Simon Boyd

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

03 February 2025 

Our ref: 

HM Coroner Chris Morris 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

By email: 

Dear Mr Morris, 

Thank you for the Regulation 28 report of 6 November 2024 sent to the Secretary of State 
about the death of Simon Boyd. 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 Boyd’s 
death, and I offer my sincere condolences to his family and loved ones. The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention. 

Your report raises concerns about ambulance response times and the script used by call 
handlers. In preparing this response, my officials have made enquiries with NHS England to 
ensure we adequately address your concerns. I understand NHS England are writing to you 
regarding the  specific concerns you have raised on the current wording used in the  NHS 
Pathways script by call handers. 

This Government recognises that in recent years, ambulance response time performance 
has been below the high standards that patients should expect.  That is why this Government 
has committed to supporting the National Health Service to improve performance, including 
ambulance services achieving the safe operational response times standards set out in the 
NHS Constitution. 

On 5 December 2024 the Government published the Plan for Change,  which set out clear 
milestones  in  five  national  missions  that  set  the  mandate  for  the  direction  of  change, 
including building an NHS that is fit for the future.  The Plan for Change is available here: 
https://assets.publishing.service.gov.uk/media/6751af4719e0c816d18d1df3/Plan_for_Cha
nge.pdf    

The Government has been honest about the challenges facing the  NHS and it is serious 
about tackling the issues, however we must be clear that there are no quick fixes.  We are 
determined to turn things around through providing investment and implementing reforms.  

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 That is why the Chancellor announced £25.6 billion of additional healthcare funding over the 
next two years covering 2024-2026. In Spring 2025, to accompany this additional investment 
the Government will publish its 10-Year Health Plan, that will set out the radical reforms for 
the NHS so it can tackle the problems of today and tomorrow.   

The 10 Year Health Plan will focus on ensuring three big reform shifts in the way our health 
services deliver care.  First, from ‘hospital to community’ to bring care closer to where people 
live.  Second,  from  ‘analogue  to  digital’  with  new  technologies  and  digital  approaches  to 
modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with 
ill-health by preventing illnesses before they happen. The reforms will support putting the 
NHS on a sustainable footing for the future. 

In the short-term, by this Spring we will set out the lessons learned from this winter and the 
improvements that we will put in place to improve urgent and emergency care ahead of next 
winter. 

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

Yours sincerely,  

MINISTER OF STATE FOR HEALTH 

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Christopher Morris  
HM Area Coroner  
Manchester South Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

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

24 December 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Simon Robert Boyd who 
died on 1 June 2024  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  6 
November 2024 concerning the death of Simon Robert Boyd on 1 June 2024. In advance 
of responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Simon’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that  the  concerns  raised  about  Simon’s  care  have  been 
listened to and reflected upon.  

Your Report raised concerns that the current wording used in the NHS Pathways script 
could create the impression that an ambulance has been dispatched to a caller when 
this is not the case, and that ambulance responses can be cancelled without first being 
discussed with the person who has dialled 999. I note that your Report has also been 
addressed to the Secretary of State for Health and Social Care, to address the issue of 
national targets for ambulance response times not being adhered to. NHS England has 
not dealt with this particular concern within this response.  

Background information about NHS Pathways Clinical Decision Support System 

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that 
is used to support Call Handlers (Health Advisors) in Urgent and Emergency services. 
The  product  is  owned  by  the  Secretary  of  State  for  Health  and  Social  Care  and  is 
manufactured and managed by the Transformation Directorate of NHS England.  It is 
used in NHS 111 and over half of 999 ambulance services. It is the triage product used 
by North West Ambulance Service (NWAS), who received Simon’s 999 call. 

NHS Pathways supports the remote assessment of over 25 million calls a year. 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. 

Calls  to  services  using  the  NHS  Pathways  triage  product  are  managed  by  specially 
trained non-clinical health advisors and clinicians. Their training is specific to the NHS 
Pathways product, and this enables them to use the information provided by callers to 
pass cases to suitable services, based on the patient’s health needs at the time of the 
call. 

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 The  NHS  Pathways  triage product  is built  to  progress  through  a  clinical  hierarchy of 
urgency.  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.  Dispositions  range  from  an  emergency 
ambulance to self-care. 

