Jake Hartwright

Private and Confidential 
Dr Elizabeth Didcock 
Assistant Coroner for the coroner 
area of Nottinghamshire 

Trust Headquarters 
1 Horizon Place 
Mellors Way 
Nottingham Business Park 
Nottingham 
NG8 6PY 

Website: www.emas.nhs.uk 

02 February 2026 

Dear Dr Didcock 

Re: Report regarding the case of Mr Jake Kieran Hartwright deceased.  

I am writing in response to the concerns you raised following the inquest into 
the sad death of Mr Jake Kieran Hartwright, which concluded on 12 December 
2025. 

Thank you for your Regulation 28: Prevention of Future Deaths report 
regarding the contacts between Mr Hartwright and East Midlands Ambulance 
Service (EMAS), as well as the pathways involving NHS 111 and Nottingham 
Emergency Medical Services (NEMS). 

I understand that you will be sharing this response with Mr Hartwright’s 
family, and I would like to express my sincere condolences to them for their 
loss. 

The Trust acknowledges the concerns you have identified, and I provide below 
our clarifications, the actions already taken, and our ongoing commitments. All 
issues raised have been reviewed through the Trust’s Incident Review Group, 
which is responsible for considering matters escalated through inquests and 
Prevention of Future Deaths reports, ensuring that learning is identified and 
acted upon to address any systemic or procedural issues. 

Matters of Concern Raised on 12 December 2025 

1.The urgent care pathway across Nottinghamshire does not optimally 
support patients with serious systemic illness (e.g., sepsis) who receive a 
Category 3 ambulance disposition. 

Page 1 of 4 
Respond | Develop | Collaborate 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust recognises that, while the urgent care pathway performs well for 
most patients, those presenting with serious but not immediately 
life‑threatening systemic illness may not be supported as effectively as 
required. To address this, the Trust has worked in partnership with NEMS, DHU 
and other system organisations to develop a technological solution enabling 
the full, accurate transfer of patient information across services. This will 
strengthen clinical decision‑making and ensure that patients with complex or 
deteriorating conditions receive more appropriate and timely care. 

2. Detailed clinical information received in the EMAS Computer Aided Dispatch 
(CAD) system from NHS 111 is not always reliably reviewed or considered 
when ambulance responses are cancelled and cases are referred to NEMS. 

In December 2025, the Trust upgraded its CAD system to ensure that all 
information captured during the initial 999 call is automatically transmitted to 
subsequent receiving systems. This enhancement has been fully tested with the 
Trust and NEMS and now supports the transfer of more comprehensive clinical 
information at the point of referral. 

Further improvements are planned as the Trust transitions to the national 
Booking and Referral Standard (BaRS) within the next 12 months. BaRS will 
enhance interoperability across urgent care services, streamline information 
flow, and reduce the potential for communication gaps between providers. 

3. Families awaiting an ambulance following a 111 clinical assessment are not 
informed by EMAS if an ambulance will not be sent. 

The current CAD system does not provide an automatic mechanism for 
notifying callers in these circumstances. To address this, the Trust has submitted 
a development request to the system supplier (MIS). The planned enhancement 
will ensure that, when a call is transferred through the Interoperability Toolkit 
(ITK), the caller receives a text message confirming the status of their request. 
The proposed message will be as follows: 

“Hello from East Midlands Ambulance Service. We're currently experiencing 
extreme pressures and long delays. Your call has been passed over to a Clinical 
Assessment Service where a clinician will call you back to arrange the most 
appropriate treatment for you. If you decide that an ambulance is no longer 
required, please call back on 999 to cancel. Only call back on 999 if your 
condition worsens or you develop new symptoms. Do not call back for an ETA 
as our call handlers won’t be able to give you this information.” 

Page 2 of 4 
Respond | Develop | Collaborate 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This enhancement aims to provide clarity for patients and families, improve 
transparency, and reduce uncertainty during periods of operational pressure. 

4. Category 3 calls have been reviewed by non‑clinicians in the EMAS 
Emergency Operations Centre (EOC) who may not have the required skills to 
safely transfer calls to NEMS. 

