Joel Colk

Ms Joanne Andrews 
Area Coroner 
West Sussex, Brighton and Hove  
The Coroner’s Office 
Woodvale 
Lewes Road 
Brighton  
BN2 3QB  

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 – Joel Phillip Colk who died 
on 2 October 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  13 
November  2024  concerning  the  death  of  Joel  Phillip  Colk  on  2  October  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Joel’s family and loved ones. NHS England are keen 
to assure the family and the Coroner that the concerns raised about Joel’s care have 
been listened to and reflected upon. 

In  your  Report,  you  raised  that  the  NHS  Pathways  system  does  not  differentiate 
between types of, severity of or the drugs / chemicals reported as being the cause of 
an  overdose.  The  system  also  does  not  take  into  account  the  amount  reported  as 
ingested, the timing of ingestion or the patient's weight. In the case of sodium nitrite 
ingestion, treatment is only effective if medications are administered before the patient 
suffers  a  cardiac  arrest.  The  Coroner’s  view  is  that  the  Pathways  system  does  not 
reflect the time sensitive nature for an effective response.   

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 care (UEC) 
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. 

NHS Pathways is an interlinked series of algorithms, or pathways, that link questions 
and  care  advice  to  lead  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 presenting symptoms. A disposition will 
specify  the  skill  set  and  time  frame  that  a  patient  requires  and,  where  required, 
appropriate care/worsening advice is provided. 

NHS  Pathways  is  built  around  a  clinical  hierarchy,  meaning  that  life-threatening 
symptoms  are  assessed  at  the  start  of  the  call  to  trigger  ambulance  responses, 
progressing through to less urgent symptoms which require a less urgent response (or 

                                                                                                                       
 
 
 
 
 
 
  
 
 
  
 disposition) in other settings. NHS Pathways is not diagnostic, but instead works on 
the basis of 'ruling out'.   

Clinical Governance of the NHS Pathways Product 

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  (AoMRC).  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. 

Overview of the Management of Overdoses and Suicidal Callers 

Ambulance  Emergency  Operation  Centres  (EOCs)  use  one  of  two  approved  triage 
tools  to  take  999  emergency  calls  –  AMPDS  or  NHS  Pathways.  The  outcome 
(disposition) reached at the conclusion of the initial assessment must be mapped to 
approved, contracted standards. There is a requirement to map these outcomes to the 
various  categories  (Categories  1  –  5)  set  out  within  the  NHS  Constitution  and 
Ambulance Service 999 contracts. Category 5 (originally Category 4H) relates to calls 
that do not require an ambulance response; there is no standard for Category 5 calls.  

The  grading  of  999  calls  are  clinically  based  decisions  and  any  changes  are 
considered  by  the  NHS  England  Emergency  Call  Prioritisation  Advisory  Group 
(ECPAG),  based  on  receipt  of  a  review  of  the  evidence  base  with  formal 
recommendations from the NHS England Clinical Coding Review Group (CCRG), with 
endorsement of the clinical rationale of proposed changes by the National Ambulance 
Service Medical Directors group (NASMeD). Any recommendations that are made and 
implemented will be formally reviewed with ongoing monitoring from ECPAG.  

Overdoses,  whether  intentional  or  accidental,  can  be  challenging  cases  to  assess 
remotely;  many  different  substances,  medicines,  doses  and  combinations  are 
possible.  This  poses  challenges  to  classify  and appraise  the  relative  lethality  of  the 
substances involved and balance this risk against the symptoms and circumstances 
at the time of the call. Where an overdose has occurred, and in the absence of signs 
or  symptoms  indicating  an  immediate  life-threat  (reduced  consciousness  level, 
breathlessness or shock, for example), the lowest disposition that can be reached is 
a Category 3 ambulance response. A higher response will be reached where there are 
symptoms indicating an immediate threat to life. 

 
 
 
 
 
 
 
 
 Ambulance  EOCs  follow  specific  principles on  their  respective  triage  tool  to  ensure 
clinical  oversight  for  patients  calling  and  presenting  with  overdose  and  suicidal 
ideations.  These  principles  have  been  reviewed  and  strengthened  through  several 
national recommendations since 2019. 

