Kenneth Cully

Date of report	30 Apr 2026
Reference	2026-0248
Deceased	Kenneth Cully
Source	judiciary.uk record
Responses published	1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS
2013

Please do not include any living persons’ names in this document, in
accordance with the Chief Coroner’s PFD Publication Policy (2026).

1.

CORONER

I am Miss Lorraine HARRIS, Area Coroner for the coroner area of East Riding
of Yorkshire and City of Kingston Upon Hull.

2.

DATE OF REPORT

30th April 2026

3.

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.

THIS REPORT IS BEING SENT TO

1. NHS Pathways

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 25th June 2026. I, the coroner, may extend the period if an
appropriate application is made.

4.

YOUR RESPONSE

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.

I have a duty to send a copy of your response to the Chief Coroner.

In accordance with the Chief Coroner’s Publication Policy, you should send me
any representations regarding publication of your response. These
representations should be made at the same time as the response is provided.
I will pass any representations received to the Chief Coroner for a decision.

Please note any links to webpages included in the response will not be
checked for sensitive information prior to publication, as the information is
already online.

 The names of those who do not respond to PFD reports are regularly
published on the Chief Coroner’s webpages Non-responses to Prevention of
Future Death (PFD) reports - Courts and Tribunals Judiciary.

5.

SUMMARY OF CORONER’S CONCERN

Missing question on NHS Pathway that would identify where a bleed was
controlled or not

6.

ACTION SHOULD BE TAKEN

In my opinion unless action is taken to address the above concerns then there
is a significant risk of future deaths and I believe each of you have the power
to take such action.

7.

INVESTIGATION AND INQUEST

On 18th September 2025, I commenced an investigation into the death of Dr
Kenneth Wilson CULLY, aged 82 years.

The medical cause of death was
1a Haemorrhagic shock (exsanguination)
1b Erosion of blood vessel dorsum of left foot

How, when and where
On 17th September 2025 Kenneth Wilson CULLY, aged 82 years, made a call
to the ambulance service due to the fact he was unable to stop a catastrophic
bleed on his foot, he indicated that he was on blood thinning medication.
During the call Dr CULLY ceased responding. Due to high demand, an
ambulance was not available to attend for 1 hour and 20 minutes. When the
crew arrived at his home Meadow View, 18 Long Street, Rudston, Driffield,
East Riding Yorkshire, Dr CULLY had died. Pathology revealed that Dr
CULLY's artery and vein had lost their integrity. It would be unsafe to say
exactly when Dr CULLY died and whether an ambulance arriving more
promptly would have been able to save his life.

Conclusion

Catastrophic bleed following loss of integrity in the dorsal pedal artery and
vein.

 8.

CIRCUMSTANCES OF DEATH

 Dr Kenneth Wilson CULLY led a healthy life and he was able to
maintain this until 2022 when his health began to deteriorate.
 He became unsteady on his feet, in 8-9 months before death

had become clumsy.

 In December 2024 during an admission to hospital, it was noted
that he had a non-occlusive thrombus of the left long sapneous
vein and was advised by a hospital consultant to commence a 3
month course of Rivaroxaban.

 This blood thinning medication should have been ceased by the
surgery on 10th March 2025.  There was a human error regarding
how this medication was input on to the system which led to it
being given to Dr CULLY as a repeat prescription.

 Dr CULLY had interactions with the surgery and hospital both
before and after the recommended end date for his blood
thinning medication, providing multiple opportunities to identify
the issue with the prescription being incorrectly recorded as on
repeat.

 On 14th and 23rd January 2025 Dr CULLY had su(cid:431)ered bleeding 
from foot.  On those occasions he had telephoned nearby
family ﬁrst.

 On 17th September 2025 Dr CULLY telephoned 999 ambulance
service and reported that a scab had come o(cid:431) his foot and he 
was unable to stop the bleeding.

o It would be unsafe to say exactly how the bleed began,
evidence stated it could have happened spontaneously
for reasons such as a peak in high blood pressure, or
something as minor as knocking the scab o(cid:431).

o Pathology found that the bleed was at the dorsum of the

foot.  There was an ulcer in the location.

o Both the dorsal pedal artery and the vein had lost their
integrity and hence the bleed became catastrophic.
o The fact Dr CULLY was on blood thinning medication
would have impacted his blood’s ability to clot.

o It would also be unsafe to say how long it was after the
bleeding commenced that he made the decision to call
the ambulance.

 o The call went through to the Welsh Ambulance Service
who were dealing with calls on behalf of the Yorkshire
Ambulance Service.

o The call was categorised at this stage as a category 2.

