Jake Hartwright
5 Jan 2026 · Coroner Elizabeth Didcock · Nottinghamshire
The coroner's concerns
1. systemic illness not immediately life threatening requiring Category 3 ambulance
“The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response”
2. information not reliably read or considered by EMAS staff
“There remains detailed information in the EMAS CAD transferred from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS”
3. families not informed ambulance will not be sent
“Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent”
4. non-clinicians interpreting Category 3 calls
“Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation”
5. no agreement on Category 3 call transfer criteria
“There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS”