Hollie Loraine

Mr David Place 
HM Senior Coroner for Sunderland 
Office of HM Coroner for Sunderland 
and HM Coroner’s Courts  
City Hall 
Plater Way 
Sunderland  
SR1 3AA 

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

14th May 2026  

Dear Coroner, 

Re:  Regulation 28 Report  to  Prevent  Future Deaths  –  Hollie Elizabeth Loraine 
who died on 30th August 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st April 
2026 concerning the death of Hollie Elizabeth Loraine on 30th August 2025. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Hollie’s  family  and  loved  ones.  NHS  England  is  keen  to 
assure the family and yourself that the concerns raised about Hollie’s care have been 
listened to and reflected upon.   

Your report raises concerns that the national NHS pathways telephone triage system 
does not provide guidance to health advisors dealing with calls with patients who are 
expressing  suicidal  ideation  and  whether  the  advisor  ought  to  maintain  telephone 
contact with them and how to ameliorate the risk of that patient ending their own life. 

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 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.  Alongside  this  external 
scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, 
including  NICE  (National  Institute  for  Health  and  Care  Excellence),  Resuscitation 
Council UK 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 while maintaining safety. 

In  telephone  settings,  assessments  are  conducted  by  trained  non-clinical  Health 
Advisors.  These  advisors  complete  a  rigorous  training  programme  and  are  always 
supported by clinicians. If a case 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. 

Clinical alignment of Ambulance Response Codes between systems 

The  NHS  Pathways  system  is  developed  and  maintained  by  the  Transformation 
Directorate of NHS England. The ambulance responses (dispositions) are ratified by 
the National Ambulance Services Medical Directors (NASMeD). This is an advisory 
group to Association of Ambulance Chief Executives (AACE), comprising the Medical 
Directors of ambulance services in England, Wales, Scotland and Northern Ireland. 
This group endorses the categorisation of ambulance codes across both AMPDS and 
NHS  Pathways,  and  these  codes  are  further  ratified  by  the  Emergency  Call 
Prioritisation Advisory Group (ECPAG). 

The purpose of the 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  membership  consists  of  AACE,  NHS  England,  NASMeD, 
ambulance Heads of Control and representatives of the principle triage systems. 

NHS  England  has  led  several  national  discussions  regarding  the  management  of 
suicidal  callers.  The  NHS  Pathways  system  has  been  adjusted  to  accommodate 
changes and the introduction of a national process. In this process, ambulance and 
NHS  111  providers  facilitate  an  urgent  clinical  review  for  cases  flagged  as  ‘Risk  of 
Suicide’,  which  is  further  described  below.  These  changes  acknowledge  that  risks 
relating to suicidal intent are complex and may be multifactorial. Although non-clinical 
health  advisers  receive  significant,  structured  training  to  use  the  NHS  Pathways 
system, this system is organised to triage cases for further clinical input or assessment 
in most cases.  

In the NHS Pathways triage system, where the patient or caller reports either a suicide 
attempt  or  active  suicidal  intent,  the  lowest  disposition  that  may  be  reached  is  a 
Category  3  emergency  ambulance  response.  A  higher  category  of  ambulance 
response would be reached where other relevant symptoms/conditions, such as loss 
of consciousness or difficulty breathing, are present at the time of assessment. These 

 
 
 
 align  to  the  Ambulance  Response  standards  set  by  the  Ambulance  Response 
Programme (ARP).  

In  early  2019,  NHS  England,  with  endorsement  of  NASMeD  and  other  associated 
groups, instructed ambulance and NHS 111 providers that any suicide-related cases 
reaching a Category 3 ambulance outcome should receive an urgent remote clinical 
review  facilitated  by  a  clinician  working  with  the  999  ambulance  control  room.  This 
enables a prioritised clinical assessment, considering the individual circumstances of 
each  case.  Such  assessments  should  determine  the  appropriate  level  of  response, 
which  could  include  upgrading  the  response  to  a  Category  1  or  2  emergency 
ambulance response.  