Historically, non‑clinical staff reviewed Category 3 calls in the EOC, creating risk 
where inclusion and exclusion criteria required clinical interpretation. To 
address this, in January 2026, the Trust implemented a significant change to 
operational practice: 

•  A full reversal of the non‑clinical push model. 
•  All transfers now occur through a clinical push only. 

Enhanced clinical review: 

•  Clinicians now review all available information prior to transferring 

any call. 

•  No clinically assessed calls are pushed to any EMAS Clinical 

Assessment Service (CAS). 

•  NEMS no longer supports the manual push of calls into their system; 
therefore, this model now applies across all regional CAS providers. 

This change ensures that only suitably qualified clinicians make decisions 
regarding call transfers, thereby improving patient safety and mitigating risks 
arising from ambiguous criteria. 

5. There is no agreed set of criteria between EMAS and NEMS for the transfer 
of Category 3 calls, including whether previous clinical validation should 
prevent transfer. 

The Trust acknowledges that there is currently no formal agreement in place 
defining the criteria for Category 3 call transfer between the Trust and NEMS. 
Manual ITK push transfers to NEMS have now ceased. 

Ongoing collaborative work continues between the Trust, the Integrated Care 
Board and NEMS to ensure safe and sustainable staffing models that will 
support the reinstatement of the manual push process where appropriate. This 
joint approach is aimed at strengthening system capacity and ensuring that 
patients across Nottinghamshire consistently receive the right care, first time. 

Conclusion 
The core purpose of the Trust is to respond to patients’ needs in the right way, 
continually improving our organisation so that we deliver safe, effective, and 

Page 3 of 4 
Respond | Develop | Collaborate 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 compassionate care. We remain committed to developing a culture of 
compassion, continuous learning, and system-wide collaboration to improve 
patient outcomes. 

I trust that this response provides assurance of the steps we have taken, and 
our continued commitment to learning and improvement across our services.  

Please do not hesitate to contact me if I can be of any further assistance in this 
matter. 

Yours sincerely 

Chief Executive 

Page 4 of 4 
Respond | Develop | Collaborate

Dr Elizabeth Didcock 
Assistant Coroner 
Nottinghamshire Coroner’s Service 
The Council House 
Old Market Square 
Nottingham  
NG1 2DT 

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

4th March 2026 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Jake Kieran Hartwright 
who died on 17th January 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  5th 
January 2026 concerning the death of Jake Kieran Hartwright on 17th January 2025. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Jake’s family and loved ones. NHS England are 
keen to assure the family and yourself that the concerns raised about Jake’s care have 
been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  to Jake’s family  or  friends.  I  realise  that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them.  

Your Report raised the following concerns:  

1.  The  urgent  care  pathway  across  Nottinghamshire  poorly  serves  patients  with 
systemic illness that is serious, but not immediately life threatening, and where the 
clinical assessment disposition reached is for a Category 3 ambulance response. 
2.  Detailed information  in  the East  Midlands  Ambulance  Service (EMAS) Computer 
Aided  Dispatch  (CAD)  transferred  from  the  111  service  is  not  reliably  read  or 
considered by EMAS staff, when cancelling a requested ambulance response and 
referring  a  case  on  to  the  Clinical  Assessment  Service  provided  by Nottingham 
Emergency Medical Service (NEMS).   

3.  Families, waiting for an ambulance response, following a clinical assessment by a 
111 clinical adviser are not told by EMAS that an ambulance will not be sent.  
4.  Category 3 calls are viewed by non-clinicians who do not have sufficient skills to 
safely  transfer  calls  to  NEMS,  as  the  inclusion/exclusion  criteria  are  open  to 
interpretation.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 5.  There is no agreement between EMAS and NEMS as to the criteria for transfer of 
including whether  or  not a  previous clinical  validation 

a  Category  3  call, 
would preclude transfer to NEMS.  

We consider that the third concern listed above falls within NHS England’s remit and 
we have endeavoured to address this concern below. The remaining concerns would 
be  better  addressed  by  EMAS,  NEMS  and  Nottingham  and  Nottinghamshire 
Integrated Care Board (ICB), who have also been sent your Report.  

Background 

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.    

