“The Court heard that when a call is made to 999 that the call is categorised using NHS…”

The coroner’s concerns

The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category. The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose. The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight. The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical. Secondly, the Court heard that in the case of ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature for an effective response when it is known that has been ingested and would not create a higher disposition requiring more urgent attendance than category 3. The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.

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, 2024-0621

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