An HSJ investigation has uncovered 11 prevention of future death reports since 2015 where coroners raised safety concerns about NHS Pathways software used by NHS 111 and 999 call handlers.

Concerns raised about the deaths of Barbara Patterson, Caragh Melling, Colin Sluman and John Scott, are covered separately to this story detailing central agencies’ response to concerns raised. 

The other patient deaths where concerns were raised include:

Susan Longden, 69, died at Bristol Royal Infirmary in February 2018 after suffering a rare complication from a routine colonoscopy while at home. On 18 December 2018, a coroner wrote to NHS Digital, raising issues with Mrs Longden’s care, specifically that NHS Pathways software used when Mrs Longden’s husband called NHS 111 did not include a question about recent surgical or interventional procedures when a patient has severe abdominal pain or prompt call handlers to seek to talk directly to patients where possible. NHS 111 provider Care UK told HSJ it had raised similar concerns regarding talking to a patient directly with NHS Digital after a separate patient incident in April 2018. The provider said: “It is important that the reviews which can follow this feedback are timely and that agreed changes are implemented quickly.”

NHS Digital said any error in Mrs Longden’s care did not relate to NHS Pathways but as a result of a Care UK clinician overruling advice given by the software. However, it also told the coroner it was considering making an improvement to questions about recent surgical or interventional procedures when a patient has severe abdominal pain. 


Peter Cotter, 84, died during surgery in January 2017, following a fall at home. The ambulance service that responded to a 999 call from Mr Cotter’s wife after his fall told the coroner the response was not sufficiently urgent because NHS Pathways did not recognise Mr Cotter’s head injury.  

The ambulance service referred the coroner’s concern to NHS Digital, which determined that Mr Cotter had been triaged correctly and no change to NHS Pathways was required.


Valerie Margaret Ellis, 82, was in and out of hospital in the lead-up to her death in June 2016 after she fractured her hips. On the day of her death, her husband called NHS 111 about his wife’s nose bleed. The coroner later identified delays, a missed call and incorrect triage advice offered to Mr Ellis by call handlers using the NHS Pathways system. By the time an ambulance arrived at their home, Mrs Ellis had already died.

Several failings related to how NHS 111 provider, IC24, handled Mr Ellis’ call, the coroner said. But, in addition, concerns were raised by both IC24 and the South East Coast Ambulance Service about the NHS Pathways software and its failure to elicit “vital information” about Mrs Ellis’ blood thinning medication. The regional NHS 111 service told the coroner it raised concerns about “imprecise” algorithms used in NHS Pathways with the Department of Health, but it was unclear whether any action was taken. The coroner did not raise concerns directly with either NHS Digital or DH.


Harry Gill, 72, died in May 2016, after his wife’s calls to NHS 111 raising concerns about his vomiting were incorrectly processed, leading to delay in an ambulance being dispatched. The ambulance service that responded to Mr Gill told a coroner that questions in the NHS Pathways around vomiting blood and faeces were “poor” and “misleading” for call handlers and, after Mr Gill’s death, concerns had been raised with NHS Digital.

In response to a report from the coroner, NHS Digital said it had amended questions in the software to “allow for a more focused interrogation” of vomiting symptoms.


Sebastian Hibberd, six, died of intussusception in October 2015 in hospital, with a coroner finding that an NHS 111 call handler failed to spot warning signs when his parents called.

According to a BBC report last month, based on an as-yet-unpublished report, a coroner specifically told NHS Digital and NHS England the NHS Pathways software was not adequately assisting the call handler to make the right decisions about children over five with symptoms of intussusception. In response, NHS Digital told the BBC it would “ensure any necessary lessons are learned”.


Two-year-old Robert Hogg died from an acute bacterial infection in April 2014, after the seriousness of his condition was not picked up by NHS 111 call handlers, leading to delays in his attending accident and emergency. South Central Ambulance Service Foundation Trust, the provider, told the coroner that after Robert’s death an investigation found NHS Pathways did not always identify very sick children and this was “possibly not the first event relating to incidents involving toddlers/children”. At the time of the coroner’s inquest in 2015, no changes had been made to the software.

In response, NHS Digital strongly disagreed that there were any errors in how NHS Pathways treated sick children and blamed the local provider for failure in Robert’s care. It said: “In this case, we consider it a grave error if the patient’s family have been led to believe that the NHS Pathways system is in any way attributable for this, or any other similar death.” Nevertheless, it said it had amended the software in response to Robert’s death.


In November 2013, Terrence Smith, 32, died from a combination of factors including drug-induced excited delirium exacerbated by police restraints. In February 2019, a coroner found that, among the many failures of different agencies that led to Mr Smith’s death, a 999 call handler had failed to identify his condition because of shortcomings in NHS Pathways’ advice. More than five years after Mr Smith’s death, the coroner found that NHS Pathways still did not have a path for identifying “excited delirium or acute behavioural disturbance” in patients.

While waiting for pathways to be updated, the South East Ambulance Service FT told the coroner its 999 call handlers have developed a local workaround for identifying excited delirium or acute behavioural disturbance. NHS Digital said no concerns were raised directly following Mr Smith’s death until February 2019 and changes have been made in an NHS Pathways update going live this month.

Exclusive: Government overruled concerns with 999 IT system