“Triaging by ‘111’ and EMAS call handling systems, including in relation to sepsis”
Dated 9 Jan 2019, from the coroner for Northamptonshire. 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 publishedOrganisations 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 dated9 Jan 2019
- Deadline6 Mar 2019
- Published on judiciary.uk11 Apr 2019
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| East Midlands Ambulance Service NHS TrustNamed in the report as “East Midlands Ambulance Service” | Response publishedPublished on judiciary.uk in April 2019. |
| 111 Service | Response publishedPublished on judiciary.uk in April 2019. |
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
– 1. Triaging by ‘111’ and EMAS call handling systems, including in relation to sepsis. In the present case, Mrs Gudgeon had collapsed, passed out, been confused and had been vomiting. These are signs of central nervous system/neurological problems but were not regarded as urgent. Despite EMAS being told that Mrs Gudgeon may have a urinary tract infection, no escalation occurred. 2. It was suggested in evidence that if the same facts are inputted into the ‘999’ AMPDS triaging system they are likely to allocate a higher priority to the call than the ‘111’ Pathway triaging system would. 3. The shortage of double crewed ambulances and fast response vehicles in the Northampton Division. 4. The effectiveness of the EMAS Capacity Management & Escalation Plan (CMP) including, inter alia, the fact that:a) CMP status 1 – 3 does not trigger the deployment of additional 2 vehicular resources. b) CMP 4 is only triggered when 200 calls are holding (this was previously 150) – this is a high threshold. c) A Technical Commander can overrule a CMP status e.g. even if 200 calls are holding (CMP 4), this can simply be downgraded to CMP 3 by the Technical Commander.
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, 2019-0015
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use