Robert Gracey

Private and Confidential 
Mr Paul D Smith 
HM Senior Coroner for the 
coroner area of Greater 
Lincolnshire 

Dear Mr Smith 

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

02 February 2026 

Re: Report regarding the case of Mr Robert Shaun Gracey deceased.  

I am writing to you in response to the concerns that you highlighted to the 
East Midlands Ambulance Service NHS Trust following the inquest hearing into 
the sad death of Mr Robert Shaun Gracey that concluded on 18 December 
2025.  

Thank you for your Regulation 28 report regarding the absence of a locally 
agreed protocol for the management of suspected Acute Behavioural 
Disturbance (ABD) incidents in Lincolnshire. 

I am aware that you will share my response with Mr Gracey’s family, and I 
firstly wish to express my sincere condolences to them.  

The Trust acknowledges the concerns raised by you and I would like to offer 
the following clarifications and commitments. 

The concerns highlighted in your report have been reviewed and discussed by 
the Trust’s Incident Review Group, which convenes twice a week to consider 
issues raised through complaints/concerns raised, incident reporting, inquests 
and Regulation 28 reports. This process ensures that lessons are identified and 
appropriate actions are taken to address any systemic or procedural 
shortcomings. 

Matters of Concerns raised on 18 December 2025 

Although the letter issued on 24 July 2019 by Deputy Assistant Commissioner 
(DAC) Twist, on behalf of the National Police Chiefs’ Council (NPCC), clearly 

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Respond | Develop | Collaborate 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 recommended that police forces develop established ABD protocols with their 
local ambulance ensuring suspected ABD incidents are treated as medical 
emergencies with a Category 1, eight‑minute response standard, no such 
protocol has yet been implemented in Lincolnshire. 

Under the current NHS Pathways system, ABD does not have its own allocation 
pathway and a referral for ABD will only be allocated a Category 2 response in 
the absence of police restraint. 

ABD Protocols 

We acknowledge the recommendation, referenced above, made by DAC Twist 
on behalf of the NPCC in the letter dated 24 July 2019.  

Current Position 

The Trust operates under NHS Pathways (NHSP), a nationally mandated triage 
system that determines clinical priority based on structured questioning during 
the 999 calls.  

ABD is treated as a medical emergency; however, NHSP does not currently 
include a specific ABD protocol that automatically assigns Category 1 status (7 
minutes). ABD has a specific answer stem within NHSP. This limitation means 
that suspected ABD cases are triaged according to presenting symptoms rather 
than a standalone ABD category at the time of the call being made. The police 
should always, at the earliest opportunity, contact 999 for any patient that 
they believe to be experiencing ABD symptoms.  

Our clinical teams within our Emergency Operations Centre review ABD 
presentations from the police which can then be flagged for higher priority 
within existing NHS Pathways constraints if required. The Trust also has 
guidance for call handlers and clinicians to ensure suspected ABD cases are 
escalated promptly. 

The Future 

As NHS Pathways is a nationally mandated triage system, this is not something 
that the Trust can change individually and would require a change to the 
national triage system. This would need to be initiated by NHS England.  

In addition, the Trust recognises that there is not currently a national pathway 
for ABD, however the Trust has in place a process for a response to ABD as 
governed by the Emergency Call Handling Protocols that was ratified by the 

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 Trust’s Clinical Governance Group in October 2023 when the Trust went live 
with NHS Pathways.  

The Trust currently operates across six counties within the East Midlands, 
creating logistical hurdles when ensuring policies and response protocols are 
consistent across multiple counties and multiple police forces.  The Trust will, 
however, continue its participation in the Police Regional Clinical Governance 
Forum to align training and response protocols for ABD.  

The Trust will also continue to work with regional police forces and health 
partners to explore the development of a single joint operational framework 
for ABD management.  

In the meantime, The Trust will continue to review its internal clinical guidance 
to ensure consistency with police training and national best practice. 

