Delayed recognition of excited delirium in ambulance dispatch
NHS England received 2 coroners' reports about this hazard between 21 Feb 2019 and 6 Jan 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from NHS England was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly.”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 6 years 10 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Under the current NHS Pathways system, ABD does not have its own allocation pathway.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2026Robert Gracey6 years 10 months after Terrence Smith · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that the NHS Pathways system does not adequately recognise or prioritise excited delirium/acute behavioural disturbance, leading to inappropriate ambulance responses.
Terrence Smith · 21 Feb 2019
“The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly.”
Original on judiciary.uk ↗ Robert Gracey · 6 Jan 2026
“Under the current NHS Pathways system, ABD does not have its own allocation pathway.”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2026 | 0.76 | 0.17 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
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- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.