Muluembet Yohanes

Ms Melanie Sarah Lee 
HM Assistant Coroner  
Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London  
N1C 4PP 

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

17th August 2026  

Dear Ms Lee,  

Re: Regulation 28 Report to Prevent Future Deaths – Muluembet Yohanes who 
died on 25 February 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  17 
June 2026 concerning the death of Muluembet ‘Mulu’ Yohanes on 25 February 2025. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to  Mulu’s family and loved ones. NHS England  is 
keen to assure the family and yourself that the concerns raised about Mulu’s care have 
been listened to and reflected upon.   

Your Report raised the following concerns:  

1.  London Ambulance Service (LAS) informed you that they have advised NHS 
Pathways of Mulu’s case and recommended that neurosurgery be added to the 
supporting  information  for  ‘head  injury’  and  ‘vomiting’  algorithms.  You  were 
unclear if this action had been agreed upon and what the timescales for are. 

2.  Without  a  dedicated  pathway  for  ‘neurosurgery’,  it  is  left  to  call  handlers  to 
choose the most appropriate pathway. ‘Head injury’ is not reflective of elective, 
non-trauma surgery.  

3.  Pathways does not include a question for post-discharge surgery patients about 
whether they have been given discharge, worsening or red flag advice by their 
surgical team.  

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.  

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 
specially trained non-clinical health advisors and in some cases by a clinician. These 
advisors  complete  a  comprehensive,  structured  training  programme  to  ensure  they 
can use the NHS Pathways algorithms safely and effectively. If a case is complex or 
unclear,  health  advisors  are  required  to  escalate  to  clinical  colleagues.  The  NHS 
Pathways licence (which NHS 111 and 999 providers must enter into in order to use 
the system) 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. 

A fundamental component of training is learning how to manage complex calls. The 
"complex call process" provides a clear protocol for health advisors to seek assistance 
or transfer a complex call to a clinician. This process should be followed in situations 

 
 
 
 involving declared medications, medical procedures, or terminology that complicates 
triage. A complex call is one which isn’t straightforward, or where the Health Advisor 
is working at or beyond the limits of their knowledge or experience.  This approach is 
reinforced by the training motto:  

“If in doubt, shout.” 

1.  Adding Neurosurgery to NHS Pathways algorithms at the recommendation 

of LAS 

The NHS England NHS Pathways Team formally received the case on 30th July 2026. 
This was reviewed by the team on 31st July 2026.   

In  respect  of  the  request,  the  algorithms  do  have  ‘key  points’  which  help  a  health 
advisor know which pathway to use, and which are supported by an extensive training 
and mentoring package all health advisors must undergo before they are able to use 
the  live  system.  This  includes  multiple  scenarios  to  familiarise  themselves  with  the 
range of different options. 

However, a specific situation such as previous neurosurgery would not  generally be 
added as a key point, and so the NHS Pathways team do not consider that this specific 
change should be made. The triage system uses a symptom-based approach rather 
than having separate specific routes for every possible medical procedure or medical 
condition, as it would not be practical or possible to add a question on every single 
possible scenario. This means that within the triage assessment different questions 
will be presented to establish symptoms of concern, and as noted above, serious and 
potentially  life-threatening  symptoms  are  assessed  first  to  ensure  rapid  escalation, 
such as reaching an ambulance outcome 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. Therefore, specific situations or 
conditions are not referenced, as instead there are questions to identify symptoms that 
indicate onward need for care such as signs of confusion, drowsiness, not responding 
normally, as well as other symptom markers. 

Instead, to address risks that may arise from such situations, and to cover the issue 
as in this case, where a patient has had recent treatment or been given specific advice 
in advance, NHS Pathways also has a clear route for callers who have what is referred 
to as ‘Predetermined management plans.’ All health advisors must complete training 
associated  with  this  within  their  mandatory  core  module  training.  This  includes 
scenarios  of  when  this  route  applies  including:  ‘Recent  hospital  discharge;  Medical 
devices fitted e.g. pacemaker; chronic, terminal, rare or serious illnesses; Patient with 
other special needs’. 

