Man’s overdose death prompts changes to 999 software

A coroner’s report, published last month, said the NHS Pathways system is unable to recognise that certain drugs, such as heroin, will put a patient at greater risk of sudden collapse than if they had taken a weaker substance, such as paracetamol.

The prevention of future deaths report — by area coroner for Birmingham and Solihull James Bennett — added some NHS trusts and ambulance services were not aware of this issue with the system, meaning some cases were not treated with the appropriate level of urgency.

NHS Digital has confirmed steps have been taken to highlight high-risk overdose patients in the Pathways system through the introduction of new coding. 

The report covered the inquest of 49-year-old Allan Davies, who died in February this year after inadvertently taking too much crack cocaine, heroin and mamba — a form of synthetic cannabis.

Mr Davies called 999 and explained to a clinician he was experiencing breathlessness following the overdose. His case was classed as “category three” and he was told an ambulance would be with him within two hours.

Five ambulances were sent out to Mr Davies over the course of two hours, but they were diverted to patients who were considered to require more urgent treatment, according to the report.

When paramedics eventually arrived at Mr Davies’ home, they discovered he had collapsed and was in cardiac arrest.

NHS Pathways

Mr Davies’ inquest is the latest to raise concerns over shortcomings in the NHS Pathways system and call for urgent changes to be made to the software. 

NHS Pathways is a piece of clinical software, run by NHS Digital, that is used to assist non-clinician call handlers to establish symptoms and dispatch medical assistance based on a patient’s call.

NHS 111 and 999 providers are expected to strictly adhere to prompts and scripts in the software to establish what the best next steps are to take. Call handlers are supported by clinicians who can provide guidance or take over the call if needed.

The software contains more than 800 symptom pathways and its content is overseen by a national clinical governance group, hosted by the Royal College of GPs, which regularly reviews and updates the content twice a year.

In July, an HSJ Investigation unearthed 11 prevention of future death reports published since 2015 where coroners raised safety concerns linked to the Pathways software. Since then, warnings about Pathways have also been raised in the cases of the deaths of a teenager and a 73-year-old woman.

‘Generic’ triaging of overdose cases continued

During the inquest — which took place in June — representatives from West Midlands Ambulance Service said if an overdose patient is conscious and breathing when they call 999, then NHS Pathways advises an urgent “category three” ambulance response regardless of the substances taken, according to the coroner’s report.

The report said: “When an overdose patient calls 999, the NHS Pathways telephone triage system does not distinguish between the type of drug(s) taken and the corresponding risk of sudden collapse.

“If the patient is breathing and conscious at the time of the call, NHS Pathways advises a category 3 response (ambulance within two hours), regardless of the type of drug(s) taken.”

A witness from WMAS added this “generic” triaging of overdose cases continued despite numerous concerns being raised with Pathways.

Changes to Pathways coding

Responding to the report, NHS Digital said: “NHS Digital (along with NHS England and NHS Improvement as detailed below) is aware of the issues associated with the unpredictability of deterioration in overdose cases and ensuring care is provided when needed.”

But it added, “it is not possible” for Pathways to identify higher risk patients based on the type of drug taken as it is “a computer-based system operated by non-clinical call handlers”.

NHS Digital added that, when a patient calls 999 after intentionally taking an overdose, the call handler can put details of the type of drug taken in a “free text” box in the Pathways system.

While this does not contribute to the final decision in Pathways, it can be viewed by any clinician who may take over the call to assess the patient.

In January 2019, prior to Mr Davies’ death, a letter was sent by the national clinical director for urgent and emergency care for NHS England to all ambulance service chief executives urging them to review how they monitor self-harm — including accidental overdoses — and suicidal patients.

Another letter was then sent in April 2019, urging ambulance service CEOs to ensure they have “robust clinical oversight” in control rooms to monitor self-harm cases, particularly those classed as category three and four.

In light of this, NHS Digital confirmed to HSJ a new code has been added into the Pathways system which will “facilitate the early identification of higher risk suicidal patients” following an overdose, who are classed as category three.

This coding — introduced last month — will ensure the patient undergoes an early clinical review from the 111 or 999 call handling centre. However, it does not apply to callers who have accidentally overdosed.

Steps have been taken to introduce a similar code for patients who have accidentally overdosed, which is expected to be introduced in the next version of Pathways in April 2020, according to NHS Digital.