Clinical Governance of NHS Pathways 

The safety of the clinical triage process endpoints resulting from an NHS 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  (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:- 

a.  NICE (National Institute for Health and Care Excellence); 
b.  The UK Resuscitation Council; and 
c.  The UK Sepsis Trust. 

Wording of scripts 

In Simon’s case, an emergency ambulance response (Category 3) was generated and 
the wording in relation to that disposition is that an ambulance ‘is being arranged’. The 
wording which Health Advisors (HAs) are expected to convey is shown below: 

Following the disposition, HA’s are trained to give care advice and worsening advice 
presented by the system as shown below. This includes any symptom specific advice, 
and  advice  about  what  to  do  should  the  situation  change.  This  is  an  essential  risk 
management technique, as it is vital that callers know what to do should the situation 
worsen,  change  or  if  they  have  any  other  concerns  or  develop  new  symptoms. 
Worsening advice should be used in its entirety as this has been specifically designed 
to address this range of situations. 

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 The timelines within which an ambulance response should be provided vary according 
to  the  urgency  of  the  call.  Ambulance  response  standards  and  ambulance  quality 
indicators are the nationally agreed timeframes for ambulances to arrive at the patient’s 
location following a call passed to the ambulance service.  Further information  can  be 
found at https://www.england.nhs.uk/urgent-emergency-care/arp 

All NHS Pathways ambulance response disposition codes are ratified by the Clinical 
Coding Reference Group (CCRG), the National Ambulance Services Medical Directors 
(NASMeD) and Emergency Call Prioritisation Advisory Group (ECPAG). NASMeD is 
an  advisory  group  consisting  of  medical  director  representatives  from  all  ambulance 
services  in  England,  Wales,  Scotland  and  Northern  Ireland  who  endorse  the 
categorisation of ambulance codes. 

The purpose of ECPAG is to advise NHS England and the 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  the  Association  of  Ambulance 
Chief  Executives  (AACE),  CCRG,  NHS  England,  NHS  Pathways,  the  National 
Ambulance  Commissioning  Network  (NACN),  NASMeD  and  Ambulance  Heads  of 
Control. 

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 The  information  given  to  callers  about  ambulance  dispatch  is  aligned  with  the 
ambulance response standards, and NHS Pathways is not designed to take account 
of  operational  delays  as  these  can  be  very  variable  and  do  not  represent  the 
recommended clinical disposition. 

In order to support ambulance providers to manage their available resources, NHS 
England  has  issued  a  national  directive,  requiring  providers  to  undertake  clinical 
validation of Category 3 and Category 4 ambulance responses within both NHS 111 
and 999 services.  This involves validation of the disposition by a clinician (arranged 
locally), which can result in a different disposition being subsequently reached. The 
information captured in NHS Pathways may allow a clinician to re-categorise the call 
without  direct  contact  with  the  patient.  The  Ambulance  Trust’s  Computer  Aided 
Dispatch (CAD) system, rather than NHS Pathways, is used to manage the validation 
process.  It is a requirement that the CAD must be able to provide appropriate exit 
scripts  for  Category 3 /  Category  4  codes  or  dispositions.  The  wording of  the exit 
scripts is for local determination. 

In addition, where there is high demand on a service, providers are permitted and do 
implement their own scripts when it comes to the delivery of dispositions to try and 
manage expectations. 

Cancellation of ambulances 

In Simon’s case, the Health Advisor followed the training provided by NHS Pathways 
in delivering the disposition and completing the relevant call. 

Simon  was  subsequently  spoken  to  by  a  clinician  within  the  Greater  Manchester 
Clinical  Assessment  Service,  who  would  have  cancelled  the  ambulance.  This 
validation  and  cancellation  of  an  ambulance  is  not  within  the  remit  of  the  NHS 
Pathways system, and no data is provided back to NHS Pathways or the provider as 
to the changing of a disposition. Should the Coroner wish to investigate this further, 
he  would  be  best  placed  contacting  the  Greater  Manchester  Clinical  Assessment 
Service.  

The  NHS  111  and  999  services  have  Standard  Operating  Procedures  in  place  to 
manage this. These are determined locally and are not mandated nationally. 

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 
Simon, 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.  

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 Yours sincerely,  

National Medical Director   

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