Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed recognition of excited delirium in ambulance dispatch
The earlier warning
Terrence Smith · 21 Feb 2019 · Richard Travers, Surrey
“The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly.”
judiciary.uk/prevention-of-future-death-reports/terrence-smith
What was promised
No published response from NHS England was found for the earlier reports.
What recurred
- 6 Jan 2026 · Robert Gracey · Paul Smith · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Terrence Smith · 21 Feb 2019
“The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly.”
Later · Robert Gracey · 6 Jan 2026
“Under the current NHS Pathways system, ABD does not have its own allocation pathway.”
What happened next
No web check of the stated actions has been published for this chain.