This route allows a caller to identify any symptoms related to any hospital discharge 
information (including recent neurosurgery) or instructions and allows onward referrals 
for an ambulance, Emergency Department attendance or returning to a specific ward 
for example. It also allows for referral for a further assessment by a doctor or health 
care professional. In light of this case, the NHS Pathways team will review this training 

 to  ensure  that  the  intended  route  to  check  whether  patients  may  have  such  a 
predetermined management plan is as clear as possible.  

Additionally, even if the predetermined management plan route was not followed and 
the recent surgery and post operative instructions were not shared, the triage pathway 
for  vomiting  and/or  nausea  with  or  without  abdominal  pain,  also  includes  initial 
questions to ensure there are no ‘red flag’ symptoms such as, unconsciousness, signs 
of  shock,  respiratory  distress/severe  breathlessness  which  would  lead  to  an 
ambulance  outcome.  The  assessment  then  continues  to  establish  any  signs  of 
concern  such  as  confusion,  breathlessness,  vomiting  blood,  repeated  vomiting  and 
continues to ask symptoms markers until a level of care is reached. As above, recent 
neurosurgery itself is not a specific marker as the basis for the assessment relies on 
the symptoms presenting at the time of the call. However the assessment does contain 
a question asking a wider question relating to whether there has been any operation 
or  surgical  procedure  within  the  last  7  days,  which  without  any  other  symptoms  of 
concern such as those mentioned (which may lead to a higher level of care) would 
recommend further clinical assessment. 

2.  ‘Head injury’ is not reflective of elective, non-trauma surgery 

NHS Pathways have advised that ‘head injury’ is not an appropriate pathway to assess 
vomiting unless the vomiting was associated with a head injury. However, as set out 
above  there  are a  range  of  triage  assessments  for vomiting  and/or nausea,  with  or 
without abdominal pain, and the ‘Predetermined management plans’ route is designed 
to  pick up  whether an  individual patient  should  be  assessed  differently  due  to  their 
specific circumstances such as recent surgery, as above. 

Health advisors are also trained to probe to establish what is the main problem for the 
caller to ensure the best triage assessment option is taken. 

3.  Pathways does not include a question for post-discharge surgery patients of 

any discharge advice from their surgical team 

The ‘Predetermined management plans’ route described above does provide a route 
for those who have been given specific post-operative advice or a plan in the event of 
certain criteria. In view of this case, this route and the associated training is also being 
re-examined to ensure that it is considered by call handlers in cases where a caller 
does not specifically mention their recent surgery, or in case the potential relevance 
of this is not obvious, to ensure that the call is identified as complex and passed to a 
clinician for review.  

Additionally,  as  above,  if  this  route  was  not  chosen  and  instead  a  caller  had  a 
symptomatic assessment there is a question within the relevant symptomatic triage 
assessments that asks if there has been any surgical procedure or operation within 
the last 7 days. This question may not be reached in all pathways as the system works 
on the symptom-based approach as described above and so symptoms detailed may 
result in an outcome being reached before this question is asked.  

 
 
 The outcome ‘to speak to a clinician in a local service within 2 hours’, as was reached 
in this case on 31 January at 16:00 hours, is an urgent referral for clinical assessment.   
We  cannot  comment on  the  workings  of  specific Clinical Assessment  Services,  but 
note that medical history should be a key factor in any clinical assessment. 

We would also like to reassure the Coroner that the triage system does provide a route 
for when triage cannot be completed by a health advisor due to the caller being remote 
from  the  patient.  Any  such  call  flags  the  need  for  clinical  review  and  local  clinical 
management  by  the  NHS  111/999  service  receiving  the  call.  This  needs  to  be 
managed on a case-by-case basis as the potential situational factors are infinite and 
beyond the scope of triage.  

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 Mulu, 
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