“The protocol supplied by NHS Pathways to South Western Ambulance Service Trust (SWAST)…”
Dated 21 Jun 2017, from the coroner for Exeter and Greater Devon. 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 16 Aug 2017.
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 dated21 Jun 2017
- Deadline16 Aug 2017
- Published on judiciary.uk28 Jul 2017
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in July 2017. |
| South Western Ambulance Service NHS Foundation TrustNamed in the report as “South Western Ambulance NHS Foundation Trust” | Response publishedPublished on judiciary.uk in July 2017. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) The protocol supplied by NHS Pathways to South Western Ambulance Service Trust (SWAST) call handlers does not include reports of “dizziness” and "patient on their own” as important triggers for a rapid response to a report of catastrophic haemorrhage. (2) Call handlers are not clinically trained and are completely reliant on the Protocol for categorising responses (in this case amber was used). (3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports.
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, 2017-0200
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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