Firstly,  on  2  April  2019,  Professor 
  –  the  then  National  Clinical 
Director for Urgent and Emergency Care at NHS England – wrote to ambulance trusts 
and NHS 111 providers to mandate that robust clinical oversight was in place in control 
rooms and call centres to monitor self-harm and suicidal patients safely and effectively. 

Secondly,  in  2020,  the  then  Healthcare  Safety  Investigation  Branch  (HSIB), 
investigated the potentially under-recognised risk of harm from the use of propranolol. 
They made a safety recommendation for NHS England to evaluate current approaches 
to clinical oversight of overdose calls within ambulance control rooms, and to develop 
a  national  framework  to  describe  requirements  for  appropriate  clinical  oversight  of 
overdose calls. 

In April 2021, NHS England in conjunction with the Association of Ambulance Chief 
Executives (AACE) published a new operational procedure for all ambulance services 
in  England  entitled,  “Category  3/  999  Overdose  and  Suicidal  Ideation  Calls;  Initial 
Assessment  of  Lethality/Toxicity  Principles  Document”).  This  document  followed  a 
detailed review that had been undertaken to consider agreed ambulance control room 
processes,  to  ensure  suicidal  patients  receive  the  correct  clinical  response.  This 
review had also been the catalyst for NHS England contacting all ambulance and NHS 
111  services  in  early 2019 as described above.  The  guidance  highlights  the  critical 
importance  of  clinical  oversight  and  review  (rather  than,  for  example,  a  re-
categorisation of calls to Category 1 on a case-by-case basis) and sets out that: 

• 

•  where an overdose is declared, further clinical intervention should take place 
within 30 minutes, or the case must be automatically upgraded if this does not 
occur within 40 minutes. 
it  is  good  practice  for  TOXBASE®  (clinical  toxicology  database  of  the  UK 
National  Poisons  Information  Service)  to  be  viewed  for  each  overdose  / 
accidental  ingestion  incident,  despite  the  familiarity  of  the  reviewing  clinician 
with that particular toxicity profile, which includes sodium nitrite. It is noted that 
management  practices  often  change  in  relation  to  specific  toxins,  therefore 
guidance  around  the  use  of  TOXBASE®  was  issued  instead.  Utilising 
TOXBASE® similarly ensures that the relevant current guidance is accessed 
when managing emerging and novel substance ingestion enabling the clinician 
to assess risk on an individual case basis. 
the initial clinical review should also consider any ongoing suicidal ideation with 
a specific plan / means. 

• 

Most  recently,  the  overdose  guidance  was  updated  in  November  2023  to  include 
callers who reach a Category 5 disposition (hear and treat). This followed a review by 
ECPAG,  NHS  England  and  NASMeD,  part  of  the  AACE,  to  ensure  it  remained 
clinically  fit  for  purpose.  For  those  cases  which  do  not  automatically  result  in  a 
Category  1  or  2  emergency  ambulance  response,  an  urgent  remote  clinical 
assessment will take place, pending which the case will be dealt with as a Category 3 
emergency ambulance response. The objective of further remote clinical assessment 

 
 
 
 is to determine the likely threat to the patient by gathering the clinical information about 
the  substance(s)  ingested  and  their  quantities.  Following  this  assessment,  if  the 
clinical  view  is  that  the  case  should  be  upgraded  to  a  Category  1  or  2  emergency 
ambulance response, then this is done without delay. 

In early 2019, NHS England also instructed ambulance and NHS 111 providers that 
any suicide-related cases reaching a Category 3 ambulance outcome should receive 
urgent  clinical  review.  This  would  enable  a  clinician  to  consider  the  individual 
circumstances of each case, with a view to determining whether the case should be 
clinically upgraded to a Category 1 or 2 emergency ambulance response. 

