Lee Armstrong

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

28 January 2025 

Our ref: 

HM Coroner Robert Cohen 
Fairfield 
Station Road 
Cockermouth 
Cumbria CA13 9PT 

By email: 

Dear Mr Cohen, 

Thank you for the Regulation 28 report of 29 October 2024 sent to the Secretary of State for 
Health and Social Care about the death of Mr Armstrong. I am replying as the Minister with 
responsibility  for  urgent  and  emergency  care.  I  am  thankful  for  the  extension  you  have 
granted.     

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of  Mr 
Armstrong’s death, and I offer my sincere condolences to  his family and loved ones. The 
circumstances your report describes are concerning and I am grateful to you for bringing 
these matters to my attention. I understand that your report and matters of concerns have 
also been sent to NHS England (NHSE), who are responding to each of your concerns. 

The  NHS  Pathways  Clinical  Decision  Support  System  triage  product  is  used  to  support 
urgent and emergency care in England and is embedded in NHS 111 and 999 call systems 
of ambulance providers. Your report raises concerns that NHS Pathways does not ask call 
handlers  to  ascertain  if  patients  have  preexisting  conditions.  You  also  highlight  concerns 
that patient information  gathered from NHS 111 online and patient medical records more 
generally, are not available to 999 call handlers.  

Ambulance  services  are  required  to  use  an  approved  triage  system  to  aid  initial  999  call 
prioritisation  –  the  two  approved  systems  are  the  Advanced  Medical  Dispatch  Priority 
System (AMPDS) and the NHS Pathways system. These systems are approved on the basis 
of being able to determine (as far as possible) differing levels of acuity, from immediately 
life-threatening emergencies to patients with an urgent care need. 

NHSE has advised the Department that it has in place a process to appropriately map the 
outcomes of 999 call triage systems against ambulance response time categories. NHSE 
has responsibility for the production, maintenance, review and revision of the dataset used 
in  these  systems,  which  is  managed  by  the  NHSE-chaired  Emergency  Call  Prioritisation 
Advisory Group (ECPAG). ECPAG keeps the categorisation of calls under continual review, 
and ambulance services support this process through providing evidence and expertise to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 reduce  unwarranted  variation  across  services,  helping  ensure  appropriate  prioritisation, 
equity of access and uniformity of response across England. In the case of Mr Armstrong, I 
understand that his pre-existing condition of Addison’s disease would have changed his call 
categorisation, and that NHS England, as the appropriate body, will be responding to your 
concerns raised on this matter as well as on the issue of appropriate patient record sharing 
and access to information gained from NHS 111.  However, I would note that interpreting 
full medical records is outside of the scope and expectations of call handlers. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Mr Robert Cohen  
HM Assistant Coroner for Cumbria 
Fairfield  
Station Road 
Cockermouth 
Cumbria  
CA13 9PT 

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

27 December 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Lee Armstrong who died on 
2 February 2024  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  29 
October 2024 concerning the death of Lee Armstrong on 2 February 2024. In advance 
of responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Lee’s family and loved ones. NHS England are keen to assure the 
family and the Coroner that the concerns raised about Lee’s care have been listened to 
and reflected upon.   

Your first concern focused on the NHS Pathways system not asking callers to identify 
potentially  relevant  pre-existing  health  conditions  and  the  potential  risks  posed  by 
expecting patients to volunteer information about their conditions themselves.  

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product 
that is used to support Urgent & Emergency Care (UEC) in England. The product 
is owned by the Secretary of State for Health and Social Care and manufactured 
and managed by the Transformation Directorate of NHS England. It is embedded 
within host systems in NHS 111 and 999 ambulance providers where it interacts 
with  other  technology  products  to  support  the  assessment,  sorting  and  onward 
management of calls received by those services. It supports online triage on NHS 
111 online, accessible to the public via the NHS website (www.111.nhs.uk) and the 
NHS App. 

NHS Pathways was the triage product supporting calls at  North West Ambulance 
Service (NWAS), where Lee’s case was managed. Calls to services using the NHS 
Pathways triage product are managed by specially trained clinical and non-clinical

 
 
 
 
  
 
 
 
 
  
 health  advisors.  Their  training  is  specific  to  the  Pathways  product,  and  this 
enables  them  to  use  the  information  provided  by  callers  to  both  request 
ambulance resources, or to pass cases to other suitable services, based on the 
patient’s health needs at the time of the call. 

