Callers not prompted to seek companionship during emergency calls
NHS Pathways received 2 coroners' reports about this hazard between 14 Feb 2019 and 14 Jan 2021.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“1. Is there anyone else with you or are you alone? If there is anyone else with you may | please speak to them.”
Original on judiciary.uk ↗ NHS Pathways responded, stating 1 specific action.Response (PDF) ↗
“Call handlers using NHS Pathways are always trained to speak directly with the patient when it is a 3° party call, this ensures that the questions being asked are answered as accurately as possible to ensure both a safe outcome and that questions are not mis-interpreted through a 3 party.”
Stated timescale: May 2020
- 1 year 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“The script currently used by NHS Pathways in respect of emergency callers does not positively persuade callers to call someone to be with them, particularly in circumstances where paramedic attendance is delayed due to demands on the service.”
Original on judiciary.uk ↗ NHS Pathways responded, stating 1 specific action.Response (PDF) ↗
“In circumstances where paramedic attendance is delayed due to demands on the service. Whilst using NHS Pathways, the health advisor may not be aware of delays within the 999 service. This information is held on the 999 providers host system and does not influence the NHS Pathways triage. Once an ambulance disposition is reached, the disposition script can be amended by a provider or local SOP to require health advisors to give further information depending on the circumstances. Demand management”
- All reports to NHS Pathways
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 → 2021Karl Bolam1 year 11 months after John Scott · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that NHS Pathways call scripts do not adequately prompt lone callers to seek companionship or inform them they can call someone for support while waiting for an ambulance.
John Scott · 14 Feb 2019
“1. Is there anyone else with you or are you alone? If there is anyone else with you may | please speak to them.”
Original on judiciary.uk ↗ Karl Bolam · 14 Jan 2021
“The script currently used by NHS Pathways in respect of emergency callers does not positively persuade callers to call someone to be with them, particularly in circumstances where paramedic attendance is delayed due to demands on the service.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Call handlers using NHS Pathways are always trained to speak directly with the patient when it is a 3° party call, this ensures that the questions being asked are answered as accurately as possible to ensure both a safe outcome and that questions are not mis-interpreted through a 3 party.”
Stated action · timescale: May 2020
“Call handlers using NHS Pathways are always trained to speak directly with the patient when it is a 3° party call, this ensures that the questions being asked are answered as accurately as possible to ensure both a safe outcome and that questions are not mis-interpreted through a 3 party.”
Stated action
“In circumstances where paramedic attendance is delayed due to demands on the service. Whilst using NHS Pathways, the health advisor may not be aware of delays within the 999 service. This information is held on the 999 providers host system and does not influence the NHS Pathways triage. Once an ambulance disposition is reached, the disposition script can be amended by a provider or local SOP to require health advisors to give further information depending on the circumstances. Demand management”
- 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 Pathways 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 → 2021 | 0.71 | 0.05 | Closely related · 0.85 | 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.