Theo Tuikubulau
6 Jan 2026 · Coroner Louise Wiltshire · Devon, Plymouth and Torbay
The coroner's concerns
1. inconsistent ambulance categorisation for breathing difficulties
“assessment and resultant ambulance dispositions for breathing complications were likely to be different depending on whether that call was triaged via the MDPS or NHS Pathways systems”
2. cyanosis not detected in NHS Pathways triage
“presence of cyanosis is not interrogated within NHS Pathways and as such this symptom / sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways”
3. inconsistent handling of cyanosis in pediatric respiratory distress
“variation between the two triage systems with regards to respiratory distress in children under 5, specifically in relation to the management of declared cyanosis”