Drew Greaves-Pimblett

Anita Bhardwaj 
Senior Coroner for Sefton,  
St. Helens and Knowsley 
Town Hall Bootle 
Oriel Road 
Bootle  
Liverpool 
L20 7AE 

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

3 March 2026 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Drew John Greaves-
Pimblett who died on 22nd March 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  8th 
January  2026  concerning  the  death  of  Drew  John  Greaves-Pimblett  on  22nd  March 
2025. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Drew’s family and loved ones. NHS England 
is keen to assure the family and yourself that the concerns raised about Drew’s care 
have been listened to and reflected upon. 

Your Report raised concerns that there is a gap in national pathways for call handlers. 
You  asked for consideration to  be  given to  further guidance  and  assistance  for  call 
handlers on probing questioning for fundamental aspects such as for breathing and 
general presentation (e.g. how best to assess how cold a body is and where to take a 
pulse),  so  that  call  handlers  can  make  more  informed  decisions  as  to  whether 
someone is breathing and if CPR is required.   

Regional Response 

NHS  England’s  Regional  North  West  Team  have  liaised  with  the  North  West 
Ambulance  Service  (NWAS)  regarding  your  Report.  They  have  advised  that  when 
Drew was found not breathing and unresponsive, a 999 call was made to NWAS. The 
caller stated he was blue, had swollen lips, was very cold and not breathing. The call 
was initially categorised as a  Category 1, the highest level of  ambulance response, 
but  was  then  downgraded  to a  Category 4  following  responses  to further  questions 
asked (note that one of the outcomes on NHS Pathways for a person who is clearly 
deceased  is  a  Category  4  response,  and  where  death  is  not  expected  this  can  be 
onward  referred  to  the  police).  The  police  were  notified  of  the  unexpected  death, 
attended within 30 minutes and stated that Drew was blue and unresponsive but was 
slightly warm, and therefore they started CPR – the police documented that pressing 
Drew’s chest was very difficult. NWAS were called again and arrived within 2 minutes 
of the police officer arriving at the scene. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 The attending NWAS clinician completed an assessment and confirmed that Drew had 
passed away. He stated when asked that Drew was very cold. 

NWAS audited the call after the event and did find that there had been some deviation 
and the need for more probing before the downgrade, which resulted in the ambulance 
being stood down, with feedback given at the time to the NWAS call handler on this.  

NHS England was not a party to the inquest, but has been informed that the Coroner 
accepted all of the evidence and concluded that it was more likely than not that Drew 
had been deceased for some time before NWAS’s arrival.  

National Position  

Background 

NHS  Ambulance  Services  are  required  to  process  999  calls  through  an  approved 
triage system. There are currently two long established systems approved in England 
for  primary  999  triage;  NHS  Pathways  and  the  Medical  Priority  Dispatch  System 
(MPDS).  The  systems  are  used  to  prioritise  999  calls  received  into  Ambulance 
Services’  Emergency  Operations  Centres  (EOCs).  The  North  West  Ambulance 
Service (NWAS) uses the NHS Pathways system. 

The  primary  purpose  of  triage  is  to  quickly  identify  priority  symptoms  (e.g. 
unconsciousness,  difficulty  breathing,  chest  pain)  and  to  assign  an  appropriate 
response  priority.  The  outcome  (disposition)  reached  based  on  the  information 
provided by the caller is mapped to one of the five national categories (Categories 1 – 
5)  set  out  within  the  NHS  Constitution  and  Ambulance  Service  999  contracts.  The 
development of triage question sets and instructions lies within the remit of the triage 
system provider. 

NHS Pathways Background 

NHS  Pathways  is  the  Clinical  Decision  Support  System  (CDSS)  used  for  remote 
clinical  assessment  (triage)  in  urgent  and  emergency  care.  In  use  since  2005,  it 
underpins  all  NHS  111  services  and  more  than  half  of  England’s  999  telephony 
services. It is also used for self-service triage via NHS 111 online and at the front door 
of Emergency Departments. 

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. The 
tool  also  supports  enhanced  clinical  assessments  via  modules  such  as  the  NHS 
Pathways Clinical Consultation Support (PaCCS) system. 