The NHS Pathways triage product – both online and via telephony – does not 
provide a diagnosis. It is built to progress through a clinical hierarchy of urgency, 
enabling  symptoms  and  discriminatory  clinical  features  to  be  matched  to 
appropriate services or endpoints. This means that life-threatening symptoms or 
problems  are  assessed  first,  and  less  urgent  symptoms  or  problems  are 
assessed  sequentially  thereafter.  The  endpoint  of  an  assessment  is  reached 
when a clinically significant factor cannot be ruled out and so a “disposition” is 
reached, ranging from Emergency Ambulance to Self-Care.  

Clinical Governance of the NHS Pathways Product 
The  safety of the  clinical triage  process  endpoints  resulting from  NHS  111  or  999 
assessments  using  NHS  Pathways  is  overseen  by  the  National  Clinical 
Assurance Group (NCAG), an independent intercollegiate group hosted by the 
Academy  of  Medical  Royal  Colleges  (AoMRC).  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 organisations including NICE (National Institute for Health and 
Care  Excellence),  the  Resuscitation  Council  UK  and  the  UK  Sepsis  Trust, 
amongst others. 

Outcomes of triage 
The system enables matching of relevant symptoms or  clinical  features to an 
appropriate service. In telephone services, demographic details are known from 
the start of the call. This  information is more limited in online services, unless 
the patient is logged in on the NHS App. This means that triage outcomes can 
appear differently, depending on the necessity to gather demographic details to 
match the patient to their NHS number via the Personal Demographic Service 
(PDS). 

Past medical history and triage using NHS Pathways 
The  NHS  Pathways  system  is  symptom-based.  This  means  that  the  presenting 
clinical picture  drives  the  assessment.  Where  pre-existing  conditions may  alter 
the outcome of symptom assessment, these conditions are enquired a b o u t  after 
the initial assessment.  Such  enquiry  is  limited  to these circumstances because 
detailed  or  unnecessary  enquiry  into  past  medical  history  may  delay 
assessment – not only of the caller in question, but globally across the system 
by  affecting  average  call  lengths  –  without  impacting  upon  the  disposition 
reached. 

Implication of Reduced Conscious Level/Confusion 
As described above, it is not necessary for patients to recall complex medical 
information  or  medications,  unless  it  is  specifically  enquired  after.  Symptoms 
such as confusion that could indicate a reduced conscious level are assessed 
based on the clinical hierarchy. NHS England has not had access to the specific 

                                                                                                                       
 
 
 
 
 
 
 
 
 details  of  triage  in  this  case,  however,  confusion  that  indicates  a  reduced 
conscious level will – in combination with other features – result in an emergency 
response  such  as  an  emergency  ambulance  or  referral  to  the  emergency 
department. Other acute presentations of more mild confusion will lead to very 
urgent outcomes such as urgent review for further clinical assessment within 1 
or 2 hours. 

Your second concern raised that information supplied to 111 online is not shared with 
North West Ambulance Service (NWAS).  

111 online can reach a number of different disposition types: 

• 

• 

• 

• 

“Go  to”  –  The  person  is  advised  to  go  to  a  specific  local  care 
setting/service. There is no formal referral and the receiving service has 
no  information  about  the  person  including  their  activity  on  NHS  111 
online e.g. a person is told to go to A&E. 
“Refer  and  Go  to”  –  A  referral  is  sent  to  a  service  including  the 
demographic  details  and  triage  answers  as  entered  by  the  user.  The 
referral is  not  required for the service to see the person. The person is 
told the next action is for them to go to that setting e.g. when a  person 
books  an  arrival  time  at  an  Urgent  Treatment  Centre  (UTC)  and  is 
advised to make their way there. 
“Callback” –  A  referral  is  sent  to  a  service  providing  clinical  callbacks, 
including the demographic details and triage answers as entered by the 
person. 
“Phone” – The person reaches the end of their triage and is told to phone 
another service e.g. call 111, call 999, call a local service phone number 
(mental health crisis team). 