Concern  3:  Families,  waiting  for  an  ambulance  response,  following  a  clinical 
assessment by a 111 clinical adviser are not told that an ambulance will not be 
sent 

timelines  within  which  an  ambulance 

response  should  be  provided 
The 
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 Review Group (CCRG), the National Ambulance Services Medical Directors 
(NASMeD)  and  the  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),  Clinical  Coding  Review 
Group, NHS England, NHS Pathways, NASMeD and Ambulance Heads of Control.   

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 guidance requires Category 3 and 4 calls to 
be clinically navigated, validated and where appropriate triaged in ambulance control 
centres, as included in the NHS England » 2025/26 priorities and operational planning 
guidance, and the NHS England » 2026/27 ambulance emergency and urgent care 
service  specification  and  the  NHS  England  »  Integrated  urgent  care  service 
specification.  This  involves  validation  of  the  disposition  by  a  clinician  (arranged 
locally), which can result in a different disposition being subsequently reached.   

Following transfer of the case to the ambulance service, 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.  For  999  calls,  all  ambulance  services  should 
have in place call exit scripts and procedures for dealing with response delays when 
under operational pressure. NHS England supports a position that callers should be 
provided with sufficient information to make informed decisions, including whether an 
ambulance  has  been  dispatched  to  the  patient.  For  incidents  that  are  eligible  for 
clinical  validation,  the  call  exit  script  should  outline  that  patients  may  receive  a  call 
back  from  a  clinician  to  conduct  a  further  assessment  and  who  may  guide  them 
towards an alternative pathway of care, and patients will be asked to keep their phone 
line free. The wording of the exit scripts is for local determination.  

We  are  unable  to  comment  on  the  concern  that  families  are  not  informed  that  an 
ambulance  is  not  being  sent  as  it  was  NHS  111  and  the  Nottingham  Emergency 
Medical Service (commissioned by NHS Nottingham and Nottinghamshire ICB)   who 
spoke to the patient, rather than the ambulance service. The ICB will therefore be best 
placed to address any concerns on their exit scripts.  

Regional Response 

 
 
 
 
 NHS  England’s  Regional  Midlands  Team  have  liaised  with  Nottingham  and 
Nottinghamshire ICB. The ICB has advised that they facilitated a system-wide After 
Action  Review  (AAR)  with  EMAS,  NEMS  and  111  partners.  This  was  held  on  21st 
January 2026. 

The following next steps were agreed: 

1.  All  participant  organisations  to  the  review  agreed  to  refer  to  the  fact  that  a 
system wide AAR had occurred involving the Derby-Nottingham footprint. 
2.  As  improvement  initiatives  identified  by  the  review  will  require  collaboration, 

obtaining agreement to finalise the AAR was an important first step. 

3.  Those  improvement  initiatives  once  established  will  be  taken  through  and 
monitored  for  assurance  within  the  existing  governance  for  the  relevant 
systems. 

The AAR will be shared with the Regional Quality Board for oversight once it has been 
finalised and agreed by participating organisations. Should the Coroner require further 
information regarding the improvement initiatives agreed as part of the AAR, this can 
be provided in due course. 

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 Jake, 
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.  

I  am  aware that the Coroner  issued another  PFD  Report  on  5 January  2026 which 
touches upon the same issues which have been raised in this case. NHS England will 
respond to that Report separately, for completeness, but it may be the case that there 
is an element of duplication in the information which has been provided. No disrespect 
is intended to the Coroner in this regard.   

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  
NHS England

Confidential  

Dr Elizabeth Didcock, Assistant Coroner, 
for the coroner area of Nottinghamshire 

Platform One 

Station Street 

Nottingham 

NG2 3AJ 

Thursday 26th February 2026 
Telephone: 0115 916 6060 

Dear Dr Didcock 

Response to Matters of Concern Regulation 28 Report 
Re: Jake Kieran Hartwright 

NEMS acknowledges the coroner’s findings and the concerns raised under Regulation 28 
following the inquest into the death of Jake Kieran Hartwright. 

