Recurance · prevention of future deaths reports
Pre-inquest brief
Unclear wording in NHS Pathways triage questions
The earlier warning
Alexander Davidson · 2 May 2019 · Laurinda Bower, Nottinghamshire
“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.”
What was promised
Stated action 1 · response to Alexander Davidson (2 May 2019) · stated timescale: none stated
“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 recurred
- 4 Mar 2026 · Roman Barr · Linda Lee · Closely related · confidence 0.90 (high)
- 3 Apr 2026 · Roman Barr · Linda Lee · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No evidence found either way · stated action 1
“Our AI training allows businesses to boost customer service while controll”
Effective Communication Skills Training for Call Center Agents · secondnature.ai/…/effective-communication-skills-training-for-c…
“To unlock this page and access all your member benefits, please complete your Member Profile by uploading a profile photo.”
Active Listening Skills Every Call Centre Agent Needs · acxpa.com.au/active-listening-skills-for-call-centres
No evidence found does not mean the action did not happen.