The Trust’s core purpose is to respond to patient needs in the right way, 
developing our organisation to become outstanding for patients and staff, and 
collaborating to improve wider healthcare. We always aim to deliver safe, 
effective, compassionate care for patients, embedding a culture of compassion 
and continuous improvement. We are committed to improving the recognition 
and response to ABD incidents. 

Thank you for highlighting this important issue. Please do not hesitate to 
contact me should you require further information. 

Yours sincerely 

Chief Executive 

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Respond | Develop | Collaborate

Butterley Hall, Ripley, Derbyshire, DE5 3RS 

Tel: 

0300 122 5550 

Our ref: 
Your ref: 
Date: 

LIN001.124692 

1 April 2026 

Mr Paul D Smith 
HM Senior Coroner 
Lincolnshire Coroner’s Service 
The Myle Cross Centre 
92 Macauley Drive  
Lincoln 
LN2 4EL 

By email LincsCoroner@lincolnshire.gov.uk 

Dear Coroner 

Regulation 28 report to prevent future deaths (Robert Shaun Gracey deceased) 

I am writing in response to the concerns raised that action should be taken to prevent future deaths in respect 
of the following matters arising from the following: 

1.  Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of 
the NPCC that "police forces have established ABD protocols with their local ambulance service so 
that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 
minutes)", there is still no such protocol in Lincolnshire. 

2.  Under the current NHS Pathways system, ABD does not have its own allocation pathway. 

3.  Under the current NHS Pathways system a referral for ABD will only be allocated a category 2 response 

in the absence of police restraint. 

I apologise for the late delivery of this correspondence.  

Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) 
to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) 
and since September 2025 learning from the Coronial process has been shared with EMAS with a view to 
creating and then implementing guidance in relation to this issue.  

A further action was raised in December 2025 that EMAS were producing a joint working policy on ABD. At 
that stage, guidance was still outstanding from the Enhanced Care Group which, EMAS advised, was required 
before finalisation.  

The following meeting of the Forum took place on the 18th March 2026. Mark Folman from EMAS provided 
an update on the progress of the joint working policy in relation to ABD in light of the guidance which has 
been obtained from the Enhanced Care Group to EMAS.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 All Forces in the East Midlands contribute to the work of the Forum. The Forum as a whole decided that the 
basis of the work should be carried out by EMAS given that the medical response was a crucial element of the 
policy and therefore EMAS were best placed to lead upon it. The joint working policy will therefore inform 
the response on the part of other Police Forces within the East Midlands.  

Lincolnshire Police will continue to work with EMAS and partners within the Forum in order to  develop and 
align practices and training to deal with ABD, response times, and restraint practices.  

It was acknowledged at the Regional Clinical Governance meeting on the 18th March 2026 that issues had been 
raised by HM Coroners within the region, noting a disconnect between police and ambulance terminology. The 
overview of the draft guidance being issued by EMAS will be to recommend that cases of suspected ABD 
receive  a  category  1  response  if  the  detainee  is  restrained,  and  category  2  response  if  the  detainee  is  not 
restrained.  

An escalation model of green-amber-red will be utilised, with ‘red’ cases involving high risk and requiring 
critical  care  intervention.  The  group  was  advised  that  EMAS  is  developing  an  advanced  scope  of  practice 
enabling practitioners to deliver enhanced support and medical care, and the guidance is currently progressing 
through governance.  

The  meeting  was  further  advised  that  future  plans  would  include  potential  video  triage  to  support  earlier 
decision-making and joint training with air ambulance teams, with a view to incorporating the involvement of 
the Police.  

Lincolnshire Police will continue to work with EMAS and NHS Trusts to ensure consistency between training 
and clinical guidance and is committed to ensuring that the health and safety of detainees is and remains a 
priority.  

Thank  you  for  highlighting  this  issue  and  please  do  not  hesitate  to  contact  me  if  you  require  any  further 
information.   

Yours faithfully 

Deputy Head 
Direct Dial: 
Email: 

Please note we do not accept service by email or facsimile

Mr Paul D Smith 
HM Senior Coroner  
Lincolnshire Coroner’s Service 
The Myle Cross Centre  
92 Macauley Drive 
Lincoln 
LN2 4EL  

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

23 February 2026 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Robert Shaun Gracey who 
died on 29 September 2021.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  6 
January 2026 concerning the death of Robert Shaun Gracey on 29 September 2021. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Robert’s family and loved ones. NHS England is 
keen to assure the family and yourself that the concerns raised about Robert’s care 
have been listened to and reflected upon.   

Your Report raised the following concerns:  

1.  Despite a clear recommendation by DAC Twist on behalf of the National Police 
Chief's Council (NPCC) that ‘police forces have established Acute Behavioural 
Disturbance  (ABD)  protocols  with  their  local  ambulance  service  so  that 
suspected ABD incidents are treated as medical emergencies’, there is still no 
such protocol in Lincolnshire.  

2.  Under the current NHS Pathways system, ABD does not have its own allocation 

pathway.  

3.  Under  the  current  NHS  Pathways  system,  a  referral  for  ABD  will  only  be 
allocated a Category 2 ambulance response in the absence of police restraint.  

Background on Acute Behavioural Disturbance 

The term “Acute Behavioural Disturbance” (ABD) is not a formal diagnosis within the 
International Classification of Diseases (ICD-11), which is the global diagnostic tool 
used in the NHS. ABD is generally used to describe behaviours linked with extreme 
agitation or distress, which may indicate a potentially life-threatening physical health 
emergency.  NHS  England  recognises  the  importance  of  ensuring  that  individuals 
presenting in extreme distress receive timely, safe, and effective care. ABD is not a 
specific  condition  with  a  set  of  defined  symptoms.  It  is  not  common  and  it  is  very 
difficult  to  identify  the  difference  between  agitation,  antisocial  behaviour,  deliberate 
violent behaviour and ABD. There is no reliable way to determine mild or severe ABD 
in the pre-hospital setting nor over the phone during a triage process.  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 ABD  is  a  complex  but  known  clinical  presentation  and  both  the  Royal  College  of 
Psychiatrists and the Royal College of Emergency Medicine have published guidelines 
on managing ABD. 

NHS Pathways Triage 

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.   

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  Medical  Priority  Dispatch  System  (MPDS).  The 
systems are used to prioritise 999 calls received into Ambulance Services’ Emergency 
Operations  Centres  (EOCs).  The  East  Midlands  Ambulance  Service  moved  to  the 
NHS  Pathways  system  in  November 2023, but  was using  the  MPDS  system at  the 
time of Mr Gracey’s death.  MPDS is published by the Priority Dispatch Corporation 
(PDC),  and  its  ongoing  development  is  supported  by  the  International  Academy  of 
Emergency  Medical  Dispatch  (IAED).    Any  queries  on  the  operation  of  the  MPDS 
system should be directed to PDC. 

The  primary  purpose  of  triage  is  to  quickly  identify  priority  symptoms  (e.g. 

 
 
 
 
 
 
 
 unconsciousness, difficulty breathing, chest pain) and assign an appropriate response 
priority. The outcome (disposition) reached, based on the information provided by the 
caller, is mapped to approved, contracted standards. There is a requirement to map 
these outcomes to the five national categories (Categories 1 -5) set out within the NHS 
Constitution and Ambulance Service 999 contracts.  

The  categorisation  of  999  calls  is  managed  through  a  specific  process  within  NHS 
England. The mapping of triage outcomes to response categories is undertaken by an 
expert  group  which  has  representatives  from  both  NHS  Pathways  and  MPDS 
ambulance  trusts.  The  coding  groups  engage  with  the  ambulance  sector  within 
England and consider reviews triggered by coroners, patient safety concerns identified 
by  the  ambulance  services  or  changes  in  national  guidance.  This  group  makes 
recommendations to the NHS England Emergency Call Prioritisation Advisory Group 
(ECPAG) for implementation across all NHS England ambulance service providers. 
This  ensures  appropriate  prioritisation,  equity  of  access  and  uniformity  of  response 
across the English ambulance services.  