NEMS wishes at the outset to express our sincere condolences to Jake’s family and to 
acknowledge the gravity of the coroner’s findings. We recognise the profound impact of this 
case and are committed to responding in a way that is open, reflective and proactive. We 
fully accept the importance of learning from the matters identified and are approaching this 
response not simply as a statutory requirement, but as an opportunity to strengthen 
systems, improve clarity across pathways and reduce the risk of future harm. Both before 
and following the inquest, we have undertaken detailed review of our processes and 
engaged with system partners to deliver meaningful, sustainable improvements. 

This response therefore sets out the immediate mitigation measures already implemented, 
the ongoing governance actions currently in place, and the further work proposed to reduce 
risk and strengthen patient safety across the urgent care pathway. 

I acknowledge that the coroner issued a further identical Prevention of Future Death Notice 
on the same day relating to another linked, but different case.  The response to both PFD 
reports are the same as there is considerable overlap but I wanted to assure the Coroner 
and the families involved, that no disrespect is intended by this.   

1. Urgent Care Pathway  

Coroner’s Concern: 
The urgent care pathway across Nottinghamshire, whilst working well for most patients, 
poorly serves patients with systemic illness that is serious, but not immediately life 
threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is 
for a Category 3 ambulance response 

Actions Taken 

79580172v1 

 
 
 
 
 
 
 
 NEMS confirms that it has not continued with manually pushed calls since 3rd December 
2026. Prior to 27th June 2025, Category 3 calls assessed by EMAS as potentially suitable for 
management within the Urgent Care Coordination Hub (UCCH) were at times manually 
pushed to NEMS. In practice, this meant that an EMAS Emergency Operations Centre (EOC) 
colleague would transfer a case directly into the NEMS clinical queue, based on the agreed 
inclusion and exclusion criteria at that time. 

As the evidence unfolded during the inquest, it became clear that the manual push model 
had the unintended consequence of positioning NEMS in a role more akin to an Emergency 
Operations Centre (EOC), rather than functioning as an urgent care provider operating within 
a clearly defined admission avoidance model. This was neither aligned with national GIRFT 
(Get it Right First Time) guidance nor consistent with the intended purpose of an Urgent 
Care Coordination Hub. GIRFT describes UCCHs as a single point of access supporting 
admission avoidance, coordinating community-based responses and enabling ambulance 
crews to access alternatives to conveyance. Since this time, we have strengthened our 
governance arrangements to ensure clear operational boundaries, robust clinical oversight, 
and full alignment with urgent primary care guidelines, thereby preventing a recurrence of 
this situation. 

Since cessation of manual pushes, referrals now occur via Directory of Services (DoS) or 
automated ITK pathways. These pathways present lower risk because they are generated 
through NHS Pathways and meet defined criteria, and no further sepsis-related patient 
safety incidents have been identified since pathway changes in June 2025. Since 27th June 
2025, NEMS implemented a pause on manually pushed calls while improvements were 
agreed with EMAS. Although manual pushes resumed on 21st July following assurance 
regarding CAD note quality and governance arrangement, NEMS confirms that it has not 
continued with manually pushed calls since 3rd December 2025.NEMS continues to 
proactively review cases transferred from EMAS and escalate concerns through joint 
governance structures, alongside close monitoring of monthly UCCH highlight reports to 
identify emerging themes  

In parallel, NEMS has worked closely with the Integrated Care Board (ICB) to review national 
GIRFT models for UCCH delivery, ensuring alignment with best practice. It is our clear 
position that interception or re-triage of EMAS calls should sit within the clinical expertise 
and statutory responsibility of EMAS. NEMS’ role is to provide urgent primary care expertise 
for appropriate admission avoidance pathways and not seek to replicate ambulance triage 
functions. Accordingly, our strategic focus has shifted towards preventing avoidable 
ambulance callouts in defined cohorts such as frail patients, care home residents and those 
at end of life, where proactive planning, anticipatory care and coordinated community 
response can safely reduce escalation to 999. This reflects the intended GIRFT model of 
supporting admission avoidance and coordinated care in the community, rather than 
intercepting higher-acuity ambulance demand. We will continue to work closely with system 

79580172v1 

 
 
 
 partners to ensure the pathway operates safely, with clear accountability and well-
understood professional roles. 