To facilitate this, 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.  

In April 2021, NHS England in conjunction with the Association of Ambulance Chief 
Executives (AACE) published a new operational procedure for all ambulance services 
in  England  entitled  ‘Category  3/999  Overdose  and  Suicidal  Ideation  Calls:  Initial 
Assessment  of  Lethality/Toxicity  Principles  Document’.  This  document  followed  a 
detailed review that had been undertaken to consider agreed ambulance control room 
processes to ensure suicidal patients receive the correct clinical response. This review 
was  also  the  catalyst  for  NHS  England  contacting  all  ambulance  and  NHS  111 
services in early 2019 as described above.  

In November 2023, the 999 Overdose and Suicidal Ideation Calls; Initial Assessment 
of  Lethality/Toxicity  Principles  Document,  which  was  issued  in  April  2021,  was 
reissued following a review by the ECPAG and NASMeD. The process outlined in that 
document  appears to have been followed within this particular case. 

NHS Pathways has additionally provided significant training information regarding the 
assessment  of  patients  suffering  from  mental  health  conditions,  including  training 
around the sensitive management of calls with a mental health element. This training 
is included in Core Module One which all Health Advisors must complete. Core Module 
One includes mandatory assessments which must be passed.  

The  training  around  sensitive  management  of  calls  with  a  mental  health  element 
explains that the manner of communication is just as important as the words said. This 
includes  being  warm,  empathetic  and  sensitive  in  approach.  Tone  of  voice  is  also 
important.  

The training references the importance of active listening and how to respond to the 
patient sensitively, and explains that there may be situations when the Health Advisor 
needs to stay on the phone with the patient.  

 
 
 
 
 
 
 
 Individual service providers develop their own policies for managing patients who are 
alone, allowing organisations to make local decisions based on continually changing 
operational constraints. 

Health Advisors are taught to listen carefully to what a caller says and to pick up on 
not just the answer to a clinical question, but to everything that is said or referred to. If 
a Health Advisor has any concerns about a patient being alone in a life-threatening or 
urgent situation, they should seek clinical support or transfer the call to a clinician via 
the system functionality of ‘early exit’.  
NHS Pathways has not been privy to the call recording of this case and therefore are 
unable to follow the exact route taken during the call in question. However, from the 
information available and following review of the possible route in NHS Pathways, it 
can be confirmed from a system perspective, there is a question that asks about the 
immediacy of the potential suicide scenario.  

Following this, if the caller is alone the Health Advisor is presented with the following 
care advice at the end of the call: 

 
 
 
 
 However, it is overall an operational decision for each ambulance service whether a 
health advisor should stay on the line with any caller. Ambulance services have access 
to their real time demand levels which NHS Pathways does not.   

Regional response  

North  East  and  Yorkshire  colleagues  have  advised  that  the  Integrated  Care  Board 
(ICB) are overseeing the North East Ambulance Service review of this case and have 
shared the Investigation Conclusion Report with us. The Report found that all clinicians 
acted appropriately. The report also notes that a separate review of NEAS dispatch 
processes confirmed that although there was a delay before an ambulance was able 
to attend to Hollie, there were no opportunities at that time to reach Hollie sooner.  

The ambulance crew who attended had noted in the electronic patient record an issue 
with the Zoll, which is a device used by paramedics and other ambulance practitioners 
in the management of cardiac arrests. When the pads were in place, CPR mode would 
not activate on the Zoll. A clinical audit found that the care at the scene was carried 
out in line with Advanced Life Support guidelines.  Although Hollie’s ECG rhythm was 
displaying correctly, it was non-shockable, meaning that the issue with the Zoll and 
the need to change the defibrillator pads did not affect the crew’s resuscitation efforts. 
The  team  continued  appropriate  life-saving  interventions  throughout.  The  Zoll  pads 
were replaced within two minutes of error identification, and the crew raised a separate 
safety incident regarding the error. The Zoll device has been sent back to Zoll by our 
equipment team for further investigation. 

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 Hollie, 

 
 
 
 
 
 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