Sandra Millard

Mr Robert Simpson 
HM Assistant Coroner  
Berkshire Coroner’s Office  
Reading Town Hall  
Blagrave Street 
Reading  
RG1 1QH  

Dear Coroner, 

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

30 May 2025 

Re: Regulation 28 Report to Prevent Future Deaths – Sandra Ann Millard who 
died on 20 May 2024  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 April 
2025  concerning  the  death  of  Sandra  Ann  Millard  on  20  May  2024.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Sandra’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the Coroner that the concerns raised about Sandra’s care have 
been listened to and reflected upon.   

Your  Report  raises  concerns  over  how  the  NHS  Pathways  triage  tool  works  when 
patients report they are stuck in situ (e.g. unable to move from a chair), as opposed to 
lying on the floor which prompts further questions. 

NHS Pathways triaging progresses through a clinical hierarchy of different urgencies, 
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” (outcome) is reached. Dispositions 
range from an emergency ambulance being called out to self-care. 

Between  2017  and  2018,  NHS  Pathways  collaborated  with  its  ambulance  service 
stakeholders to enhance the assessment of patients who may not have fallen but are 
nonetheless unable to move from their current position. Since 2018, the system has 
included functionality to assess patients in this situation, regardless of whether their 
immobility is due to disability, frailty, weakness, pain, or another factor. 

If a patient who is unable to move reaches a disposition on the basis of high acuity 
symptoms  (acuity  being  the  measure  of  severity  of  the  patient’s  condition  and  the 
urgency with which they need to be seen), and if this results in an ambulance being 
dispatched without any clinical input, a question about whether someone can stay with 
the patient is included, particularly to support them in case of any delay, or to request 
additional support if symptoms change. 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 If a patient who is unable to move does not reach such a disposition, they will progress 
further  into  the  NHS  Pathways  triage.  Given  the  wide  range  of  potential  causes  of 
immobility and the complexity of individual needs, the system is deliberately designed 
to trigger a disposition of “speak to a clinician immediately”. This ensures that a clinical 
professional  can  assess  the  specific  circumstances  and  determine  the  most 
appropriate response. The possible outcomes following this assessment can include 
dispatching  an  emergency  ambulance,  referring  to  a  community  response  team, 
involving social services, or contacting the police if there are any concerns about the 
individual’s welfare. 

In  scenarios  where  the  call  is  transferred  immediately  to  a  clinician,  the  Pathways 
system  does  not  prompt  the  question  about  whether  someone  can  stay  with  the 
patient, as this consideration should form a part of the clinician’s overall assessment. 
In Sandra’s case, the call was not immediately transferred but was instead ended by 
the call taker, who arranged for a clinician to call her back. The 111 provider would 
have  responsibility  for  the  operational  management  of  this,  however  the  system 
recommended disposition is for immediate clinical assessment.  

It is also expected that local protocols are in place to capture demographic details such 
as next of kin, as this information falls outside the remit of the NHS Pathways triage 
tool. Similarly, where a clinician is unable to make contact with the patient (noting that 
the clinician in this case attempted to call Sandra 4 times before closing the call), it is 
beyond the scope of NHS Pathways to determine the next steps. This decision lies 
with  the  local  service  provider  in  accordance  with  their  operational  policies  and 
procedures.  We  understand  that  South  Central  Ambulance  Service  (SCAS)  are 
changing their standard operating procedure as a result of the concerns raised by your 
Report, and that they will be sharing learnings through national forums. 

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 
Sandra, 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

South Central Ambulance Service NHS Trust 
Unit 7 & 8 Talisman Business Park 
Talisman Road 
Bicester, Oxon 
OX26 6HR 
Tel: 01869 365000 

PRIVATE AND CONFIDENTIAL 

Mr Robert Simpson 
HM Assistant Coroner for Berkshire 
Via email only (

) 

2nd June 2025 

Dear Mr Simpson, 

I  am  writing  to  you  in  response  to  the  concerns  that  you  highlighted  following  the  inquest 
hearing into the sad death of Sandra Ann Millard that concluded on 7th April 2025. Thank you 
for allowing us the time to review and respond to your concerns.   

To confirm, your Regulation 28 report detailed your concerns regarding the difference in the 
questions asked by the NHS Pathways triage system when a patient is unable to get up from 
the floor compared to when they are stuck in situ. You highlighted that when a patient is lying 
on the  floor  with  no reported  injuries,  questions are  asked  regarding  whether the  patient  is 
alone and contact information for their next of kin or another person who may be able to attend 
to be with the patient whilst they wait for an ambulance. When a patient is unable to move 
from another position, such as from a chair, these questions are not asked. 

Your Regulation 28 report was also issued to NHS England due to your awareness that the 
Trust  is  a user  of  the triage system  and is  not  responsible for  writing the algorithms  which 
direct which questions are asked as part of the assessment. NHS England design and manage 
the  NHS  Pathways  system  and  will  be  able to  consider  whether  a  change  to the  algorithm 
itself is appropriate. 

, Senior Quality Auditor at the 
At the inquest hearing you heard evidence from 
Trust. 
 indicated to you that she understood your concerns and she would ensure 
that the issue was reviewed and addressed by the Trust. Thank you for including reference to 
this within your report. 

In response to your concerns, a change in process has now been written by 
form of a directive to staff. The changes will include: 

 in the 

•  Ascertaining whether the patient is alone 
• 

If they are alone, requesting the phone number for a relative, friend or neighbour who 
can be contacted on their behalf 

•  Triaging  a  patient  who  advises they  are  slipping from  a piece  of  furniture  under the 
NHS Pathways falls triage algorithm to ensure the assessment reaches a minimum of 
a Category 3 ambulance response disposition despite the patient not being on the floor 
at the time of assessment 

•  Documentation  of  the  position  the  patient  is  in  to  aid  any  subsequent  clinical 

assessment that is undertaken 

 
 
 
 
 
 
 
 
 
 •  Referring  the  case  to  a  clinician  within  the  call  centre  once  the  triage  has  been 
completed  so  that  a  clinical  assessment  and  where  appropriate  upgrade  can  be 
undertaken 

•  The direction that a case must not be closed without an appropriate response being 

sent to the patient.  

The new directive was approved on 29th May 2025 and will be issued to all staff within the call 
centre along with an educational tool to clarify the importance of the change this month. We 
will write to you again to confirm that the new directive has been fully implemented within the 
call centre.  

In addition to any potential changes that NHS England may make to NHS Pathways, to ensure 
that there is the opportunity for national learning to take place, our patient safety team will also 
share the changes that we have made to our processes with their counterparts. 

I hope that this letter has adequately addressed the  concerns that you have raised. Should 
, Head of Legal 
you wish to discuss these matters further, please contact 
Services at SCAS who will be able to facilitate this. 

Yours sincerely, 

Chief Executive 

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