There were no available resources to dispatch at that time
due to high demand (sta(cid:431)ing levels were regarded as 
appropriate).

o Where an ambulance response is delayed and a patient is
a high risk of deterioration like an uncontrolled bleed, it is
good practice for a healthcare professional to support
and try to manage the situation until help can arrive.  The
Clinician who sought to do this was unable to make
contact with Dr CULLY as the line had been left open.

o I ﬁnd with all the knowledge that was known (the

catastrophic bleed that was uncontained)  at the point he
stopped responding, the call should have been a category
1.  Given the availability of the ambulances and the
distance of the nearest available ambulance I do not ﬁnd
that upgrading the call would have prevented Dr CULLY’s
death.

9.

CORONER’S CONCERNS
During the course of the inquest I heard evidence giving rise to concern. In my
opinion there is a risk that future deaths could occur unless action is taken. In
the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

Dr Kenneth Wilson CULLY telephoned the ambulance service to report an
uncontrollable bleed from his foot.

Calls are taken by control room staff who do not have medical training, they
ask a series of questions and on receipt of answers are able to categorise the
priority of response required.

At the time of the incident the Advanced Medical Priority Dispatch System was
utilised.  The ambulance service now use the NHS Pathway system.  The
ambulance service, correctly pre-empting coronial concerns about
categorisation especially in light of the duty to prevent future death, sought to
check that if provided with similar information, the new NHS Pathway system
would recognise the seriousness of an uncontrolled bleed.  It appeared that
NHS Pathway may have misunderstood the concern raised by the service and

 did not wish to “endorse” what was being stated, which was not the reason for
the referral by the ambulance service.

In the new NHS Pathway system there appeared to be an insufficiency in the
questions to correctly identify the seriousness of an uncontrolled bleed (there
is no question regarding whether the bleed is controlled or not).  This could
lead to the categorisation of the call being incorrect and a delay in treating a
catastrophic event needing immediate attention.

It is my understanding that the Yorkshire Ambulance Service are willing to work
with NHS Pathways to assist them to fully understand the concern raised.

10. COPIES AND PUBLICATION OF THIS REPORT

I have a duty to send a copy of my report to every Interested Person who in
my opinion should receive it.

I also may send a copy of the report to any other person who I believe may
find it useful or of interest.

I can confirm I have sent the report to:

1.  The Family of Dr Kenneth Wilson CULLY

2.  The Yorkshire Ambulance Service

3.  Dr CULLY’s GP surgery

I also have a duty to send a copy of the report to the Chief Coroner.

You may make representations to me, the coroner, about the publication of the
contents of this report in line with Chief Coroner’s PFD Publication Policy
(2026). Any representations will be sent to the Chief Coroner alongside the
report. Please refer to box 4 above for additional information relating to the
publication of reports and responses.

SIGNATURE

Lorraine Harris

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from NHS England

Miss Lorraine Harris
Area Coroner of East Riding of Yorkshire
and City of Kingston Upon Hull
Coroner’s Service
The Guildhall
Alfred Gelder Street
Hull
HU1 2AA

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

22nd June 2026

Dear Miss Harris,

Re: Regulation 28 Report to Prevent Future Deaths – Dr Kenneth Wilson Cully
who died on 17 September 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 April
2026 concerning the death of Dr Kenneth Wilson Cully on 17 September 2025. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Dr Cully’s family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Dr Cully’s care
have been listened to and reflected upon.

Your Report raised concerns regarding insufficiency of the questions in the NHS
Pathways system to correctly identify the seriousness of an uncontrolled bleed (with
there being no question regarding whether the bleed is controlled or not) which could
lead to the categorisation of the call being incorrect and a delay in treating a
catastrophic event needing immediate attention.

As you acknowledge in your report at the time of Dr Cully’s death the call was
managed by Welsh Ambulance Service (WAST) who were dealing with calls on
behalf of Yorkshire Ambulance Service (YAS), WAST uses Advanced Medical
Priority Dispatch System (AMPDS).

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 Advanced Medical Priority
Dispatch System (AMPDS). The systems are used to prioritise 999 calls received
into Ambulance Services’ Emergency Operations Centres (EOCs).

NHS England does not manage or oversee AMPDS and we are therefore unable to
provide comment on their system.