Further Work 

NEMS will continue to share recurring themes and individual cases of concern with EMAS 
through established governance processes to ensure that identified risks are reviewed and 
that learning is clearly documented. We have requested that EMAS report back on the 
outcomes of those reviews and share any learning relevant to NEMS, so that the process 
operates as a genuinely reciprocal and joint approach rather than a one-directional 
escalation pathway. 

NEMS will continue to participate in joint After Action Reviews with EMAS where 
appropriate, maintain focused review of systemic illness presentations within the pathway, 
and escalate any identified risks to system partners to ensure timely mitigation and shared 
learning. 

2. CAD Information Not Reliably Considered 

Coroner’s Concern: 
There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred 
from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a 
requested ambulance response and referring a case on to the Clinical Assessment Service 
provided by NEMS. 

NEMS Position 

Ideally, CAD notes should mirror the structured format of a DHU 111 report, with clear 
separation of positive findings, negative findings, outcome rationale, and advice given . At 
present, this level of clarity is not consistently achieved. 

We also acknowledge that the proposed national BARS (Booking and Referral Standard) 
solution has been identified as a potential mechanism to improve data transfer and prevent 
Category 3 calls being deprioritised within the system. However, there has been no 
confirmed implementation timeline, and its formatting and functionality benefits have not 
yet been fully tested. Notwithstanding the cessation of manually pushed calls, improved 
data transfer remains essential for safe ITK and DoS referrals, and BARS may form part of 
that longer-term solution. 

Actions Undertaken 

NEMS has engaged in ongoing discussions with EMAS and OneAdvanced, the software 
provider responsible for Adastra (the electronic patient record system used by NEMS) to 
improve the formatting, structure and clarity of CAD-to-Adastra transfers. This has included 
identifying the duplication arising from the multiple message structure and formally 
requesting technical solutions to improve legibility and presentation of narrative information 

79580172v1 

 
 
 
 In relation to role identification, OneAdvanced has updated role types to allow 
differentiation between Clinical Advisors and Health Advisors within NHS 111. In addition, 
EMAS’ CAD supplier (MIS) is scheduled, in early March 2026, to commence development 
work to enable transfer of advisor skillset information into the receiving system. This 
represents a positive step towards improving visibility of prior clinical validation and 
supporting safer downstream decision-making. 

In addition, this process has generated learning and further improvement work between 
DHU 111 and NEMS in relation to the direct transfer of information from the 111 provider 
into NEMS systems will improve clinical safety for all patients. NEMS confirms that it has 
formally agreed with OneAdvanced to implement the Booking and Referral Standard (BaRS) 
within Adastra and is progressing this work in partnership with DHU. Following system 
configuration, a formal multi-agency project involving NEMS, DHU, OneAdvanced, NHIS and 
the ICB Directory of Services team will oversee the migration of CAS and Out of Hours 
profiles from the legacy ITK framework to BARS, alongside necessary system configuration to 
ensure structured, complete and clearly displayed clinical information transfer. Although 
there are national technical dependencies, including firewall configuration and NHS England 
certification requirements that have affected wider system timelines, both organisations 
remain actively engaged and on track to implement BaRS, which will significantly strengthen 
the quality, reliability and safety of electronic note transfer between DHU 111 and NEMS. 

Further Action Proposed 

NEMS will continue engagement with EMAS, MIS (CAD Supplier) and OneAdvanced so that  
reliable identification of prior NHS 111 clinical validation is achieved and narrative transfer is 
consistently legible and structured. 

NEMS will: 

•  Continue to press for structured CAD formatting aligned to the model outlined in 

verbal evidence provided at inquest (clear overview, further information, outcome 
and advice fields). 

•  Seek clarity on the implementation timeline for BARS and its anticipated impact on 

formatting and prioritisation. 

•  Review whether additional internal NEMS risk flags should be applied where 

duplication or poor formatting obscures clinical clarity. 

•  Continue to raise concerns formally where transferred information does not allow 

safe clinical decision-making. 

Whilst many of the technical solutions sit outside NEMS’ direct control, we remain 
committed to constructive system engagement to ensure that data transfer supports safe 
and informed clinical assessment across organisational boundaries. 