In response to this request, and in order to assist organisations in easily identifying the 
cases  that  needed  an  urgent  clinical  review,  NHS  Pathways  introduced  a  new 
disposition  code  ‘Dx0124  Emergency  Ambulance  Response  for  Risk  of  Suicide 
(Category 3)’. This disposition code raises the visibility of such cases, enabling such 
urgent clinical review. This review by clinicians could involve re-triage to higher levels 
of response if required. It has also facilitated clearer visibility of such cases within the 
ambulance dispatch queue. This is in addition to information which was already fed 
into the dispatch system by NHS Pathways by way of ‘symptom discriminator codes’. 
NHS  Pathways  has  a  code  identifying  suicidal  means  and  a  plan  (SD4244-  AMB 
suicidal means and a plan). The disposition code was deployed to all service users as 
part of Release 18 in October 2019.   

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.   

Your second concern relates to the fact that it is not national protocol for ambulance 
services  to  carry  antidote medication  (Methylene  Blue)  for  on-scene  administration. 
  often  enter  cardiac 
You  have  raised  that patients  who  have  ingested 
arrest before arriving at an acute hospital within an Emergency Department.  

The carrying of particular medication by ambulance services is an operational issue 
and is up to individual ambulance trusts; NHS England does not mandate such issues.  
NHS  England  is  aware  of  a  small  number  of  ambulance  specialist  units  who  carry 
Methylene Blue. This antidote is carried by specialist clinical teams for administration 
 poisoning which can be measured through 
in cases of moderate/severe 
an exhaled breath monitor. Clinical feedback suggests it is likely Methylene Blue would 
not be used except for severe cases or where there is a long journey time to definitive 
care. 

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 Joel, 
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

Ms Joanne Andrews 
H.M Area Coroner for West Sussex, Brighton and Hove 

07 January 2025 

Dear Madam 

Joel Phillip Colk deceased 

I write in response to the Regulation 28 Prevention of Future Deaths report issued on 
13 November 2024 to the South East Coast Ambulance Service NHS Foundation 
Trust (SECAmb) following the inquest into the sad death of Mr Colk. 

I was very sorry to learn of the death of Mr Colk and I would like to convey my 
heartfelt condolences to his family and friends. 

I note the other relevant organisations named in this PFD report: 

•  NHS England & NHS Improvement 

With regard your first matter of concern: 

“The Court heard that when a call is made to 999 that the call is categorised using 
NHS Pathways and that all overdoses would be in the same classification resulting in 
the same disposition and response category. The system does not differentiate 
between types of, severity of or the drugs/chemicals reported as being the cause of 
the overdose. The system also does not differentiate call classification taking into 
account the amount reported as ingested, the timing of ingestion or the patient's 
weight. The Court heard that all of these factors can impact on the time in which care 
needs to be rendered to prevent death. The example given to the Court was that 
someone who had taken a relatively small paracetamol that would be unlikely to 
cause harm would, using Pathways, have the same resultant disposition as 
someone who had ingested a significant amount of a known lethal chemical. 

The Court heard that in the case of 
effective if medications are administered before the patient suffers a cardiac arrest. 
This likely will occur incredibly rapidly and is a known effect of the chemical. The 
Pathways system does not reflect the time sensitive nature for an effective response 
when it is known that sodium nitrite has been ingested and would not create a higher 
disposition requiring more urgent attendance than category 3.” 

 ingestion that treatment is only 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 The NHS Pathways Clinical Decision Support System (CDSS) is a triage product 
that is used to support call handlers (known as Emergency Medical Advisors within 
SECAmb). 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. 

NHS Pathways as a product has independent oversight by the National Clinical 
Assurance Group (NCAG), which in turn is hosted by the Academy of Medical Royal 
Colleges (AoMRC). Robust processes exist nationally to provide scrutiny of the NHS 
Pathways clinical content, which is built around a clinical hierarchy, meaning that life-
threatening symptoms are assessed at the start of the call to trigger ambulance 
responses. 

It is widely acknowledged that overdoses, both intentional or accidental, are 
challenging to assess remotely, with a vast array of different substances being 
presented to urgent and emergency care services resulting in a significant variance 
of potential toxidromes. 

This is further challenged in the absence of signs and symptoms which would be 
indicative of an immediate threat to life; symptoms indicating a compromise of 
airway, breathing or circulation do receive Category 1 or Category 2 ambulance 
dispositions within overdose presentations. 

