James Masheter

Ms Kate Bisset 
HM Area Coroner 
Lancashire and Blackburn with Darwen 
Coroner’s Court 
2 Faraday Court 
Faraday Drive 
Preston 
Lancashire 
PR2 9NB 

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

4 June 2025  

Dear Ms Bisset, 

Re: Regulation 28 Report to Prevent Future Deaths – James Paul Michael 
Masheter who died on 1 April 2024.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 April 
2025  concerning  the  death  of  James  Paul  Michael  Masheter  on  1  April  2024.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to James’s family and loved ones. NHS England are 
keen to assure the family and yourself that the concerns raised about James’s care 
have been listened to and reflected upon.   

Your Report raised concerns around the use of NHS Pathways to triage mental health 
situations.  Specifically,  James  was  triaged  as  Category  3  which  led  to  significant 
delays  in  an  ambulance  attending.  You  have  noted  that  it  is  not  clear  whether  it  is 
possible for serious mental health crisis situations, which present a risk to life, to be 
properly risk assessed on the basis of the current NHS Pathways mental health triage.  

My response focuses on those areas of concern that sit within NHS Pathways’ remit 
and  has  been  aided  by  engagement  with  NHS  England’s  national  NHS  Pathways 
Team and North West regional colleagues.  

The Triage Product 

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product that 
is  used  to  support  Urgent  and  Emergency  Care  (UEC)  in  England.  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 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 clinical and non-clinical health advisors. Their training is specific to the NHS 
Pathways product and this enables them to use the information provided by callers to 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 both request ambulance resources, or pass cases to suitable services, based on the 
patient’s health needs at the time of the call.   

The NHS Pathways triage product 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,  meaning  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’ 
(outcome) is reached.  

The  safety  of  clinical  triage  process  endpoints  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 the latest guidelines from organisations including the National Institute 
for  Health  and  Care  Excellence  (NICE),  Resuscitation  Council  UK  and  UK  Sepsis 
Trust, amongst others.   

Ambulance Response 

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. The response time standards vary according to the 
urgency of the call.  

NHS  Pathways’  ambulance  response  disposition  codes  are  ratified  by  the  National 
Ambulance  Services  Medical  Directors  Group  (NASMeD).  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.  Ambulance  codes  are  further  ratified  by  the  Emergency  Call 
Prioritisation Advisory Group (ECPAG). The purpose of the ECPAG is to advise NHS 
England  and  the  Department  of  Health  and  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), College of 
Paramedics,  NHS  England,  DHSC,  Advanced  Medical  Priority  Dispatch  System 
(AMPDS),  National  Ambulance  Commissioning  Network  (NACN),  NASMeD  and 
Ambulance Heads of Control.  

The Category 3 ambulance response standard does not have an average response 
target, but a 90th percentile response target of 120 minutes, meaning these types of 
calls  will  be  responded  to  at  least  9  times  out  of  10  before  120  minutes.  However, 
there is a 60-minute average response indicator which is collected nationally  by the 
ambulance quality indicators.  

Managing Suicide Risk 

 
 
 
 
 
 
 
 
 NHS England has led a number of national discussions regarding the management of 
suicidal  callers.  The  NHS  Pathways  system  has  been  adjusted  to  accommodate 
changes and the introduction of a national process. In this process, ambulance and 
NHS  111  providers  facilitate  an  urgent  clinical  review  for  cases  flagged  as  ‘Risk  of 
Suicide’,  which  is  further  described  below.  These  changes  acknowledge  that  risks 
relating to suicidal intent are complex and may be multifactorial. Although non-clinical 
health  advisers  receive  significant,  structured  training  to  use  the  NHS  Pathways 
system, this system is organised to triage cases for further clinical input or assessment 
in most cases.  

In the NHS Pathways triage system, where the patient or caller reports either a suicide 
attempt  or  active  suicidal  intent,  the  lowest  disposition  that  may  be  reached  is  a 
Category  3  emergency  ambulance  response.  A  higher  category  of  ambulance 
response would be reached where other relevant symptoms/conditions – such as loss 
of consciousness or difficulty breathing – are present at the time of assessment. These 
align  to  the  Ambulance  Response  standards  set  by  the  Ambulance  Response 
Programme (ARP).  

In  early  2019,  NHS  England,  with  endorsement  of  NASMeD  and  other  associated 
groups, instructed ambulance and NHS 111 providers that any such suicide-related 
cases reaching a Category 3 ambulance  outcome should receive an urgent remote 
clinical review facilitated by a clinician working with the 999 ambulance control room. 
This  enables  a  prioritised  clinical  assessment,  considering 
individual 
circumstances  of  each  case.  Such  assessments  should  determine  the  appropriate 
level of response, which could include upgrading the response to a Category 1 or 2 
emergency ambulance response.  

the 

To facilitate this, a new disposition code was developed in the NHS Pathways product 
in April 2019. ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 
3)’ enables clearer visibility of such cases in the Computer Assisted Dispatch (CAD) 
system  used  by  staff  in  ambulance  services,  supporting them  to  readily  identify  the 
cases requiring prioritised review due to suicide attempt. Furthermore, NHS Pathways 
provides a code identifying suicidal intent – the means and a plan to complete suicide 
– (SD4244 – AMB suicidal means and a plan). The new disposition code was created 
within  the  NHS  Pathways  system  in  April  2019,  following  the  presentation  and 
ratification of the changes to the NHS Pathways National Clinical Governance Group 
(NCGG) in February 2019. This new disposition code was deployed to all service users 
as part of Release 19 in October 2019 as planned and following sign-off by ECPAG 
on 3 July 2019.  

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 view from the Ambulance Response Programme Implementation Group at NHS 
England, supported by NASMeD, was that cases involving suicidal ideation are often 
multi-factorial  and  therefore  too  complex  for  Health  Advisors  to  apply  a  definitive 
disposition without assessment by a clinician. Instead, they require an urgent remote 
clinical  risk  assessment  in  the  absence  of  priority  airway,  breathing  or  circulation 
symptoms during triage. This means that 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.  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 should be done without delay.  

In November 2023, the 999 Overdose and Suicidal Ideation Calls; Initial Assessment 
of Lethality/Toxicity Principles Document which was issued in April 2021, was reissued 
following a review by the ECPAG and NASMed.  

In addition to the guidance and reviews in 2019, 2021 and 2023 referenced above, 
there have been ongoing discussions and reviews at various stakeholder groups. 

NHS Pathways has additionally provided significant training information regarding the 
assessment  of  patients  suffering  from  mental  health  conditions  and  has  offered  to 
advise  North  West  Ambulance  Service  (NWAS)  on  how  to  triage  mental  health 
situations.  Regional  clinical  quality  colleagues  for  the  North  West  have  also  been 
made aware of your Report for the appropriate assurance purposes.  

NHS  Pathways  does  not  have  oversight  of  local  ambulance  queues  or  their 
management, and we do note that it can be the case that waiting times may be longer 
than NHS Pathways recommends due to local resourcing and demand pressures.  

Given the significant consideration nationally of the management of callers at risk of 
suicide in recent years, and the fact that this has resulted in system changes, national 
discussions and mandates, NHS England is not considering a further system change 
to NHS Pathways at this time, but (as with all clinical content) this will remain under 
review as and when new evidence or guidance emerges.  

In this particular case, it appears from the Report that the NHS Pathways triage system 
did  elicit  the  correct  information  which  triggered  the  correct  nationally  approved 
ambulance response.  

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 
James, 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,  

Co-National Medical Director  
(Secondary Care)