79580172v1 

 
 
 
 3. Families Not Told Ambulance Will Not Be Sent 

Coroner’s Concern: 
Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical 
adviser are not told by EMAS that an ambulance will not be sent 

NEMS recognises that patients often believe an ambulance is already en route when referred 
to our service via EMAS.  

Immediate Mitigation Implemented 

NEMS has introduced a standardised opening statement: 

“I am calling on behalf of NEMS, an urgent care provider. The Ambulance Service has passed 
your call to us to determine whether an ambulance is required or whether we can provide 
an alternative option.” 

This is now embedded into clinical introductions to reduce misunderstanding and improve 
transparency. 

Further Action 

•  Audit of call recordings to ensure compliance. 

•  Ongoing discussion with EMAS to ensure consistent public messaging across services. 

4. Non-Clinician Review of Category 3 Calls 

Coroner’s Concern: 
Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, 
who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion 
criteria are open to interpretation. 

NEMS Position 

The manually pushed call model, which relied on interpretation of locally applied inclusion 
and exclusion criteria, has ceased within Nottingham and Nottinghamshire. Current referrals 
received by NEMS are either Directory of Services (DoS) driven or generated through 
automated ITK pathways. These routes follow nationally defined NHS Pathways clinical 
coding and disposition criteria and therefore do not require additional locally derived 
screening criteria. They are structured within established national algorithms rather than 
discretionary interpretation. 

5. No Agreed Criteria for Transfer (Including Prior Clinical Validation) 

Coroner’s Concern: 
There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 
3 call, including whether or not a previous clinical validation would preclude transfer to 
NEMS 

79580172v1 

 
 
 
 NEMS Position 

There is joint agreement in principle that calls which have already undergone clinical 
validation within NHS 111 should not ordinarily be transferred to NEMS for further 
validation. Where a clinician within NHS 111 has assessed a patient and determined an 
appropriate disposition, particularly where ambulance or ED attendance is indicated, this 
should not routinely result in a further layer of telephone assessment unless there is a 
clearly defined clinical rationale. 

However, NEMS is currently unable to reliably identify whether a call received via EMAS has 
already been clinically validated within NHS 111. As outlined under Point 2, this relates 
directly to the transfer of advisor skillset information and the current limitations within CAD-
to-Adastra data transfer. Without visibility of whether the original 111 disposition was 
clinician-led, NEMS cannot consistently differentiate between pathway-generated 
dispositions and those that have already undergone clinical review. 

Further Proposed Action 

NEMS proposes continued joint work with EMAS and system partners to formalise clear 
transfer principles. This should include explicit agreement that clinically validated NHS 111 
calls should not be routinely transferred for re-validation, and that where EMAS reassesses a 
call as requiring ED attendance, it should be conveyed directly to ED without further 
telephone triage. 

Further system-level review may be required to determine whether adjustments to 
Directory of Services positioning or internal EMAS processes are necessary to prevent 
avoidable sequential assessments. The shared objective is to minimise fragmentation within 
the patient journey and reduce the risk of higher-acuity patients being delayed through 
multiple telephone contacts before definitive care is accessed. 

Update on Internal NEMS Actions  

NEMS remains fully committed to learning from the tragic death of Jake and to ensure that 
the lessons identified translate into meaningful and sustained improvement in clinical 
practice and system processes. The Organisational Learning Statement previously submitted 
to the coroner outlined the actions taken to strengthen the Urgent Care Coordination Hub 
(UCCH) service, enhance telephone consultation standards, improve digital processes, and 
formalise joint governance with system partners. Those commitments have not only been 
maintained but continue to be actively progressed and embedded within routine operational 
and educational practice. 

Immediately following the conclusion of the inquests, key learning points were formally 
shared with the entire NEMS workforce on 14th December. This communication summarised 
the clinical findings, system themes and professional reflections arising from both cases, 
with particular emphasis on cumulative contacts, symptom evolution, structured history-

79580172v1 

 
 
 
 taking, recognition of sepsis, and the limitations of transferred documentation. The purpose 
of this communication was to promote transparency, reflection and collective ownership of 
learning across all clinical staff. 

