“(brief summary of matters of concern) I heard that when SCAS call takers using the NHS…”
Dated 7 Apr 2025, from the coroner for Berkshire. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Jun 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated7 Apr 2025
- Deadline2 Jun 2025
- Published on judiciary.uk11 Apr 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Central Ambulance Service NHS Foundation TrustNamed in the report as “South Central Ambulance Service” | Response publishedPublished on judiciary.uk in April 2025. |
| NHS England | Response publishedPublished on judiciary.uk in April 2025. |
The coroner’s concerns
(brief summary of matters of concern) I heard that when SCAS call takers using the NHS Pathways triage tool exit a module Regulation 28 – After Inquest Document Template Updated 30/07/2021 indicating a person is lying on the floor with no reported injuries they are prompted to ask additional questions of the caller; including whether someone else is with the caller; whether the caller can provide a number for next of kin or other person who may be able to attend the caller whilst they wait for an ambulance. This is due to the likely delay of a number of hours before an ambulance can attend. This same procedure is not applied when someone reports that they are stuck in situ, for example they are unable to move from their chair. My concern is that the additional risks of a long lie, for example rhabdomyolosis, may well apply when someone in unable to move from any position. SCAS agreed to change their standard operating procedures to incorporate additional enquiries in these circumstances. I am pleased that they have agreed to amend their procedures swiftly. However this matter has wider significance and should be considered by other users of the NHS Pathways triage tool.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0175
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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