
cases.  

On 6th April 2023, NHS Pathways discussed with NWAS:  

•  The background to decisions made. 
•  Understanding competing pressures in ambulance queue management. 
•  The requirement to not inappropriately increase risk in category 2 responses. 
•  Recommendation  that  concerns  and  proposals  for  change  should  be  raised 

with the Clinical Coding Review Group (CCRG) and ECPAG.  

•  That any changes to categorisation defined by these groups would be enacted 
into the NHS Pathways system, reflecting changes in national standards.  

•  Category 3 / 999 overdose and suicidal ideation calls. 
• 

Initial assessment of lethality/toxicity principles document that the Association 
of Ambulance Chief Executives issued in April 2021 was also re-shared. 

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  (NCAG),  an  independent  intercollegiate  group  hosted  by  the  Academy  of 
Medical Royal Colleges. This group is made up of representatives from Medical Royal 
Colleges  and  other  clinical  professional  bodies  and  groups.  Senior  clinicians  from 
these organisations 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  in  accordance  with  agreed 
processes endorsed by NCAG. 

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. 

 
 
 
 
 
 
 
 
 
 I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director