On 23rd December 2025, the Medical Director met directly with all telephone practitioners 
involved in delivering the UCCH and Clinical Assessment Service. This session provided a 
structured opportunity to review the inquest findings, discuss the process changes that have 
been implemented, and allow clinicians to ask questions, raise concerns and reflect openly 
on their practice. The discussion was constructive and professionally engaged, reinforcing a 
culture of psychological safety and shared accountability for improvement. 

On 21st January, alongside the Medical Director, I attended a formal system After Action 
Review alongside the ICB Quality Team, EMAS and DHU. This review considered both cases 
in detail, identified shared learning themes and examined the collaborative approaches 
required to strengthen inter-organisational working. Focus was given to information transfer, 
recognition of clinical deterioration across multiple contacts, and clarity of role boundaries 
within the urgent care pathway. This system-level discussion reinforced that the risks 
identified were not isolated to one organisation and require coordinated improvement 
across providers. 

On 23rd January, the Medical Director attended the Learning from Death System Forum and 
formally requested that the ICB Quality Team undertake a deep dive into other Prevention of 
Future Death (PFD) reports across Nottingham and Nottinghamshire where communication 
failures and inter-organisational information transfer were contributory factors. The themes 
identified in Jake’s cases, particularly fragmentation of care and incomplete data transfer 
across providers, are not unique risks. It is therefore important that system learning extends 
beyond individual cases to identify wider patterns across the region. 

On 3rd February, the Medical Director hosted a dedicated clinical teaching session in 
collaboration with Mr Chauhan, the consultant general surgeon who provided evidence at 
inquest. This session focused on the presentation of appendicitis, the variability of clinical 
features, the evolution of intra-abdominal sepsis, and the importance of considering 
differential diagnoses when symptoms appear non-classical. The session was well attended 
by NEMS clinicians and formed part of our strengthened education programme. It provided 
valuable specialist insight and reinforced the importance of clinical curiosity, escalation 
when uncertainty persists, and recognition of evolving systemic illness. 

These initiatives build upon the strengthened educational processes already described in the 
Organisational Learning Statement including enhanced sepsis training, structured 
competency assessments for UCCH clinicians, repeated clinical audits with reflective 
feedback, digital prompts such as the sepsis screening tool within Adastra, and tighter 
allocation of appropriately trained staff to high-acuity services. 

79580172v1 

 
 
 
 NEMS recognises that learning from such cases must be ongoing rather than reactive. We 
remain committed to maintaining enhanced audit cycles, embedding structured reflective 
practice, strengthening inter-organisational communication processes, and ensuring that 
clinicians feel supported, trained and equipped to manage complex and evolving 
presentations safely.  

In responding to this Prevention of Future Death report, we remain acutely aware that 
behind the clinical detail, governance processes and system changes sits the devastating loss 
of a young life. Jake’s death has had a profound impact on his family, and we recognise that 
no review, response or action plan can undo the pain they continue to experience. We 
extend our sincere condolences to them and acknowledge the courage and dignity shown 
throughout the inquest process. 

NEMS have taken this inquest, and the learning arising from it, extremely seriously. The work 
undertaken before, during and after the inquest has involved detailed reflection, 
engagement with clinicians, system partners and digital teams, and a careful review of both 
individual practice and organisational processes. This commitment does not end with the 
submission of this Prevention of Future Death response. The actions described are not 
reactive measures tied to a statutory deadline; they form part of an ongoing programme of 
scrutiny, education and improvement that will continue. 

These cases have been approached not simply as governance matters, but as deeply human 
events that require humility, honesty and sustained effort. We remain committed to 
learning, to strengthening our clinical practice and inter-organisational working, and to 
ensuring that the lessons identified contribute to safer care for others. Above all, we remain 
mindful that at the centre of this response is a family living with an irreplaceable loss, and it 
is with that understanding that we continue this work. 

We remain committed to honouring Jake’s memory through sustained improvement, 
transparency and collaboration. Our responsibility is to ensure that the lessons identified 
lead to safer care for others, and that we never lose sight of the human impact that sits at 
the heart of our work. 

