Jardine Williams

Response to HM Assistant Coroner's Prevention of Future Deaths Report 

This  document  has  been  prepared  in  response  to  HM  Assistant  Coroner's  Prevention  of  Future 
Deaths Report ('the PFD Report') issued on 16 March 2026, following the inquest touching upon the 
death of Miss Jardine Williams. 

Firstly, I would like to once again offer my sincere condolences to the family of Miss Williams for their 
loss. 

This document has been prepared following my review of the PFD Report and my consideration of 
the inquest bundle provided to me by the Coroner's Officer on 24 February 2026. For the avoidance 
of  doubt,  Cumbria  Health  (formerly  Cumbria  Health  on  Call)  had  not  been  designated  Interested 
Person status for the inquest, nor had I (as the author of the statement dated 20 May 2025, provided 
on Cumbria Health's behalf) been invited to attend the inquest to give oral evidence. 

In line with our statutory duty, Cumbria Health has reported themselves to the North East and North 
Cumbria Integrated Care Board and the CQC following the receipt of the PFD Report. This response 
will also be shared with those bodies. 

HM Assistant Coroner's Concerns 

I understand HM Assistant Coroner's concerns as set out in the PFD Report to be as follows:  

1.  The flow of information between North West Ambulance Service ('NWAS') and Cumbria Health 
was "unclear and at times appeared to be confused." In particular, the information passed by 
NWAS to Cumbria Health "appeared to be limited and may not have provided the receiving 
handler with the full picture of the situation." 

2.  There was a delay in Cumbria Health handing Miss Williams' case back to NWAS after the 

third unsuccessful call. 

Background Information 

I set out below relevant information regarding the Acute Patient Assessment Service (referred to as 
the 'APAS 999 service') that Cumbria Health provides to NWAS.  

The APAS 999 service has been in operation since 2017 and applies to calls made by patients to 999 
(either directly or when redirected by NHS 111) which are triaged by NWAS as Category 3 or Category 
4 calls. For clarification, Category 3 and 4 calls are for urgent or less urgent medical issues that are 
not  immediately  life-threatening.  The  APAS  999  service  is  based  on  a  formal  Memorandum  of 
Understanding between Cumbria Health and NWAS.  

When  a  call  is  received,  NWAS  triages  the  call  and,  where  appropriate,  refers  it  to  a  Clinical 
Assessment Service ('CAS') provider, such as Cumbria Health. The patient then receives a callback 
from the CAS provider for further detailed assessment. There is a pre-agreed list of symptoms which 
NWAS use to determine which cases are suitable to send to CAS providers and a list of presentations 
which are excluded.  

Of  relevance  to  Miss  Williams'  case,  whilst  CAS  providers  can  assist  with  some  mental  health 
presentations, overdose or suicidal presentations are on the exclusion list.  

cumbriahealth.co.uk 
4 Wavell Dr, Rosehill Industrial Estate, Carlisle CA1 2SE 
t 01228 514830 e ch.office@cumbriahealth.nhs.uk 
Registered in England & Wales. Company No. 03121117 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 HM Assistant Coroner's Concerns 

Flow of Information between NWAS and Cumbria Health 

When Miss Williams' case was transferred by NWAS to Cumbria Health, the comments provided by 
NWAS  were  limited  to  the  following:  “F-  can’t  do  it  anymore  MH”.  The  PFD  Report  suggests  that 
NWAS was aware of more information, including that Miss Williams was suicidal: "In this call Miss 
Williams confirmed she had been experiencing worsening mental health problems and had suicidal 
thoughts, as well as a plan and an intention to carry out that plan."  

As  set  out  above,  suicidal  presentations  are  expressly  excluded  from  the APAS  999  service. As  a 
result, Miss Williams' case should not have been transferred by NWAS to Cumbria Health. Rather, it 
should have been managed in line with NWAS's other established protocols. 

Furthermore, had further information been provided by NWAS to reflect Miss Williams' suicidal plans 
and intent, Cumbria Health would have immediately handed the call back to NWAS stating that the 
call was not appropriate for primary care management, and NWAS would then have managed the 
case in line with their established protocols. 

