Oliver Shelley

Dr Karen Henderson 
HM Assistant Coroner for Surrey 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

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

1st July 2026  

Dear Dr Henderson, 

Re: Regulation 28 Report to Prevent Future Deaths – Oliver Charles Major 
Shelley who died on 22nd July 2024.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11th 
May 2026 concerning the death of Oliver Charles Major Shelley on 22nd July 2024. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Oliver’s family and loved ones. NHS England is keen 
to assure the family and yourself that the concerns raised about  Oliver’s care have 
been listened to and reflected upon.   

Your Report raised the following concerns: 

1.  There is a lack of a sepsis algorithm pathway to assist the emergency medical 

advisor (EMA) during 111/999 calls 

2.  That Emergency Medical Advisors (EMA’s), generally have no qualifications in 
medicine  or  nursing  and  the  use  of  this  title  to  describe  their  role  raises  a 
concern they are misleading the public.  

Background of NHS Pathways Clinical Decision Support System 

The NHS Pathways Clinical Decision Support System (CDSS) is a triage product 
that is used to support Urgent and Emergency Care (UEC) in England. The product 
is owned by the Secretary of State for Health and Social Care and is manufactured 
and managed by the Transformation Directorate of NHS England. It is embedded 
within host systems in NHS 111 and 999 ambulance providers where it interacts with 
other technology products to support the assessment, sorting and onward 
management of calls received by those services. The NHS 111 and 999 providers 
are required to enter into a licence governing their use of NHS Pathways and the 
training materials. 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. The term “Health Advisor” is set by the NHS 111 service specification. 999 
services can determine this per service. Though non-clinical, these advisors complete 
a  rigorous  structured  training  programme,  which  includes  classroom  learning, 
assessments and preceptorship, to ensure they can use the NHS Pathways algorithm 
safely  and  effectively.  Once  working  independently,  health  advisors  must  be 
supervised by clinical staff, to whom they must always have access to for guidance 
and  support.  It  is  therefore  a  condition  of  the  NHS  Pathways  licence  that  clinical 
supervision and escalation support must be available 24/7. 

Health advisors using the NHS Pathways system are trained to use probing questions 
to better understand caller responses. 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,  terminology  that  complicates  triage  or  any  other  situation  when  the 
advisor  feels  they  have  reached  the  limits  of  their  knowledge  or  understanding. 
Additionally,  it  should  be  used  if  the  call  includes  three  “not  sure”  answers,  or 
information is incomplete, ambiguous, or difficult to interpret. In such circumstances 
health  advisors  are  expected  to  seek  immediate  clinical  input  from  an  experienced 
NHS Pathways trained clinician. This approach is reinforced by the principle:  

“If in doubt, shout.”  

NHS Pathways recognise there may be operational delays which must be managed 
locally.  NHS  Pathways  is  not  able  to  take  account  of  these  as  they  and  the  local 
management of them can vary, and thus NHS Pathway’s expectations are based on 
what should happen in absence of such delays. 

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’  (a  “Hot  Topic”  is  a  short,  focused  NHS  Pathways  training 
resource used to reinforce key areas of triage practice across Providers), case studies 
and  e-learning  packages,  which  support  continuous  professional  development  and 
dissemination of learning.  

Sepsis and meningitis are specifically addressed within core training, including pre-
module learning, scenario training, and ongoing learning resources such as a sepsis 
training toolkit and ‘Hot Topics’, ensuring that users are familiar with the recognition 
and escalation of these time-critical conditions.  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.  Audit  findings  are  intended  to  be  used  to  provide  structured  feedback, 
targeted coaching, and, where required, retraining to ensure ongoing competence and 
safe application of the system. 

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. 

Sepsis algorithm pathway 

Upon review of the calls, it is apparent that Oliver was seriously unwell and there were 
concerns  expressed  regarding  Oliver's  level  of  consciousness.  Unconscious  callers 
are  triaged  to  a  level  no  lower  than  a  category  2  emergency  ambulance.  NHS 
Pathways acknowledges that, although multiple symptoms were present concurrently, 
had the health advisor selected any of the declared symptoms as the main problem, 
including  ‘Behaviour  Change’,  ‘Rash’,  ‘Vomiting’  or  ‘Headache’  pathway,  the  triage 
system would have presented a question to assess whether the patient was able to 
carry out normal everyday activities (functional impairment assessment). 

In  this  case  it  appeared  that  Oliver  was  functionally  impaired,  which  in  all  of  these 
Pathways would have led to a further question about a non-blanching rash, resulting 
in the dispatch of a Category 2 ambulance. The assessment of a 'non blanching' rash 
accompanied  by  being  unable  to  carry  out  normal  activities  appears  in  over  100 
different  clinical  triage  pathways  as  NHS  Pathways  acknowledges  the  multiple 
different ways that symptoms of Meningococcal Septicaemia may present.  