Yours Sincerely 

Chief Executive 

79580172v1

Sir John Robinson House 
Sir John Robinson Way 
Arnold 
Nottingham 
NG5 6DA 

27 February 2026 

Confidential  

Dr Elizabeth Didcock, Assistant Coroner,  
for the coroner area of Nottinghamshire 

Dear Dr Didcock 

Re: Regulation 28 Report regarding the case of Mr Jake Kieran Hartwright 

I am writing on behalf of NHS Nottingham and Nottinghamshire Integrated Care Board 
(NNICB) regarding the recent inquest into the tragic death of Jake Kieran Hartwright, 
which concluded on 12 December 2025 with a Regulation 28 (Prevention of Future 
Deaths) report issued. On behalf of the Nottingham and Nottinghamshire Integrated 
Care Board (ICB), I wish to extend our sincere condolences to Mr Hartwright’s family.  

The ICB proactively ensures that learning stemming from operational challenges 
translates into system‑wide improvement. This includes assuring that learning from 
incidents is systematically captured, analysed, and translated into coordinated actions 
across partners; that cross‑organisational interfaces are governed robustly; and that 
progress against improvement actions is monitored, evidenced, and embedded into 
ongoing quality oversight. We will also continue to oversee the governance of 
cross‑organisational interfaces and track the sustainability of improvement actions, in 
line with expectations for sharing learning from Regulation 28 reports.  

Actions taken to coordinate system learning and improvement 
Following receipt of the report, the ICB facilitated a system wide After-Action Review 
(AAR) to enable collaborative learning and improvement across relevant partners.  

The AAR identified improvement priorities relevant to system safety and reliability at 
service interfaces, including: 

•  The UCCH pathway may not consistently meet the needs of patients with serious 

systemic illness where disposition is a Category 3 response. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Risks in information transfer and visibility, including whether information 

transferred into EMAS systems is consistently available and acted upon at 
decision points. 

•  The importance of clear patient/family communication where an ambulance will 

not be sent, including what to do next. 

•  Clarity of roles, skills and governance at points where Category 3 calls are 

reviewed/handled and transferred between services. 

•  The need for agreed criteria for transfer between services (including how prior 

clinical validation affects subsequent decision-making). 

NNICB will use these identified themes to structure oversight and ensure improvement 
actions are coherent and measurable. As an ICB we have met jointly with both EMAS 
and NEMS to ensure that their planned actions (as described in their responses to the 
Regulation 28 report) are clear, time specific and address the issues above. 

We have ensured the manual push remains paused and there are no plans for 
reinstatement of this pathway at this point in time, as not all actions agreed have been 
completed. Several codes that were being automatically transferred to NEMS by EMAS 
have also ceased since December 2025 and we are in the process of reviewing these 
with other similar services across the East Midlands to assess whether they should be 
removed on a larger scale.  

As the commissioner of the UCCH we have also reviewed and redefined the existing 
service specification that is included in the contract we have with NEMS, ensuring that 
all learning has been included.  

Our analytics team have recently developed the ability to join up multiple data sets that 
will from March 2026 allow us to understand the patient journey and outcomes across 
this entire pathway. This will support us to review and refine the journey for our patients, 
enhancing our ability to evaluate and adjust accordingly the service offer.  

Actions and assurance 
NNICB’s oversight actions are aimed at ensuring that provider actions are coherent, 
measurable, sustained, and transparently governed across the pathway. Maintenance 
of this oversight and assurance will continue following the recommendations of 
oversight framework designed to identify where support is needed, with a focus on 
improving patient safety, experience, and outcomes. This will include a comprehensive 
quarterly review process on progress towards these actions.  

As per the ICB’s statutory responsibilities for PFD learning and assurance actions from 
this report will be shared and embedded in: 

ICB Joint Quality and Service Improvement Committee  

• 
•  Provider review processes 
• 
•  Regional Quality Committee  

ICS System Learning from Deaths Forum  

We have also offered and committed to joining the clinical governance meeting set up 
between NEMS and EMAS to support the continued work between the two 
organisations. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

Chief Executive 
NHS Derby and Derbyshire, Lincolnshire and Nottingham and Nottinghamshire ICBs