Coroners raise concerns over NHS 111 and 999 software

Coroners investigating 11 deaths have raised concerns about the software used by NHS 111 and 999 call handlers, an investigation has found.

Research by the Health Service Journal (HSJ) found that 11 “prevention of future death” reports have been sent to NHS bosses since 2015.

In them, coroners have raised concerns about the NHS Pathways software, saying it failed to adequately raise the alarm over deteriorating patients.

Coroners have put their worries to Health and Social Care Secretary Matt Hancock, his predecessor Jeremy Hunt, NHS England, NHS Digital, the Care Quality Commission and those providing 111 and 999 services.

Although NHS Pathways is run by NHS Digital, overall responsibility rests with NHS England.

Among the cases uncovered by HSJ are the deaths of Caragh Melling, 37, in December 2014, and Barbara Patterson, 67, in January 2015.

Both suffered agonal breathing – sudden, irregular gasps of breath, requiring immediate CPR.

NHS Pathways was used to triage their calls and two separate coroners’ investigations subsequently raised concerns about how agonal breathing was handled by the software.

But prior to the deaths, stretching back as far as 2010, at least three different ambulance trusts raised concerns with the national NHS Pathways team about the software failing to advise call handlers to identify life-threatening agonal breathing, the HSJ reported.

In both the women’s cases, ambulance trusts told the coroner no changes were made to address their concerns about NHS Pathways before the deaths.

NHS Digital confirmed it had declined to make changes to agonal breathing requested by a provider in 2014, saying clinicians had reviewed the matter and felt it would delay CPR.

But it said some changes were made to the early assessment of patient breathing in 2014, ahead of the two deaths.

NHS Digital said further amendments were made in June 2015, 2016 and 2017.

Other cases cited by HSJ included children who died from conditions including intussusception – where part of the intestine “telescopes” inside of another, causing an intestinal blockage – and bacterial infections.

The HSJ detailed the case of Sebastian Hibberd, six, who died of intussusception in October 2015 in hospital.

A coroner found that an NHS 111 call handler failed to spot warning signs when his parents called the helpline.

NHS Digital said: “Changes made to the relevant pathways since this tragic incident would mean that a patient with this presentation would now be advised to attend an emergency department within one hour.”

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 A&E.

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”.

In response, NHS Digital said investigations by South Central Ambulance Services found that the outcome of a first call regarding Robert was “safe and appropriate”.

On the second call, there was “failure to follow correct procedure within the ambulance service”, it said.

But it said NHS Pathways has been enhanced since 2016 to identify those at risk of potential critical illness.

In another case,  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.

In its response to the coroner, NHS Digital said changes were not needed, and said: “NHS Pathways identifies and assesses head injuries through a detailed series of questions, and specifically identifies if callers are on anti-coagulant treatment.

“In this particular case, we triaged the call via our head injury flow as an emergency and this resulted in an emergency department disposition via ambulance transport within one hour.”

A further statement from NHS Digital said: “We take any Coroner’s report we receive very seriously and work with our partner organisations across the NHS to ensure that we respond appropriately and make the necessary changes to the system if required.

“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.”

In 2016, the NHS software hit the headlines when a report into the 2014 death of baby William Mead, from Cornwall, found the 111 software was too crude to pick up “red flag” signs of sepsis.

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