The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen 
by  the  National  Clinical  Assurance  Group  (NCAG),  an  independent  intercollegiate 
body  hosted  by  the  Academy  of  Medical  Royal  Colleges  (AoMRC).  Alongside  this 
independent  oversight,  NHS  Pathways  aligns  its  clinical  content  and  assessment 
protocols with up-to-date national clinical guidance, including from NICE (the National 

 
 Institute for Health and Care Excellence), the UK Resuscitation Council and the UK 
Sepsis Trust, amongst others. 

The  system  supports  over  2.5  million  triage  assessments  each  month  across 
telephone, digital, and face-to-face settings. 

NHS  Pathways  follows  a  structured  clinical  hierarchy.  Serious  and  potentially  life-
threatening  symptoms  are  assessed  first  to  ensure  rapid  escalation  -  such  as 
dispatching an ambulance or involving a clinician. The assessment then progresses 
through to less urgent symptoms, identifying the most appropriate level of care.  

Principles of Health Advisor Training 

In telephone settings (calls made to NHS 111 or 999), assessments are conducted by 
trained  non-clinical  health  advisors.  These  advisors  complete  a 
specially 
comprehensive, structured mandatory training programme to ensure they can use the 
NHS  Pathways  algorithm  safely  and  effectively,  and  they  are  always  supported  by 
clinicians,  as  a  condition  of  the  NHS  Pathways  licence,  which  NHS  111  and  999 
providers must enter into in order to use the system. If a case is complex or unclear, 
health  advisors  are  required  to  escalate  to  clinical  colleagues.  The  NHS  Pathways 
licence states that clinical supervision and escalation support must be available 24/7, 
and immediately accessible to health advisors during live calls. This clinical availability 
is a core system control.  

Following the initial core role preparation training, health advisors and clinicians are 
required  to  update  their  training  every  12  weeks.  They  are  also  able  to  access  a 
comprehensive library of additional training courses and educational resources such 
as ‘Hot Topics’, case studies and e-learning packages.  

NHS Pathways Assessment of Consciousness and Breathing 

Based on the information provided regarding this particular case, in respect of the NHS 
Pathways triage system we can confirm the following: 

• 

• 

them 

If a cardiac arrest is not suspected at the onset of the call, the system seeks to 
quickly establish whether there is an immediate threat to life. If the patient is not 
fitting  or  choking,  supporting  information  is  provided  to  the  health  advisor  to 
assist 
is  conscious  or  not. 
Unconsciousness  is  classed  as  when  the  individual  cannot  be  woken  or  is 
difficult to wake up. 
If the patient is confirmed to be unconscious, the next question presented seeks 
to establish whether a normal breathing pattern is present. 

to  establish  whether 

the  patient 

•  Health advisors can use the supporting information provided to advise the caller 
to check whether the chest is rising and falling regularly and/or whether regular 
breaths can be heard or felt coming from the nose of mouth. If there is doubt, 
they are prompted to ask the caller to ‘look, listen and feel’ for breathing. 
If the patient is not breathing normally, the supporting information advises that 
there may be no or very little attempt being made by the individual to breathe. 
They are advised that there may be occasional gasps or breaths with possible 
long pauses in between. The supporting information also advises here that the 

• 

 • 

skin  may  appear grey or blue,  and  where to check  for this on  the body,  and 
where to check when skin tones may be darker. 
If  the  patient  is  not  breathing  or  not  breathing  sufficiently,  this  results  in  a 
Category 1 ambulance outcome, on the basis that a cardiac arrest is likely. This 
was the outcome reached in this case based on the information provided. 
•  Once it has been established that the scene is safe, the NHS Pathways system 
seeks to establish whether the caller is within easy reach of the patient. If no 
specific scenarios where specialist instructions are required (such as hanging, 
drowning, choking etc) are present, information on how to give basic life support 
(BLS), and whether a defibrillator can be located, presents itself for the health 
advisor. 

The  only  reasons  that  a  health  advisor  should  advise  BLS  to  cease  are  if  the 
ambulance crew arrive and take over, if the patient regains consciousness, or if the 
person performing BLS is for some reason unable to continue. 

NHS Pathways does not ask the caller to try to ascertain if there is a pulse present. 
For the ordinary lay person, the identification of a pulse can prove challenging, thus 
potentially wasting valuable time in terms of dispatching an ambulance. All pathways 
relating to instructional information regarding resuscitation have been approved and 
ratified by Resuscitation Council UK. 

