Unclear wording in NHS Pathways triage questions
NHS England received 3 coroners' reports about this hazard between 2 May 2019 and 3 Apr 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
Web search (Tavily): No evidence found either way
Effective Communication Skills Training for Call Center Agents ↗- 6 years 10 months laterClosely relatedConfidence 0.90 · higha different coroner
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Original on judiciary.uk ↗ Repeated from the earlier report:Pathwaystriagecaller
NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Original on judiciary.uk ↗ Repeated from the earlier report:usedduringcaller
The most recent report. A response may not be due or published yet.
- All reports to NHS England
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.
2019 → 2026Roman Barr6 years 10 months after Alexander Davidson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that the wording of NHS Pathways triage questions can be unclear to callers, leading to misunderstandings.
Alexander Davidson · 2 May 2019
“The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child.”
Original on judiciary.uk ↗ Roman Barr · 4 Mar 2026
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
2019 → 2026Roman Barr6 years 11 months after Alexander Davidson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that the wording used in the NHS Pathways triage script can be unclear to callers, leading to misunderstandings. The earlier report focuses on confusing medical terminology for children, while the later report cites a specific question not understood by the caller.
Alexander Davidson · 2 May 2019
“The pre-determined questions are the same whether the caller is an adult or a child. [name redacted] struggled to comprehend some of the medical terminology used during these calls.”
Original on judiciary.uk ↗ Roman Barr · 3 Apr 2026
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
Stated action
“call handlers receive significant training in questioning and listening skills during initial core training and through ongoing training updates. This is supported and monitored through monthly call audit. This training and on-going monthly call audit are all mapped to the NHS Pathways Competencies.”
What happened next: No evidence found either way
The organisation's training description is not confirmed in the provided sources.
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No evidence found does not mean the action did not happen.
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.
No specific action could be extracted with a verified quote.
No published response from NHS England was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 NHS England 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 |
|---|---|---|---|---|
| 2019 → 2026 | 0.84 | 0.12 | Closely related · 0.90 | different |
| 2019 → 2026 | 0.79 | 0.15 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.