A  learning  event  meeting  was  held  with  NWAS  in  March  2026.  A  key  issue  discussed  and 
subsequently agreed was that, as set out above, Miss Williams' case should not have sent to Cumbria 
Health. It was also agreed that NWAS and Cumbria Health will continue to work closely together in 
relation to the management of APAS 999 service calls. They will continue to share significant adverse 
incidents with each other and hold quarterly meetings, and ad hoc reactive meetings if a pressing 
concern arises. The next meeting is anticipated to take place in July 2026. 

Delay in Handing Back the Call to NWAS 

Cumbria Health's ‘No Show’ Standard Operating Procedure states that a clinician should attempt to 
call a patient three times with five minute intervals. In relation to APAS 999 service calls, if the clinician 
is unsuccessful in speaking with the patient after following this procedure, the call should be handed 
back  to  NWAS  stating  “failed  contact”,  and  then  NWAS  will  manage  the  case  in  line  with  their 
established protocols. 

I have reviewed the ‘No Show’ Standard Operating Procedure (which was last reviewed on 10 July 
2025 and is due to be reviewed again on around 10 July 2027) and consider that it is fit for purpose. 
This  policy  is  a  long-standing  part  of  Cumbria  Health's  operational  approach  to failed  encounters, 
developed originally by both senior clinicians and operational managers.  

The policy was, unfortunately, not correctly applied by the clinician who conducted the third and fourth 
call attempts.  

During a supervision session in April 2026, I discussed Miss Williams' case with the relevant clinician. 
The clinician identified their error and its origin, confirmed that they will reflect on our discussion and 
amend their practice going forward to avoid a reoccurrence, and agreed to undertake further targeted 
learning  in  the  form  of  reviewing  Cumbria  Health's  key  policies  and  procedures,  including  the  ‘No 
Show’  Standard  Operating  Procedure  (discussed  above)  and  the  Clinical  Hub  Operational  Policy 
(discussed below). 

Wider learning has also taken place in the form of emails and monthly newsletters circulated to  all 
clinicians in March 2025 and November 2025. The case was also presented as a case review at the 
August  2025  Cumbria  Health  Clinical  Forum,  which  was  attended  by  Cumbria  Health  clinicians 

cumbriahealth.co.uk 
4 Wavell Dr, Rosehill Industrial Estate, Carlisle CA1 2SE 
t 01228 514830 e ch.office@cumbriahealth.nhs.uk 
Registered in England & Wales. Company No. 03121117 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (including  the  relevant  clinician  in  Miss  Williams'  case)  to  communicate  the 
lessons learned from this event. 

In addition to the clinicians actioning the APAS 999 service calls, Cumbria Health has control room 
supervisors who have a role in overseeing Cumbria Health's working call list to ensure that calls are 
not left unattended and do not breach time guidelines.  

In May to July 2025, Cumbria Health's Chief Operating Officer held meetings with control room staff 
to  discuss  Miss  Williams'  case  and  to  develop  new  guidelines  on  the  management  of APAS  999 
service calls. A new Clinical Hub Operational Policy was ratified on 31 July 2025 and sets out clear 
guidelines regarding how APAS 999 service calls should be managed to ensure time breaches do not 
occur. Control room supervisors now proactively manage these calls and send targeted messages to 
clinicians  who  may  be  available  to  pick  them  up.  If  time  breaches  occur  (usually  due  to  high  call 
volumes), the cases are handed back to NWAS stating "time expired hand back to NWAS". This new 
process was circulated to all staff on 29 August 2025. 

In January 2026, the procedure was refined further and now includes more prescriptive timelines for 
how APAS 999 service calls should be prioritised and returned to NWAS, based  on their category. 
This update was cascaded to all clinicians and control room staff by email on January 2026 and is 
intended to be incorporated into the Clinical Hub Operational Policy when it is reviewed later this year. 

If Cumbria Health may be of further assistance, please do not hesitate to contact me. 