YAS’ witness statement given by
, which YAS have provided to NHS
Pathways as part of standard feedback and reporting processes, detailed how, in their
opinion the case would have been managed if it had been dealt with by NHS
Pathways.

Background on NHS Pathways

NHS Pathways 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. The tool also supports online triage and 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 NCAG. Alongside this external scrutiny, NHS
Pathways aligns its content with up-to-date national clinical guidance, including
guidance from the National Institute for Health and Care Excellence (NICE),
Resuscitation Council UK and UK Sepsis Trust.

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 to identify 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 specially trained non-clinical health advisors. These
advisors complete a rigorous training programme and are supported at all times 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 license that clinical
supervision and escalation support must be available 24/7.

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

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 training programme to ensure they can use the NHS
Pathways algorithm safely and effectively. 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. As above, 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 initial core role training, both health advisors and clinicians are required to
undertake mandatory training aligned to each new release of the NHS Pathways
system, which typically occurs every 12 weeks. This ensures that staff remain up to
date with any changes to clinical content, pathways, and system functionality. In
addition, they have access to a comprehensive suite of ongoing learning resources,
including ‘Hot Topics’, case studies and e-learning packages, which support
continuous professional development and dissemination of learning.

Alongside this, providers are required to undertake regular quality assurance
processes, including monthly audit of calls. These audits assess a range of core
competencies, including the effective use of probing, and provide structured feedback
to support ongoing development and safe practice.

Within NHS Pathways, health advisors are trained and expected to actively probe to
clarify and refine the information provided by the caller. This is a fundamental
component of the NHS Pathways model and forms an important part of its safety
design.

NHS Pathways Assessment of Bleeding

In respect of the NHS Pathways system, we can confirm the following occurs within
the triage for all age groups:

•

Immediate establishment of whether there is, or has been, any bleeding
present, even if it has stopped at the time of the call;

• Whether the bleeding has been “heavy” within the last 2 hours. This establishes
if there is serious, or life-threatening bleeding. The supporting information
states that this may be described as “spurting, spraying, gushing or pouring, or
may have made a puddle or soaked through a towel.” The system describes
that this may equate to a loss of a mugful of blood in adults through to an egg
cupful for younger age groups;

• The triage system then seeks information about the approximate amount of
blood lost: for adults “2 mugfuls or more” progresses to asking about “bleeding
from a wound or break in the skin” and whether the “blood is spraying or
spurting out.” Answering ‘Yes’ to this, as from the information provided may
have been the case in this incident, would result in a Category 2 ambulance
disposition for Major Blood Loss. From the information submitted by YAS
this confirmed that this is the same categorisation as this case was coded in
the other triage system;

• The NHS Pathways system further prompts call takers to ask if the wound is
covered by a dressing. If the answer to this is “Yes” the system seeks to
establish if “...there is blood dripping or soaking through (the dressing)...” This
further assists in establishing where bleeding is not controlled.
In other cases where an ambulance disposition has not been reached, the
system prompts questions to ascertains what the bleeding is like at the time of
the call. I.e. is it “getting worse”, “about the same”, “slowing down but still
bleeding”, or whether the bleeding has stopped.

•

To summarise, a comprehensive assessment of bleeding occurs in NHS Pathways
triage. This is at the beginning of the assessment, where immediate threats to life are
ruled out. This assessment has been developed with oversight from the National
Clinical Governance Assurance Group for NHS Pathways, who have reviewed and
signed off the system relating to this type of clinical scenarios, cases and prior
incidents.

From the information provided regarding Dr Cully, I would wish to convey to you that
the serious nature of such bleeding would have been dealt at least as well as in the
other system. And whilst the exact wording between the two systems differs. NHS
Pathways does identify volumes of blood lost, nature of bleeding and picks up signs
of catastrophic bleeding such as pooling or soaking through dressings, rather than
asking a clinical judgement to be made by the caller as to whether bleeding is
uncontrollable or dangerous. When uncontrolled bleeding is identified, as is most likely
in a case presenting with the same or similar symptoms, the recommended disposition
in line with up-to-date national clinical guidance is for a Category 2 ambulance for
Major Blood Loss. This is the same ambulance response outcome as in this case,
although tragically due to high demand, an ambulance was not available to attend Dr
Cully for 1 hour and 20 minutes.

NHS England is in close contact with providers using the NHS Pathways system and
will liaise with Yorkshire Ambulance Service to confirm/discuss any learnings from this
case.

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 Dr
Cully, 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

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