It is correct that where, as in Lee’s case, the disposition is to ring 999 there is no 
transfer  of  information  from  111  online  to  the  999  service,  and  following  the 
advice and dialing 999 is reliant on the user following the instructions.  NHS 111 
online is a self-service, digital remote triage service for the public and is designed 
for anonymous use. It is unassisted, meaning there is no health advisor or 111 
clinician input to probe and validate the call 999 outcomes. This means there is 
no automated ambulance dispatch facility.  The advice to ‘call 999’ occurs where 
the triage indicates potential high acuity presenting symptoms, and leads to the 
user/patient being assessed further over the phone and advised if an ambulance 
is required. 

This process is deliberately designed to enable further emergency assessment, 
to  ensure  there  is  a  999  health  advisor  assessment,  and  to  ensure  that 
ambulance  dispatch  is  only  recommended  where  clinically  appropriate.  The 
system  design  takes  into  account  usability  to  ensure  the  user  does  ‘call  999’ 
without any requirement to provide further information online, and to avoid any 
delays.  

Therefore, other than when used via the NHS App, no demographic details are 
collected, and so it would not be possible to send information to a 999 service 
by reference to a particular patient. 

 
 
 
 
 
 
 This  is  however  communicated  to users.  For people  with  an  existing  medical 
condition, who follow the route “help with an existing medical condition”, the NHS 
111  online  system  explicitly  states,  “we  cannot  take  any  existing  long-term 
conditions you have into account”. Further, “if you are advised to speak to a nurse 
or visit a service you should tell them about your long-term condition”. 

For those who start a triage from “help for my symptoms or injury”, the “Start 
now” page again prompts those with complex problems caused  by  an  existing 
medical  condition  to  contact  telephony  services.  This  is designed because the 
Complex Call process that is available in telephony services, as described 
below, cannot be provided online given it is self-service. 

Your third concern raised that NWAS call handlers are not provided with access to a 
patient’s medical records or a summary of their medical history.  

Although comprehensive system training is provided, it is not within the scope or 
remit of the Health Advisor to understand or interpret the full range of medical 
elements as would be encountered in summary medical records, or from access 
to information on current medications. It is  not safe  or effective  to expect this 
staff  group  to  make  sense  of  such  information  and  it  could  add  confusion  or 
delays  and  cause  harm  if  incorrect  conclusions  were  drawn.  It  is  for  these 
reasons that questions on past medical history or pharmacology are only asked 
where it is deemed that a clear understanding can be sought and where it might 
make a difference to the outcome. 

Provision is made in the NHS Pathways system for those cases where complex 
medical history or terminology is volunteered, however. 

Complex Calls and Clinical oversight 
The  NHS  Pathways  Licence  Agreement  with  provider  services  mandates  that 
Health  Advisors  are  supported  by  round  the  clock  ready  access  to  clinical 
support. This means that clinicians may provide in-call support or take over an 
assessment.  Where  patients,  or  their  representatives,  volunteer  complex  or 
complicated clinical information is one such scenario where it is expected that 
Health Advisors request clinical input. This is described  as  the  “Complex  Call” 
process. 

The Complex Call process provides Heath Advisors with a clear process to ask 
for help or transfer the call to a clinician. This process is engaged when the call 
relates to medication, medical procedures or medical language that complicates 
the triage process, or when Health Advisors recognise that they are at the limit of 
their knowledge or understanding. It is supported through the recently introduced 
motto, “If in doubt, shout”. 

The recognition and management of complex calls is comprehensively taught in 
the initial training period. It is tested at the end of this period, prior to live call-taking, 
and is repeatedly reinforced through Continuous Quality Improvement (CQI) and 
mandatory call audits. 

 
 
 
 
 
 
 
 
 
 Hot Topics 
NHS  Pathways  produces  learning  materials  called  ‘Hot  Topics'  which  can  be 
reviewed at any time. There is a Hot Topic that touches on Addison’s disease. This 
Hot Topic gives an overview  of  how  this  condition presents  in extremis,  though 
health advisors are not expected to act independently of the system based on this. 

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Lee, 
are shared across the NHS at both a national and regional level and helps us to 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