It is noted that the health advisor sought advice from a Senior Non-Clinician as they 
wanted to know if there was a specific Pathway for meningitis before then passing the 
case to the clinical queue for inability to prioritise a main symptom. It is important to 
highlight  that  as  NHS  Pathways  is  a  non-diagnostic  clinical  assessment  tool 
'Meningitis' (or any other condition) would not present as a pathway option, however, 
questions regarding septicaemia and meningitis are covered in a variety of symptom-
based pathways and when answered positively result in an ambulance dispatch. In 
essence, rather than one ‘sepsis algorithm’ pathway, NHS Pathways has embedded 
a ‘sepsis’ algorithm into a wide range of symptom-based pathways where sepsis could 

 
 
 
 present. In this way, even if the caller does not recognise potential symptoms of sepsis, 
the  NHS  Pathways  algorithm  would  screen  for  potential  sepsis  in  a  wide  range  of 
symptom pathways.  

NHS  Pathways  training  explicitly  recognises  that  presentations  involving  multiple 
symptoms  increase  the  complexity  of  triage  and  are  associated  with  higher  clinical 
risk.  To  mitigate  this  risk,  NHS  Pathways  includes  a  structured  and  safety-focused 
approach to assessing patients with multiple symptoms. This is embedded within both 
system design and user training. 

Health advisors are trained to: 

•  Prioritise  the  rapid  exclusion  of  immediately  life-threatening  conditions 
through structured questioning in the first section of NHS Pathways (known 
as Module 0). This includes an assessment of consciousness. 

•  Progress systematically into the next section of questions (known as Module 
1) to identify the most clinically significant presenting problem, supported by 
Key Points within the system. Key points assist the health advisor to select 
the  most  appropriate  pathway  by  providing  details  on  when  to  use  each 
pathway. 

•  Recognise that where symptoms suggest potential compromise to airway, 
breathing, circulation or a reduced level of consciousness, these must take 
priority regardless of how they are described by the caller. 

•  Use targeted probing to clarify symptoms and reduce ambiguity. 

Importantly,  training  emphasises  that  where  a  caller  is  unable  to  identify  a  main 
symptom,  or  where  the  presentation  remains  unclear  or  complex,  this  should  be 
treated as an indicator of increased risk.  

In these situations, call handlers are instructed to: 

•  Seek immediate clinical support, or 
•  Undertake an Early Exit and transfer the call to a clinician 

This reflects a deliberate safety principle within NHS Pathways: that it is appropriate 
and expected for non-clinical users to escalate to a clinician when the limits of system-
supported decision-making are reached. 

This structured approach is reinforced through initial training, ongoing learning, and 
monthly audit. 

This approach is designed to ensure that complex or unclear presentations, such as 
those  involving  multiple  symptoms  potentially  consistent  with  serious  infection,  are 
identified early and managed with appropriate clinical input. 

The sequence described in the inquest, including the duration of the call and the 
timing of subsequent contact, reflects a situation that would have been deeply 
worrying for any family in those circumstances. 

While NHS Pathways does not oversee local service delivery or response times, this 
case emphasises the importance of early clinical input when presentations are 

 complex, where severity is unclear, or where it has not been possible to prioritise a 
primary symptom of concern.  

It is NHS Pathway's view that given the family clearly expressed concern that Oliver 
may have been suffering from meningitis, and recognising that Health Advisors 
receive training in the identification and escalation of serious infection including 
sepsis and meningitis, this further reinforces the importance of early clinical 
involvement if there is uncertainty about which route to take through the system.  

Emergency Medical Advisors 

The  terminology  used  to  describe  call-takers  using  the  NHS  Pathways  system  is 
described in the background and training section above. For clarity, the term Health 
Advisor is set by the NHS 111 service specification. 999 services can determine this 
per service.  

In ambulance service settings, local services may choose to adopt alternative role 
titles, such as “Emergency Medical Advisor (EMA)”. The selection and use of these 
titles is determined locally by provider organisations. 

Regardless of job title, when undertaking the Health Advisor role using NHS 
Pathways, individuals are operating within a structured clinical decision support 
system, supported by training, defined principles and access to clinical supervision. 

It is a requirement of the NHS Pathways licence that appropriately trained clinicians 
are available at all times to provide immediate advice and to take over calls where 
needed. 

NHS Pathways training and system design emphasise the importance of recognising 
the limits of non-clinical roles and escalating to clinical support where there is 
uncertainty or complexity. 

Regional Response 

NHS England's South East Regional Team have liaised with South East Coast 
Ambulance Service regarding this PFD. Following a full investigation into Oliver's 
death, SECAmb identified learning relating to the way the service responded 
when patients presented with multiple or unclear symptoms. In these situations, it 
can be harder to recognise the seriousness of a patient's condition and delays 
can occur in escalation to clinical review. The Trust has acknowledged the impact 
this had on Oliver and his family and has implemented a number of 
improvements in response to the learning identified. These include: 

 
 
 
 •  Clearer rules for escalation: Staff are now clearly instructed that when a 

patient has multiple or unclear symptoms, they must involve a clinician earlier 
rather than trying to manage the call alone. 

•  Faster access to clinicians: The Trust has removed any ambiguity around 
seeking clinical support and staff are actively encouraged to obtain clinical 
advice promptly. 

•  New technology to prioritise risk: The Intelligent Clinical Queue has been 

• 

implemented to help identify higher-risk patients and prioritise them for clinical 
review. 
Improved staff training and culture: Training and support have been 
strengthened to help staff recognise when concerns should be escalated and 
to foster a culture where raising concerns is encouraged. 

The Trust continues to review its systems, listen to staff and families, and 
implement further improvements to reduce the risk of similar incidents occurring 
in the future. 

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 Oliver, 
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