Incorrect CPR advice from software limitation
Department of Health and Social Care received 2 coroners' reports about this hazard between 30 Oct 2013 and 21 May 2015.
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 Department of Health and Social Care was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
First warning
Winston Llewellyn Johns↗
30 Oct 2013 · Louise Hunt · Powys Bridgend and Glamorgan Valleys
“The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 1 year 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non Clinical call handlers to issue CPR advice unless a patient has stopped breathing.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“The Pathways system piloted in the North East has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing. Although this fault was pointed out to Pathways by NEAS NHS Trust manager before the latest update of the system (early 2014), Pathways refused to amend the system. The fault remains in place.”
Stated timescale: early 2014
Web search (Tavily): No evidence found either way
Agonal Breathing: Why It Delays CPR and How to Recognize It - ACLS ↗ - All reports to Department of Health and Social Care
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.
2013 → 2015Barbara Patterson1 year 7 months after Winston Llewellyn Johns · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports describe a computerized decision‑support tool used by ambulance call handlers that fails to incorporate essential clinical information, leading to inappropriate CPR advice.
Winston Llewellyn Johns · 30 Oct 2013
“The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails.”
Original on judiciary.uk ↗ Barbara Patterson · 21 May 2015
“During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non Clinical call handlers to issue CPR advice unless a patient has stopped breathing.”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
Stated action · timescale: early 2014
“The Pathways system piloted in the North East has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing. Although this fault was pointed out to Pathways by NEAS NHS Trust manager before the latest update of the system (early 2014), Pathways refused to amend the system. The fault remains in place.”
What happened next: No evidence found either way
The Department of Health and Social Care did not confirm or deny the existence of the promised Pathways system update timeline in the provided sources.
“You're in the grocery store, at the gym, or standing in a hospital hallway when someone collapses. They appear unconscious - but then you notice something unsettling: they're making sounds. Labored, irregular, almost snoring-like gasps. Their chest seems to rise slightly. Your brain registers one thing: they're breathing. So you wait, you call for help, and precious seconds tick away.”
“Agonal breathing or agonal respirations are medical terms used to describe insufficient breathing that often sounds like snoring, snorting, gasping, or labored breathing. The person will appear to be choking or having an involuntary gasp reflex. Agonal breathing is not true breathing and often indicates that someone is suffering from a severe medical emergency like cardiac arrest.”
No evidence found does not mean the action did not happen.
- 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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2013 → 2015 | 0.76 | 0.25 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
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.