Under the current NHS Pathways system, ABD does not have its own allocation 
pathway 

The NHS Pathways system is designed to support symptom-based assessment. It is 
a non-diagnostic system. This means its functioning does not depend on diagnostic 
for  specific  named  conditions.  Rather,  symptom 
“allocation” 
presentation  drives  assessment,  and  additional  information  such  as  existing 
diagnoses may be sought where relevant. 

into  pathways 

Whilst it is NHS England’s understanding that Mr Gracey’s triage assessment was not 
done using the NHS Pathways system, given the details supplied in your Report, it is 
likely  that  a  Category  1  response  would  have  been  triggered  by  the  presenting 
symptoms  of  Mr  Gracey  at  the  time  of  the  police  call  to  the  ambulance  service 
(including  that  he  was  non-responsive,  no  longer  breathing  and  only  had  a  weak 
pulse). 

Under  the  current  NHS  Pathways  system,  a  referral  for  ABD  will  only  be 
allocated a Category 2 ambulance response in the absence of police restraint 

As indicated above, symptom-assessment drives the outcome of triage under the NHS 
Pathways  system.  This  means  that,  in  the  absence  of  more  immediately  life-
threatening  presentations  (e.g.  unconsciousness,  not  breathing,  etc.),  the  lowest 
response  level  that  can  be  reached  with  ABD  in  the  NHS  Pathways  system  is  a 
Category  2  emergency  ambulance  response.  In  other  words,  where  appropriate,  a 
Category  1  response  can  be  triggered.  Category  2  calls  (not  just  Category  1)  are 
treated as ‘medical emergencies’, requiring rapid assessment and intervention, and 
which,  along  with  ABD,  are  reserved  for  a  medical  emergency  such  as  suspected 
stroke, chest pain and sepsis. 

A  Category  2  response  typically  receives  the  immediate  dispatch  of  an  emergency 
ambulance (with a response time standard mean of 18 minutes) however, ambulance 
services are advised that a senior clinician within the control room should be made 
aware of the potential ABD incident to assist with further clinical oversight and decision 

 
 
 
 
 
 
 
 making. Where  indicated,  local discretion  can  be  applied  by ambulance  services  to 
rapidly upgrade the incident to a Category 1 if the patient’s condition indicated that it 
was appropriate to do so, for example, the patient’s condition has deteriorated or the 
patient is being restrained.  

The response category for ABD continues to be actively considered and reviewed by 
the bodies, and their membership organisations, who set ambulance categories. This 
topic continues to be monitored by both the NHS Pathways and National Ambulance 
Teams within NHS England, as well as more broadly by ambulance service providers 
themselves,  and  in  partnership  with  Health  and  Justice  teams.  These  active 
investigations support the categorisation decisions, managed by NHS England. More 
information about ambulance categorisation updates can be found at NHS England » 
Ambulance Response Programme. 

ABD Guidelines 

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) provides clinical 
guidelines  for  paramedics,  which  include  a  comprehensive  overview  of  various 
conditions  they  care  for.  The  guidelines  are  updated  with  the  latest  evidence  and 
developments in clinical practice, with expert advice and practical guidance, to ensure 
that paramedics have access to the most up to date information to support the delivery 
of patient care. ABD management is included in the guidelines and has been updated 
on three occasions between 2021 and 2025. The guidelines for the management of 
ABD  are  crucial  for  ensuring  patient  safety  and  effective  emergency  care.  They 
provide  a  framework  for  paramedics  and  healthcare  professionals  to  recognise, 
assess and manage ABD effectively, reducing the risk of death and improving patient 
outcomes. 

ABD in NHS Pathways 

As  described  above,  life-threatening  presentations  such  as  a  person  falling 
unconscious or not breathing reach a Category 1 response in Module 0 of the NHS 
Pathways triage system. Where the patient is awake, and in the absence of other life-
threatening symptoms, the triage system prompts call-takers to seek answers to the 
following questions relevant to ABD: 

DOES EITHER OF THE FOLLOWING APPLY? 

