“In the UK, 999 calls are triaged using one of two approved triage tools (also referred to…”

The coroner’s concerns

In the UK, 999 calls are triaged using one of two approved triage tools (also referred to as call prioritisation systems) approved by NHS England: the Medical Priority Dispatch System (“MPDS”) and NHS Pathways. LAS uses MPDS. The MPDS looks at signs and symptoms and prioritises them into dispatch codes, which assign a level of priority to the call, and in turn inform the type of ambulance resource that will be allocated to manage the incident. MPDS is designed for use by non-clinical call handlers. MPDS involves a system of structured questions which identify priority symptoms and thereby the clinical need of patients. The structured questions fall into different protocols and a patient can be shunted, or moved, between one protocol and another depending on the answers to specific questions. In these circumstances, and for sound operational reasons, there is necessarily an element of rigidity in the MPDS. In Mr Robinson’s case, LAS accepted that the first 999 call was incorrectly triaged and received an inaccurate categorisation of the urgency of the response required: it was allocated a Category 3 (urgent) rather than Category 2 (emergency) response. Given the rigidity of the structured questions, there was no capacity within MPDS to account for information provided on behalf of Mr Robinson during the first 999 call, namely that he thought and felt like he was having a heart attack. The evidence heard at the inquest was that: (1) there are no individual MPDS determinants, under the relevant protocol, Protocol 10 (Chest Pain), that are specific for a heart attack; and (2) under the MPDS this information (reporting a heart attack) would not result in a dispatch code justifying a Category 1 (life threatening) response, with an average response time of 7 minutes and 90% of calls responded to within 15 minutes. This means that for a patient who is conscious and breathing, but reporting a heart attack, the highest possible category of emergency response on the MPDS Chest Protocol is Category 2 (average response 18 minutes; 90% calls within 40 minutes). However, this rigidity and categorisation may give rise to a risk of future death, namely: the risk their heart attack leads to a cardiac arrest immediately or shortly following the cessation of the call, and because they are on their own, they are unable to re-call 999; and/or the cardiac arrest may cause their death prior to a Category 2 (or subsequent Category 1) ambulance arriving at their location. This risk also arises in the context of increasing nationwide demand on UK ambulance services which has given rise to delays in allocation and dispatch of ambulances.

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, 2025-0340

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