Daniel Forrest

Ms Joanne Andrews 
HM Coroner  
West Sussex, Brighton and Hove  
The Coroner’s Office 
Woodvale  
Lewes Road 
Brighton  
BN2 3QB 

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

3 August 2026 

Dear Ms Andrews, 

Re: Regulation 28 Report to Prevent Future Deaths – Daniel Charles Forrest 
who died on 1 October 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  15 
June  2026  concerning  the  death  of  Daniel  Charles  Forrest  on  1  October  2025.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Mr Forrest’s family and loved ones. NHS England is 
keen  to  assure  the  family  and  yourself  that  the  concerns  raised  about  Mr  Forrest’s 
care have been listened to and reflected upon.   

Your Report raised the following concerns:  

1.  The Southeast Coast Ambulance Service NHS Foundation Trust ‘SECAMB’ are 
incorrectly  advising  callers  that  an  ambulance  is  being  arranged,  when  any 
Category 3 or 4 dispositions are required to be validated by clinical staff before 
they can be added to the ambulance dispatch queue.  

2.  NHS Pathways does not allow callers to be advised of the estimated time that 
they  may  have  to  wait  for  ambulance  attendance.  SECAMB  have  requested 
that  the  wordings  provided  by  NHS  Pathways  be  altered  so  that  there  is 
provision to give further information to callers about how long they may wait for 
an ambulance to attend but this has previously been declined by NHS England.   

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), 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 while maintaining safety. 

In  telephone  settings,  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 case is complex or unclear, health advisors are required 
to  escalate  to  clinical  colleagues.  It  is  therefore  a  condition  of  the  NHS  Pathways 
licence (entered into by NHS 111 and 999 providers in order to use the NHS Pathways 
content) that clinical supervision and escalation support must be available 24/7. 

Clinical alignment of Ambulance Response Codes between systems 

In  2017  NHS  England  undertook  a  review  of  the  categorisation  of  ambulance 
responses.  This  programme  of  work  was  known  as  the  Ambulance  Response 
Programme (ARP). Further information about this can be found here NHS England » 
Ambulance Response Programme. As part of this, and ongoing since, activities are 
managed  by  NHS  England’s  National  Ambulance  Team  to  ensure  the  alignment  of 
clinical scenarios between the triage systems in use in the sector. These activities are 
undertaken in partnership with the Ambulance sector. 

The  NHS  Pathways  system  is  developed  and  maintained  by  the  Transformation 
Directorate of NHS England. The ambulance responses, or dispositions, are ratified 
by the National Ambulance Services Medical Directors (NASMeD). This is an advisory 
group  to  the  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, 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 principal triage systems. 

1. Call handler advice that an ambulance is being arranged 

 
 
 
 Following review of a case, and categorisation to an ambulance dispatch category, the 
case  is  transferred    to  the  ambulance  service.  The  information  captured  in  NHS 
Pathways may allow a clinician to reassess and re-categorise the call, depending on 
the clinical context. This can happen either without direct contact with the patient or 
following  further  contact.  The  Ambulance  Trust’s  Computer  Aided  Dispatch  (CAD) 
system, rather than NHS Pathways, is used to manage the validation process. So, for 
incidents  that  are  eligible  for  clinical  validation,  any  delivered  call  exit  script  should 
outline  that  patients  may  receive  a  call  back  from  a  clinician  to  conduct  a  further 
assessment  and  who may guide  them  towards  an  alternative pathway  of  care,  and 
patients will be asked to keep their phone line free. However, if the clinician is unable 
to contact the caller, as in this case, then the original categorisation would still stand, 
ie an ambulance would be dispatched in line with that prioritisation.  

2. Providing callers with an estimated waiting time 

For  999  calls,  all  ambulance  services  should  have  in  place  call  exit  scripts  and 
procedures for dealing with response delays when under operational pressure. NHS 
England  has  Resource  Escalation  Action  Plan  (REAP)  levels  which  are  used  to 
manage operational pressures across ambulance services. NHS England supports a 
position that callers should be provided with sufficient information to make informed 
decisions, including whether an ambulance has been dispatched to the patient.  

NHS England have been approached previously to provide a standard national script 
for instances where the Ambulance Response Programme (ARP) standards are not 
going to be met, and has worked with ambulance services to develop these. However, 
after  deployment,  due  to  the  complexities  of  operational  delays  REAP  levels  and 
availability of clinical resource, NHS England were asked by ambulance services to 
reverse  this  work,  and  maintain  operational  information,  such  as  wait  times  within 
emergency operations centres, as outside the remit of NHS Pathways triage. REAP 
level  and  rapidly  changing  operational  factors  can  also  impact  which  calls  may  be 
subject to clinical validation and need alternative instructions at different times, and 
how  long  an  individual  ambulance  dispatch  is  likely  to  take.  Therefore,  these 
circumstances  are  now  managed  locally,  by  the  individual  ambulance  services, 
following their own internal governance and Standard Operating Procedures (SOPs).  

NHS England is aware that these situations are complex and difficult to manage. After 
reviewing  the  sequence  of  events  described  in  the  inquest,  regarding  the  timing  of 
contacts,  we  acknowledge  the  situation  would  have  been  deeply  worrying  for  the 
family.  

For  the  reasons  provided  above,  operation  information,  such  as  wait  times  within 
emergency operations centres sits outside the remit of triage and is best placed to be 
dealt with locally by individual Ambulance Trusts.  

As above the National Ambulance team have advised that for incidents that are eligible 
for  clinical  validation,  patients  should  be  advised  that  they  may  receive  a  call  back 

 
 
 
 
 
 
 from a clinician for further assessment, who may direct them to an alternative pathway. 
Patients should be asked to keep their phone line free.  

All ambulance services are required to provide appropriate exit scripts for Category 3/ 
Category  4  codes  or  dispositions.  For  999  calls,  ambulance  services  should  have 
procedures and call exit scripts in place to manage response delays during periods of 
operational pressure. While the specific wording of exit scripts is determined locally, 
the  scripts  must  include  safety  advice  about  what  action  to  take  if  the  patient’s 
condition deteriorates.  

NHS England supports a position that callers should be given sufficient information to 
make  informed  decisions,  including  whether  an  ambulance  has  been  immediately 
dispatched  to  the  patient  or  if  a  delay  is  likely  due  to  demand  or  other  operational 
pressures.  

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  Mr 
Forrest, 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