• Another coroner warns of future deaths if action is not taken to improve NHS Pathways system
  • Inquest heard 17-year-old Alexander Davidson was confused by medical terminology used by 111 call handler 
  • NHS Pathways chief says “routine review” of pathways relating to gastrointestinal issues is underway

The NHS has faced fresh calls to make changes to its 111 service after a coroner blamed its triage system for confusing a 17-year-old who later died.

Alexander Davidson, from Nottinghamshire, died in February 2018 after he developed sepsis as a result of complications with gallstone pancreatitis, a rare condition for someone of his age.

An inquest into his death heard Alexander “struggled to comprehend” the medical terminology used during conversations with 111 call handlers, after he developed abdominal pain, vomiting and diarrhoea in January 2018, according to a coroner’s report.

Assistant coroner for Nottingham City and Nottinghamshire, Laurinda Bower, ruled that Alexander had died from natural causes, but warned there could be a risk of future deaths if action wasn’t taken to improve the NHS Pathways service.

Ms Bower is the latest coroner to call for changes to the NHS Pathways service, which is used to triage 16 million NHS patients a year.

Last month, an HSJ investigation uncovered at least three instances where patients triaged by the NHS Pathways software died months, sometimes years, after central agencies were alerted to safety concerns by ambulance trusts, but declined to make the changes requested.

Ms Bower raised concerns that call handlers are not allowed to deviate from the wording of pre-determined questions, “creating confusion and inconsistency” in Alex’s answers.

The report stated: “Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.”

It also stated the algorithm for triaging vomiting and diarrhoea symptoms is “unclear”, as patients may not understand terminology used such as “soil” or “coffee ground” vomit, to identify whether they are vomiting blood.

Alexander’s triage notes were not uploaded to his patient record until seven days after the 111 call, preventing his GP from reviewing the information before his appointment.

The coroner’s report added: “There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.”

The coroner ruled Alex died from natural causes, adding: “The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition.”

Responding to the coroner’s concerns deputy clinical director of NHS Pathways, Darren Worwood, said call handlers can reword questions provided by the system with the help of supplementary information provided.

He added a “routine” review of pathways relating to gastrointestinal issues was being carried out with changes set to come into force in May 2020.”

After first developing symptoms on 17 January, Alex contacted his GP three times, had four assessments via NHS 111 and two admissions to accident and emergency at the Kingsmill Hospital.

He was eventually admitted to Queens Medical Centre emergency department on 8 February – where it was discovered he had developed sepsis due to an infected pancreatic pseudocyst.

Alex died on February 26, 2018 despite attempts by medical staff to save his life.

According to the report there was no consideration before February 8 that Alex may have had either gallstones or pancreatitis.

NHS England has been contacted for a comment, but did not respond in time for publication.

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