When an absence of immediately life-threatening symptoms such as the above is 
being presented in intentional overdose, the lowest ambulance disposition that can 
be reached is a Category 3 emergency ambulance outcome. However this Category 
3 outcome is supported by additional measures specific to overdose that have been 
in place within SECAmb since July 2019 and further amendments to local 
procedures following the publication of a operational guidance by NHS England and 
the Association of Ambulance Chief Executives (AACE) entitled, “Category 3 – 999 
Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality / Toxicity 
Principles Document” in April 2021, subsequently being further updated in November 
2023. 

SECAmb has procedures and processes in place to fully follow the principles as set 
out, which include: 

•  Where an overdose is declared, further clinical intervention should take place 
within 30 minutes, or the case must be automatically upgraded if this does not 
occur within 40 minutes. 

• 

It is good practice for TOXBASE® (clinical toxicology database of the UK 
National Poisons Information Service) to be viewed for each overdose / 
accidental ingestion incident, despite the familiarity of the reviewing clinician 
with that particular toxicity profile, which includes 
management practices often change in relation to specific toxins, therefore 
guidance around the use of TOXBASE® was issued instead. Utilising 
TOXBASE® similarly ensures that the relevant current guidance is accessed 
when managing emerging and novel substance ingestion enabling the 
clinician to assess risk on an individual case basis. 

. It is noted that 

 
 
 
 
 
 
 
 
 •  The initial clinical review should also consider any ongoing suicidal ideation 

with a specific plan / means. 

999 Overdose and suicidal ideation calls – initial assessment of lethality / toxicity principles document, (NHS 
England, 2023) 

Although SECAmb followed the 999 Overdose and suicidal ideation calls – initial 
assessment of lethality / toxicity principles with the call being automatically upgraded 
to a Category 2 response as a clinical review did not take place within 40 minutes, 
we do recognise that in this case Mr Colk volunteered the information to the 999 call 
handler that he had taken 
response provided by the National Ambulance Resilience Unit (NARU) indicate 1 
case of 
ambulance services, so whilst the incidence of 
increasing, it is still a very rare occurrence (Courts and Tribunals Judiciary - 
Response from NARU, 2024). 

 being ingested for every 0.5 million 999 calls in UK 
 poisoning is 

. Recent reports cited within a PFD 

As a Trust, we would like to use this case alongside others to support a workstream 
in early development that we are undertaking, regarding the potential for the use of 
new and emerging technologies, such as Artificial Intelligence to ‘ambiently listen’ to 
999 calls. The aim is to enhance patient safety and reduce human cognitive burden, 
potentially highlighting certain calls to clinicians that have rare or unique risks earlier.  
We are in the early stages of understanding this technology and undertaking this 
work alongside four other NHS Ambulance Trusts as part of the Southern Ambulance 
Collaborative, and although we envisage if successful this having wider benefits to a 
range of presentations that 999 ambulance calls present, we have included 
 overdose as an example within the proposed case for change. 

With regard your second matter of concern: 

 ingestion as this is not within national guidance. I heard that 

“The Court was also told that clinicians do not carry on any Ambulances within South 
East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the 
antidote to 
in some areas there are ongoing trials for some areas that this is on board vehicles 
within the HART (Hazardous Area Response Team). Therefore in this area the 
treatment is only available when a patient reaches an acute hospital with an A&E 
department and the evidence was that often patients enter cardiac arrest before this 
occurs.” 

Governance and Decision-Making 

SECAmb employs a rigorous and comprehensive governance framework to 
determine which medications are carried by its clinicians. Our Medicines 
Governance Group (MGG)—chaired by the Chief Pharmacist and comprising senior 
clinicians, operational managers, academic representatives, public members, and 
subject matter experts—oversees all medication-related decisions. Any proposal to 
add or amend a medicine within our formulary requires a robust New Drug 
Application (NDA) and consideration of clinical evidence, operational feasibility, 
financial sustainability, and alignment with national best practice. 

 
 
 
 
 
 
 
 
 
  
 Challenges in Pre-Hospital Diagnosis and Treatment 

 poisoning causes methaemoglobinaemia, which can only be reliably 

diagnosed using specialised diagnostic equipment (e.g., Masimo Rainbow SET 
sensors). In a pre-hospital context, the accurate identification of sodium nitrite 
ingestion is complicated by non-specific presentations and the unlikelihood of having 
immediate access to this specialist equipment on every frontline vehicle. 
Consequently, the administration of methylene blue in the pre-hospital setting poses 
significant diagnostic and logistical challenges, especially given the low incidence of 
confirmed sodium nitrite poisonings. 