1)  The patient is under active restraint RIGHT NOW 

Additional supporting information for health advisors includes: ‘This means the patient 
is being actively restrained to reduce the risk of harm to themselves and/or to others. 
This includes restraint for acute behavioural disturbance (ABD), also known as excited 
delirium or acute behavioural disorder.’ 

OR 

2)  The  patient  is in  need  of  restraint  OR  acute  behavioural disturbance  (ABD)  has 

been declared 

 
 
 
 
 
 
 
 
 
 
 
 Additional supporting information for health advisors includes: ‘This means restraint is 
required but active restraint is not being applied currently. This includes any declared 
acute  behavioural  disturbance  (ABD),  also  known  as  excited  delirium  or  acute 
behavioural  disorder.  THE  AMBULANCE  SERVICE  WILL  NOT  RESTRAIN  THE 
PATIENT. LOCAL POLICY SHOULD BE FOLLOWED.’ 

If  either  of  these  2  prompts  are  present,  then  the  current  Category  2  response  is 
recommended.  Should  the  patient  be  collapsed  or  unconscious,  a  Category  1 
response does not depend on the declaration of these terms.   

Attend Incident 

It should be noted that, as well as the main triage assessment, ambulance services 
using  the  NHS  Pathways  system  have  access  to  a  specially  designed  module  to 
respond  to  incidents  from  custodial  services.  This  is  named  “Attend  Incident”.  This 
module  enables  access  to  reduced  detail,  “high  sorting”  pathways,  specifically 
designed for the types of contacts from services such as the Police and Prisons. 

In the ‘Attend Incident’ functionality of 999 ambulance services, in the absence of life-
threatening  symptoms,  when  ABD  is  declared  by  the  police,  prison  service  or  a 
healthcare  professional,  a  Category  2  ambulance  response  is  triggered,  and  the 
following question is presented: 

1)  Has active restraint been declared? 

This question is presented to assist the onward transmission of information I.e. this 
information is collected to assist the attending practitioners and as part of the patient’s 
records. 

Additional Training 

NHS England’s teams closely monitor incidents relating to ABD to evolve and develop 
the NHS Pathways system, and training of its use, in step with emerging evidence. 

To support health advisors, a training consolidation pack specifically covers ABD or 
Excited Delirium (as ABD was referred prior to being referred to as ABD)  as follows: 

“Acute behavioural disturbance (or disorder) is not an actual diagnosis, but rather 
an ‘umbrella’ term for several different conditions that cause a sudden and very 
noticeable change in someone’s behaviour. It is an emergency situation, that can 
be caused by several things including: 

• Substance abuse or withdrawal  
• Certain physical conditions such as a head injury or hypoglycaemia  
• Other mental health conditions such as psychosis  

Commons symptoms include:  
• Agitation  

 
 
 
 
 
 
 
 
 
 
 
  
 
 • Feeling hot to touch, a high temperature and often profuse sweating  
• Rapid breathing and rapid pulse  
• Aggression, hostility and violence  
• Extreme strength and insensitivity to pain” 

Regional Response 

NHS  England’s  Midlands  regional  colleagues  have  reached  out  to  Derby  and 
Derbyshire  Integrated  Care  Board  (ICB)  who  has  advised  that  East  Midlands 
Ambulance Service will be responding directly to the concerns you raised. The Trust 
has  confirmed  that,  as  part of  the  learning  and  actions  arising  from  this  process,  a 
review of all existing Memorandums of Understanding (MOUs) is underway to ensure 
appropriate governance arrangements are in place for each agreement. Through their 
Mental Health lead, the Trust is also working collaboratively with system partners to 
revise the relevant clinical presentation protocols.  

Regional colleagues  have  highlighted  that  there  was  another PFD report within  the 
region where similar themes relating to ABD pathways and protocols between police 
and EMAS. They have reached out to that ICB for an update on the actions identified 
as a result of that report.    

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 
Robert, 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 
NHS England