Safety concerns raised about software used to triage NHS 111 calls

Coroners have called for action to prevent further fatalities linked to the NHS Pathways system following 11 patient deaths.
By Tammy Lovell
04:43 AM

Coroners have linked 11 patient deaths with safety concerns about NHS Pathways.

Coroners have linked 11 patient deaths with safety concerns about NHS Pathways, the clinical software used to triage patients calls to the NHS 111 and 999 services.

An investigation by the Health Service Journal (HSJ) revealed that coroners have issued ‘regulation 28’ reports calling on the NHS and Department of Health and Social Care, to take action to prevent future fatalities.  

The reports issued since 2015, warned that NHS Pathways’ algorithms were not precise enough to elicit vital information about several life-threatening health conditions.

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Following two patient deaths in 2014 and 2015, coroners called for amendments to how the software handled agonal breathing – a type of laboured breathing which frequently leads to cardiac arrest.

A report sent to NHS Pathways’ clinical director in April 2016 stated that action had not been taken about the absence of a breathing analysis tool, despite the organisation being contacted in 2014.

But NHS Digital said a request made for the tool was rejected, because it might delay CPR advice. Enhancements were made to the clinical content of the agonal breathing pathway in 2014, 2015, 2016 and 2017.

Among the 11 deaths flagged by coroners, two were children: Sebastian Hibberd, six, who died of bowel collapse and Robert Hogg, two, who died of a bacterial infection.

Last month, senior coroner Ian Arrow urged a review of NHS Pathways, claiming that without changes call handlers would not be adequately assisted to recognise acutely unwell children.


The NHS Pathways triage system supports the remote assessment of more than 16.5 million calls a year, according to NHS figures.

NHS 111 previously faced controversy in 2014, when a report into the death of baby William Mead, found the system did not pick up signs of sepsis.


 “It is categorically untrue that there are any cases where concerns have been raised and changes have not been made to the system where they have been deemed clinically necessary,” an NHS Digital spokesperson said. “We conduct regular reviews of NHS Pathways to ensure that it follows the latest clinical evidence, with all changes assessed by the independent National Clinical Governance Group, chaired by the Royal College of General Practitioners.”

“NHS 111 services deal with over 16 million calls every year, and while incidents like these are therefore extremely rare, where concerns are raised they are clinically investigated and any necessary changes made - building on the NHS’ reputation as one of the safest health systems in the world,” an NHS England spokesperson said.

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