Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of sepsis detection tool in emergency call handling
The earlier warning
Michael Clarke · 3 May 2024 · Alison Mutch, Manchester South
“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”
judiciary.uk/…/michael-clarke-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Michael Clarke (3 May 2024) · stated timescale: 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”
judiciary.uk/…/2024-0245-Response-from-NHS-England-and-NHS-GMIC…
What recurred
- 11 May 2026 · Oliver Shelley · Karen Henderson · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Michael Clarke · 3 May 2024
“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”
Later · Oliver Shelley · 11 May 2026
“The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls”
What happened next
No evidence found either way · stated action 1
“ARP is now a specific work stream within the wider Ambulance Improvement Programme, led by NHS England and NHS Improvement.”
Ambulance Response Programme (ARP) Impact Assessment · england.nhs.uk/…/ambulance-response-programme-impact-assessment…
No evidence found does not mean the action did not happen.