Inappropriate triage coding delays mental health ambulance response
Association of Ambulance Chief Executives received 2 coroners' reports about this hazard between 27 Jan 2020 and 24 Oct 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier”
Original on judiciary.uk ↗ Association of Ambulance Chief Executives responded.Response (PDF) ↗
- 4 years 9 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The evidence I heard at inquest was that the call was coded at 25-C-1, which was as a Category 3 call.”
Original on judiciary.uk ↗ Repeated from the earlier report:callcodedCategory
Association of Ambulance Chief Executives responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Association of Ambulance Chief Executives
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2024Aran Bradbury4 years 9 months after Helen Sheath · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that ambulance call triage led to an inappropriate priority category, delaying mental‑health‑specific response. The core issue is the reliance on non‑clinically trained handlers using MPDS, resulting in under‑triage.
Helen Sheath · 27 Jan 2020
“If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier”
Original on judiciary.uk ↗ Aran Bradbury · 24 Oct 2024
“The evidence I heard at inquest was that the call was coded at 25-C-1, which was as a Category 3 call.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Association of Ambulance Chief Executives at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2024 | 0.69 | 0.07 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.