Yours sincerely 

Medical Director  
MB ChB DMJ FRCGP 

28 May 2026 

cumbriahealth.co.uk 
4 Wavell Dr, Rosehill Industrial Estate, Carlisle CA1 2SE 
t 01228 514830 e ch.office@cumbriahealth.nhs.uk 
Registered in England & Wales. Company No. 03121117

Mr Andrew Cousins 
HM Assistant Coroner for the County of Cumbria 
HM Coroner’s Office  
Fairfield  
Station Road  
Cockermouth 
Cumbria  
CA13 9PT 

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

6th May 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Jardine Williams who 
died on 24 March 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  16 
March 2026 concerning the death of Jardine Williams on 24 March 202. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Miss Williams’ family and loved ones. NHS England is keen to 
assure the family and yourself that the concerns raised about Miss Williams’ care have 
been listened to and reflected upon.   

Your report raised concerns around the lack of pathway questions seeking to address 
the immediacy of plans when a patient indicates plans to  end their own life, and that 
the  absence  of  this  question  from  the  pathway  and  thus  the  absence  of  such 
information may not have assisted the call handler in compiling as clear a picture as 
could have been possible about the case they were receiving.  

Background of NHS Pathways Clinical Decision Support System 

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 
systems.  The  tool  also  supports  online  triage,  in-person  and  enhanced  clinical 
assessments via modules such as the NHS Pathways Clinical Consultation Support 
(PaCCS) system.  

The safety of the 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 
external  scrutiny,  NHS  Pathways  aligns  with  up-to-date  national  clinical  guidance, 
including National Institute of Health and Care Excellence (NICE), UK Resuscitation 
Council and UK Sepsis Trust.  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 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 
to less urgent symptoms, identifying the most appropriate level of care. The tool is not 
diagnostic.  Instead,  it  works  by  systematically  ruling  out  more  serious  causes  of 
symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically 
necessary to minimise triage time whilst maintaining safety.  

Telephone assessments are conducted by trained non-clinical health advisors. These 
advisors complete a rigorous training programme and are supported, at all times, by 
clinicians.  If  a  patient’s  presentation  is  complex  or  unclear,  health  advisors  are 
required  to  escalate  to  clinical  colleagues.  It  is  therefore  a  condition  of  the  NHS 
Pathways licence is that clinical supervision and escalation support must be available 
24/7.  

In the NHS Pathways triage system, where the patient or caller reports either a suicide 
attempt or active suicidal intent, the lowest endpoint (disposition) that may be reached 
is a Category 3 emergency ambulance disposition. A higher category of ambulance 
disposition  would  be  reached  where  other  relevant  symptoms/conditions  –  such  as 
loss of consciousness or difficulty breathing, are present at the time of assessment. 
This  aligns  to  the  ambulance  response  standards  set  by  the  Ambulance  Response 
Programme (ARP).  

A new disposition code was developed in the NHS Pathways  product in April 2019. 
‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ enables 
clearer visibility of such cases in the Computer Assisted Dispatch (CAD) system used 
by staff in ambulance services, supporting them to readily identify the cases requiring 
prioritised review due to suicide attempt. Furthermore, NHS Pathways provides a code 
identifying suicidal intent – the means and a plan to complete suicide (SD4244-AMB 
suicidal means  and  a plan). The  new disposition  code  was  created  within  the  NHS 
Pathways  system  in  April  2019,  following  the  presentation  and  ratification  of  the 
changes to the former NHS Pathways National Clinical Governance Group (NCGG) in 
February 2019. This new disposition code was deployed to all service users as part of 
Release  19  in  October  2019  as  planned  and  following  sign-off  by  Emergency  Call 
Prioritisation Advisory Group (ECPAG) on 3 July 2019.  

NHS  Pathways  has  additionally  provided  a  significant  volume  of  training  materials 
regarding the assessment of patients with mental health conditions to all provider of 
NHS  111  and  the  ambulance  services  that  use  NHS  Pathways,  and  has  offered  to 
work with and to advise North West Ambulance Service (NWAS) on how best to triage 
mental health situations. Regional clinical quality colleagues for the North West have 
also been made aware of your Report for the appropriate assurance purposes.  

