“I heard that the NHS Pathways system tells call handlers to advise callers that an…”

The coroner’s concerns

I heard that the NHS Pathways system tells call handlers to advise callers that an ambulance is being arranged. However I heard that within SECAMB category 3 and category 4 dispositions are validated by clinical staff before being added to the Dispatch queue for an Ambulance to be allocated. I heard that this was in line with National Guidance from The Association of Ambulance Chief Executives. Therefore, callers are not informed that no ambulance is being arranged at the time of their call. I also heard that the NHS Pathways does not allow callers to be advised of the estimated time that they may have to wait for ambulance attendance. The evidence was that SECAMB have requested that the wordings provided by NHS Pathways be altered so that there is provision to give further information to callers about how long they may wait for an ambulance to attend but this has previously been declined by NHS England. I consider that both of the above matters mean that patients cannot make informed decisions about whether they wait for the arrival of an ambulance or escalate worsening symptoms on the basis that they anticipate that an ambulance is being arranged so will be with them shortly when this may not be the case. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to:  Family of Mr Forrest I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Joanne ANDREWS Area Coroner for West Sussex, Brighton and Hove

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, 2026-0307

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