Availability and Cost Implications 

Methylene blue is supplied in 50 mg vials in the UK, with treatment for 
methaemoglobinaemia potentially requiring several vials per patient, depending on 
body weight. Equipping the entire SECAmb fleet of over 300 clinical vehicles with 
sufficient stock—much of which may expire before use—would place significant 
demands on the service in terms of finance, logistics and workforce training. 
Additional resource investment would also be necessary for specialised diagnostic 
equipment, further complicating routine operations. 

Specialist Resource Considerations 

Although certain regions are trialling the use of Hazardous Area Response Teams 
(HART) to carry methylene blue, these teams are designed for high-risk 
environments. SECAmb’s HART operates from two bases (Ashford and Crawley), 
but their geographic reach and the unpredictable nature of 
do not guarantee they would always be the initial or timely responders to these 
cases. In many instances, rapid transfer to hospital—where comprehensive 
evaluation and definitive treatment (such as intubation, ventilation, inotropic support, 
or exchange transfusion) can be provided—remains the most pragmatic approach. 

 poisonings 

Cardiac Arrest Considerations 

Critically, for those patients who have already sustained a cardiac arrest by the time 
ambulance clinicians arrive, the likelihood of restoring spontaneous circulation using 
methylene blue is indicated to be low. Advanced cardiac life support measures—
including prompt hospital transfer for definitive care—are therefore prioritised, as per 
current clinical best practice. 

Ongoing National Discussions 

SECAmb is aware that discussions are ongoing nationally regarding the role of 
methylene blue for sodium nitrite poisoning. We remain actively engaged with NHS 
ambulance services and will carefully review any future recommendations that 
emerge, particularly if published via JRCALC or other authoritative bodies. 

 
 
  
 
 
 
  
 
  
 
 In conclusion, SECAmb remains committed to delivering the highest standard of pre-
hospital care within the framework of evidence-based clinical practice. We 
continuously review our medication formulary in line with emerging guidance and 
new evidence. At present, and in accordance with current national 
recommendations, equipping all front-line ambulances with methylene blue and 
specialist diagnostic tools is neither clinically feasible nor cost-effective. 
Nevertheless, we will continue to monitor evolving guidance and, where appropriate, 
modify our protocols to maintain patient safety and optimise outcomes. 

I hope this response clearly sets out our commitment to meet the needs of all 
patients requiring an emergency care response from us and from the wider system. 
If I can be of any further assistance, please do not hesitate to contact me.  

Yours sincerely  

Chief Executive Officer  
South East Coast Ambulance Service NHS Foundation Trust 

References 

Courts and Tribunals Judiciary (2024). Response from NARU - Fern Foster: 
Prevention of future deaths report. Available at: https://www.judiciary.uk/prevention-
of-future-death-reports/fern-foster-prevention-of-future-deaths-report/  

Hikin, L.J., et al. (2023). 
post-mortem blood nitrite and 
International, 345. 

 poisoning: A series of 20 fatalities in which 
 concentrations are reported. Forensic Science 

NHS England (2023). 999 Overdose and suicidal ideation calls – initial assessment 
of lethality / toxicity principles document. [Internal NHS circulation]. 

Neth, M. R., et al. (2021). Fatal 
Prehospital Providers. Prehospital Emergency Care, 25(6), 844–850. 
https://www.rcemlearning.co.uk/reference/methaemoglobinaemia/#1570186523779-
7b60584d-ee3f 

 Poisoning: Key Considerations for 

McCann, S. D., Tweet, M. S., & Wahl, M. S. (2021). Rising incidence and high 
mortality in intentional 
 exposures reported to US poison centers. 
Clinical Toxicology, 59(12), 1264–1269. 

Stephenson, L., et al. (2022). Increasing use of 
emerging trend. Forensic Sci Med Pathol, 18, 311–318  

 in suicides—an