Also, of relevance to this particular case, in terms of additional training regarding the 
assessment of consciousness and breathing, health advisors utilising NHS Pathways 
who have completed the core training are provided with ‘CPR Toolkit Training’. This 
encompasses  what  is  called  the  ‘No,  No,  Go’  approach  where,  if  the  patient  is  not 
conscious  or  not  breathing  (either  normally  or  at  all),  health  advisors  are  trained  to 
proceed  immediately  to  the  initiation  of  cardiopulmonary  resuscitation  (CPR)  as 
presented by the system. This additional training seeks to ensure that health advisors 
are supported to proceed quickly to the required life supporting advice. 

The CPR Toolkit training explains that evidence from multiple studies indicates that 
performing CPR on a patient who is not in cardiac arrest is unlikely to cause harm. 
Health advisors are therefore trained that, where there is any uncertainty regarding 
whether a patient’s breathing is normal, or if the patient is not breathing at all, they 
should initiate telephone-guided CPR.  

NHS Pathways Management of Expected or Unexpected Death 

A  ‘triage  not  possible’  route  exists  within  the  NHS  Pathways  system  for  the 
management  of  an  expected  or  unexpected  death.  From  the  limited  information 
provided regarding this case, it is not possible to comment on whether or not the health 
advisor  should  have  selected  the  option  for ‘discovery  of  a  stone  cold  or  stiff  dead 
body’. 

Even if the health advisor in this case had thought that Drew was already deceased 
and  this  route  was  selected,  the  option  of  ‘Sudden  Unexpected  Death’  would  have 
likely  been  chosen.  This  route  follows  the  consciousness/breathing  assessment  as 
described  above,  whereby  BLS  instructions  are  presented  as  the  system  in  this 

 scenario  assumes  that  CPR  should  be  performed  as  the  exact  moment  of  cardiac 
arrest is not known. 

NHS Pathways Additional Health Advisor Support 

Almost  every  question  in  the  NHS  Pathways  triage  system  has  ‘supporting 
information’, shown under the question text, enabling the health advisor to ask probing 
questions. This supports health advisors to ensure the caller’s responses match the 
answer  selection.  ‘Probing’  is  extensively  trained  in  the  health  advisors’  mandatory 
training,  and  the  facility  is a  fundamental  aspect  of  the  NHS  Pathways  system  and 
how it differs from fixed-script based systems. The supporting information provided to 
support  the  identification  of  an  immediate  threat  to  life  is  extensive  as,  in 
circumstances whereby a patient may not be conscious or breathing, this is recognised 
as an exceptionally stressful situation for all involved including the health advisor. 

The Medical Priority Dispatch System (MPDS)  

In addition to the NHS Pathways response detailed above and whilst this falls outside 
of  NHS  England’s  direct  remit,  for  completeness,  NHS  England  has  discussed  the 
concerns in your Report with the provider of the MPDS triage system. The 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).  

 PDC has advised that: 

•  Upon the report of a patient found on the floor ‘unresponsive and not breathing’, 
with no other indication of trauma or cause of injury, the 999 call handler will 
utilise the MPDS instructions to provide CPR advice to the caller.  

• 

•  CPR advice will not be discontinued until a responder is at scene to take over, 
unless there is definite evidence that the patient is no longer in cardiac arrest.  
In the event that a caller provides additional information that indicates a patient 
may be beyond help, the call handler will continue to provide CPR instructions 
unless a specific set of individual ambulance service Medical Director approved 
identifiers  are  mentioned,  which  include  the  patient  being  cold  and  stiff  in  a 
warm environment, or if the patient’s condition is incompatible with life. 
If any of the identifiers are confirmed, the MPDS will direct the call handler to 
ask an additional safety question to confirm the detail and ensure the caller is 
clear that  the patient  cannot be  resuscitated.  Only  in  this  instance would the 
call handler cease advice and clear the line. This obvious death information is 
only addressed if volunteered by the caller.  

• 

•  Where a patient is unconscious and not breathing, CPR advice will be delivered 

and no other interruption to the guidance for the caller will occur. 

Should the Coroner require any further information relevant to the MPDS, we would 
advise that you contact PDC directly. 

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 Drew, 
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