Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0006, written 6 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jan 2026 |
|---|---|
| Reference | 2026-0006 |
| Deceased | Theo Tuikubulau |
| Coroner | Louise Wiltshire |
| Coroner area | Devon, Plymouth and Torbay |
| Category | Child Death (from 2015) |
| Organisation named | University Hospitals Plymouth NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. NHS England
1
CORONER
I am Louise Wiltshire, assistant coroner, for the coroner area of the County of Devon,
Plymouth and Torbay
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 12 July 2022 I commenced an investigation into the death of Theo Gordon
Tuikubulau. The investigation concluded at the end of the inquest, heard before a jury,
on 3 July 2025.
The narrative conclusion of the inquest was as follows:
Theo died from an invasive Group A streptococcal infection, contributed to by missed
opportunities to render earlier care and treatment.
The medical cause of death was:
1a Sepsis
1b
1c
II
4
CIRCUMSTANCES OF THE DEATH
Theo was a three-year-old boy who died on 8 July 2022 as a result of sepsis, arising
from an invasive strep A infection (i-GAS) .
1
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
During the course of the inquest evidence was heard that assessment and resultant
ambulance dispositions for breathing complications were likely to be different depending
on whether that call was triaged via the MDPS or NHS Pathways systems. Between 5
and 8 July 2022 various calls were made to 999 and 111 by Theo's mother. Breathing
complications were described by Theo's mother during those calls as; Theo's lips had
turned "a little blue", and that he was fighting for every breath. This information triggered
a category 1 ambulance disposition via MPDS and a category 2 disposition via NHS
Pathways.
The 111 provider used the NHS Pathways system to assess and triage calls. The 999
provider used MPDS to assess and triage calls.
The difference in assessment and triage of calls under these two systems appears to
create a two-tiered system of assessment and ambulance categorisation in the Devon
area (and potentially nationally). It appears that similar breathing complaints requiring
urgent medical attention will result in a different ambulance disposition depending on
whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS
Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to
prevent future deaths was engaged in this case. However, I was conscious that I did not
hear evidence directly from those responsible for the NHS Pathways or MPDS systems
during the inquest.
I therefore requested further information from both of the organisations responsible for
NHS Pathways and MPDS about why there appears to be a two tier system in Devon
(and potentially nationally) which would result in a different ambulance categorisation
(category 1 under MPDS and category 2 under NHS Pathways) when a caller describes
breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both,
for further information about what is being done to address those differences in call
assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the
International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls
triaged via the MPDS system and confirmed that these calls had been properly assigned
a category 1 response time. They were unable to comment on the calls triaged by NHS
Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about
2
the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority
Dispatch Corporation (PDC), and its ongoing development is supported by the
International Academies of Emergency Dispatch (IAED)… NHS England does not
manage or oversee the MPDS and we are therefore unable to provide comment on their
system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical
assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is
developed and maintained by the Transformation Directorate at NHS England, and is
overseen by the National Clinical Assurance Group (NCAG), an independent
intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all
NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and
acuity (severity and urgency of the symptoms/condition) of the patient based on the
identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest
pain). If, during the call, the patient’s condition changed (either improves or worsens),
then there is an exception that the call handler will re-triage with the new information
which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC)
Teams, it is clear that there is variation between the two triage systems with regards to
respiratory distress in children under 5, specifically in relation to the management of
declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller
volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the
MPDS triage. However, the presence of cyanosis is not interrogated within NHS
Pathways and as such this symptom / sign is not a specific trigger for generating a
Category 1 disposition for ineffective breathing within NHS Pathways, instead resulting
in the generation of a Respiratory Distress disposition that is mapped to a Category 2
response."
I was advised within the letter that NHS England will work with the clinical coding groups
and NHS Pathways to review this to ensure that the triage and categorisation of
ineffective breathing and respiratory distress is consistent across the two triage systems
and remains clinically appropriate, for which I am grateful. However, as this has not yet
occurred and the two tiered triage system continues to exist, so does my duty to make a
report to prevent future deaths in this matter.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
3
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3 March 2026. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons; the family, South West Ambulance Services NHS Trust, Herts Urgent Care and
University Hospitals Plymouth NHS Trust.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
Louise Wiltshire
6 January 2026
4
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