“Advice given by the ambulance service, following NHS Pathways, is inconsistent with the…”

The coroner’s concerns

Advice given by the ambulance service, following NHS Pathways, is inconsistent with the NICE guidelines on management of neutropenic sepsis. Evidence was heard from two medical consultants that, in a patient who has recently undergone chemotherapy, if they report a high temperature, this gives rise to a concern of neutropenic sepsis and they require urgent assessment in hospital. NICE guidance says to suspect neutropenic sepsis in patients having anticancer treatment who become unwell. Refer them immediately for assessment in secondary or tertiary care. The advice given, following the NHS Pathways tool, was to seek advice from primary care. The NHS Pathways does not appear to take into account the recent chemotherapy and the risk that this poses. The evidence I heard from the clinical delivery manager was that thousands of people have cancer, it’s a chronic condition and not acute, but this does not take into account that recent chemotherapy plus a temperature makes it acute. The evidence was that this is not a question in the Pathway and is therefore not a factor which is considered. As well as being at odds with the NICE guidance, the advice to contact a GP within an hour does not take into account the availability of a GP appointment, as the call handler does not have access to the booking system. There was no advice given about what to do if a GP could not be contacted within an hour, for example to go to hospital. It adds an extra step, and therefore delay, in what can be a time critical situation. The Pathways tool does not support giving advice for a patient to attend hospital themselves, if they are able. 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: [please do not use individual’s names, but instead roles/titles]   , husband of the deceased         The Clatterbridge Cancer Centre         North West Ambulance Service NHS FT         The Countess of Chester Hospital NHS FT 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 Victoria DAVIES Area Coroner for Cheshire Sheila Bastedo – Prevention of future deaths report – 2026-0389_Published Download

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judiciary.uk, Prevention of Future Deaths reports, 2026-0389

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7 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