NHS  Pathways  does  not  have  oversight  of  local  ambulance  queues  or  their 
management, and note that it can be the case that waiting times may be longer than 
the national response times due to local resourcing and demand pressures. Given the 

 
 
 
 
 
 
 
 significant consideration nationally of the management of callers at risk of suicide in 
recent  years,  and  the  fact  that  this  has  resulted  in  system  changes,  national 
discussions and mandates, NHS England is not considering a further system change 
to NHS Pathways at this time, but (as with all clinical content). This will remain under 
review as and when new evidence or guidance emerges.  

In  this  particular  case,  it  appears  from  your  report  that  the  NHS  Pathways  triage 
system did elicit the correct information  from the patient  which triggered the correct 
nationally approved ambulance response.  

NHS Pathways has not been privy to the call recording of this case and is therefore, 
unable to follow the exact route taken during the call in question. However, from the 
information provided in your report and following review of the NHS Pathways system, 
it  can  be  confirmed  that  there  is  a  question  that  asks  about  the  immediacy  of  the 
potential suicide scenario.  The question is worded ‘do you feel you are  going to do 
that now?’. The question  rationale is for the health advisor handling the call ‘to find 
out if there is immediate risk of a suicide attempt’. The supporting information available 
for the health advisor states ‘this means the patient is intending to end their own life 
now’. Please see the screenshot below. This question presents for both first and third 
party callers and will generate a Category 3 Emergency Ambulance Response for Risk 
of Suicide, as detailed above.  

In  April  2021,  NHS  England  issued  guidance  to  ambulance  services  relating  to 
overdoses taken with suicidal intent. This was further updated in November 2023 to 
include  callers  who  reach  a  Category  5  disposition  (hear  and  treat).  The  guidance 
highlights the critical importance of clinical oversight and review and sets out that: 

•  Where a potential threat of suicide is declared, an urgent clinical review should 
take place within 30 minutes or the case must be automatically upgraded to a 
Category 2 if this does not occur within 40 minutes.  

•  The initial clinical review should consider any ongoing suicidal ideation with a 

specific plan/means.  

 
 
 
 
 
 
 NHS  England’s Emergency  Call Prioritisation  Advisory  Group  (ECPAG)  wrote to all 
ambulance  trusts  asking  them  to  confirm  compliance  with  all  aspects  of  the  NHS 
England guidance on ‘999 overdose and suicidal ideation calls’. NWAS confirmed that 
appropriate measures were in place as per NHS England guidance. To ensure this 
remains  the  case,  NHS  England  will  review  NWAS’  current  operational  practise  in 
relation to overdose and suicidal ideation incidents to ensure alignment with national 
guidance.  

Regional response  

NWAS  have  advised  that  colleagues  from  the  Trust  attended  the  Inquest  and  are 
currently drafting its own formal response to the Regulation 28 concerns raised by HM 
Coroner.  

All incidents that are pushed to external Clinical Assessment Service (CAS) providers 
for  validation  of  ambulance  outcomes,  including  those  presenting  with  overdose  or 
suicidal ideation, are reviewed by senior clinicians who then ‘pushes’ the incident to 
the CAS provider. NWAS have advised they are compliant with the requirement for a 
timely  clinical  review  of  such  cases.  NWAS  have  advised  that  in  the  specific 
circumstances of this case, the initial transfer of the call to Cumbria Health On Call 
(CHOC)  should  not  have  occurred  as  suicide  related  calls  fall  outside  of  their  CAS 
criteria. As such, NWAS is reviewing the incident further to ensure that incidents are 
passed as compliant with the relevant service acceptance criteria. NWAS have made 
amendments to their CAD systems to allow for automatic upgrade when any clinical 
review  has  not  taken  place,  as  per  the  national  specification.  In  addition,  NWAS 
operated a proprietary question for all overdose cases which provides an opportunity 
for incidents to be upgraded to a Category 2 based on the substance ingested being 
at high risk. NWAS operates robust clinical oversight within its Contact Centres, the 
safety of patients with mental health needs remains a priority for the Trust.  

For further information on NWAS’ system changes and for their review of this incident, 
please contact them directly or refer to their own response to your 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 Miss 
Williams, 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 Director of Patient Safety  
NHS England