Oliver Shelley
11 May 2026 · Coroner Karen Henderson · Surrey
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. absence of sepsis algorithm
“The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls”
2. misleading title of Emergency Medical Advisors
“Emergency Medical Advisors (EMA's), generally have no qualifications in medicine or nursing”
3. failure to recognise caller's meningitis concern
“[the deceased]'s parents gave an extreme clear assessment of [the deceased]'s condition and also informed the EMA that they were concerned it was meningitis”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”
This report
“The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls”