John England

Mr Andrew Cox 
HM Senior Coroner  
Cornwall & the Isles of Scilly Coroner’s Service 
Pydar House  
Pydar Street 
Truro  
Cornwall  
TR1 2AY 

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

england.coronersr28@nhs.net  
1 July 2025  

Dear Mr Cox, 

Re: Regulation 28 Report to Prevent Future Deaths – John Stephen England 
who died on 15 March 2023.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9 May 
2025 concerning the death of John Stephen England on 15 March 2023. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  John’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and yourself that the concerns raised about John’s care have been 
listened to and reflected upon.   

Your Report raises concerns around whether the Advanced Medical Priority Dispatch 
System  (AMPDS)  is  sufficiently  nuanced  to  distinguish  between  different  types  of 
abdominal  complaints  and  to  ensure  that  those  who  need  to  be  recognised  as  a 
surgical  emergency  receive  a  disposition  resulting  in  a  patient  being  conveyed  to 
hospital within an appropriate timeframe.  

My  response  to  the  Coroner  has  been  supported  by  NHS  England’s  National 
Ambulance Team.  

NHS ambulance services are required to process 999 calls through an approved triage 
system.  There  are  currently  two  systems  approved  in  England  for  primary  999 
assessments; NHS Pathways and the AMPDS. The systems are used to prioritise 999 
calls  received  into  the  Ambulance  Services’  Emergency  Operations  Centres 
(EOCs). South Western Ambulance Service NHS Foundation Trust (SWASFT) uses 
the AMPDS system under licence from Priority Dispatch Corp (PDC).  

The  primary  purpose  of  triage  is  to  quickly  identify  priority  symptoms  (e.g. 
unconsciousness, difficulty breathing, chest pain) and assign a response priority. The 
outcome  (disposition)  reached  following  the  initial  assessment  must  be  mapped  to 
approved, contracted standards. There is a requirement to map these outcomes to the 
various  categories  (Categories  1  to  5)  set  out  within  the  NHS  Constitution  and 
ambulance service 999 contracts. In the case of abdominal pain, the Abdominal Pain 
Protocol seeks signs, symptoms, and history that may be related to the conditions of 
aortic aneurysm, myocardial infarction, and ectopic pregnancy. Patients with signs or 

                                                                                                                       
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 symptoms of severe blood loss, such as a decreased level of consciousness, fainting 
or near fainting, or an ashen/grey colour, are prioritised. Moreover, patients within a 
common cardiac age range (patients aged 35 years and older) are further assessed 
and coded based on their age and the location of the pain. However, whilst the AMPDS 
system’s Abdominal Pain Protocol is able to identify and prioritise based on priority 
symptoms, triage systems are not designed to make differential diagnoses that would 
require additional visual, historic and diagnostic information that cannot be provided 
via telephone triage. 

In  John’s  case,  the  call  was  determined  as  a  Category  5  response  following  initial 
triage. This response category identifies patients who do not necessarily require an 
immediate emergency ambulance response and may be suitable for management via 
an alternative care pathway. In such cases, where the response required by the patient 
is  not  immediately  clear  from  the  triage  outcome,  ambulance  services  have  other 
clinical approaches that they can initiate, including the use of clinical assessment, as 
a means of trying to elicit further clinical detail over the telephone than was initially the 
case at the point of initial triage. Category 5 therefore is not an inferior response, but 
rather an opportunity to identify any additional information that may allow for a better 
patient outcome than the rapid dispatch of an ambulance resource on scene.  

Patients should receive a timely enhanced clinical assessment to determine the most 
appropriate  outcome.  There  should  be  robust  clinical  oversight  of  patients  awaiting 
enhanced  clinical  assessment  to  ensure  allocation  to  a  clinician  in  a  timeframe 
appropriate to their clinical need. The clinical assessment may still result in the call 
being  upgraded  by  the  clinician  to,  for  example,  an  ambulance  response,  and  a 
resource dispatched accordingly. John’s call was clinically navigated and assessed as 
being  suitable  for  further  assessment,  which was  carried  out  by  a Clinical  Advisory 
Service 2 hours and 17 minutes following the initial call and a Category 2 ambulance 
response was then requested.  

During this clinical assessment, the patient’s current condition should be explored as 
well as considering the past medical history to be able to determine if an ambulance 
response  is  required.  At  the  conclusion  of  the  clinical  assessment,  additional 
information can be provided by the clinician to the caller about what actions to take if 
the  patient’s  condition  appears  to  be  worsening  or  there  are  any  other  concerns. 
Individual ambulance services should have appropriate processes in place to facilitate 
the  timely  clinical  navigation  and  validation  of  all  calls  that  require  further  clinical 
assessment. It is critical that services consider their clinical navigation and validation 
timescales  and  processes  in  full  to  prevent  patients  from  experiencing  delays  in 
receiving clinical assessment to identify the appropriate outcome required to meet their 
clinical needs. 

On  review  of  the  specific  concerns  in  this  case,  there  are  two  aligned  triage 
system/clinical coding and oversight groups that are engaged by NHS England: 

•  Within NHS England, the mapping of triage outcomes to response categories 
is undertaken and reviewed by an expert group which makes recommendations 
to the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) for 
implementation across all NHS ambulance service providers. This provides a 
governance  framework  to  ensure  appropriate  prioritisation,  equity  of  access 

 
 
 
 
 
 and  uniformity  of  response  across  the  English  Ambulance  Services.  The 
production, maintenance, review and revision of the categorisation dataset is 
the responsibility of NHS England. However, engagement with the ambulance 
sector  within  England,  including  SWASFT,  along  with  reviews  triggered  by 
Coroners  and  patient  safety  concerns  more  generally,  have  a  vital  role  in 
providing  information,  robust  clinical  evidence,  and  expert  advice  to  NHS 
England  regarding  the  categorisation  dataset  and  the  prioritisation  of 
emergency calls.   

•  As regards to SWASFT being users of the AMPDS system, the Priority Dispatch 
Corp  (PDC)  is  responsible  for  and  manages  the  commercial  international 
AMPDS system, including making any changes to the protocols and questions 
asked.  This may  be on  the  basis  of  a  recommendation  from  NHS  England’s 
ECPAG, or as part of PDC’s own improvement and triage development work, 
which draws on its international user base.  

To respond directly to the Coroner’s concerns on abdominal pain, NHS England has 
obtained the specific details of this case from SWASFT, which will be discussed within 
the  NHS  England  AMPDS  clinical  coding  sub-group,  in  collaboration  with  PDC,  to 
determine if there are opportunities to improve the assessment and differentiation of 
abdominal  pain  presentations  within  the  AMPDS  triage  system.  NHS  England  has 
additionally  shared  the  Coroner’s  concerns  with  PDC,  who  have  outlined  that  they 
welcome  the  opportunity  to  review  any  dispatch-specific,  non-visual  interrogation 
suggestions to further improve the discovery of surgical emergencies associated with 
the compliant of abdominal pain.  

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 John, 
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)