Lack of sepsis detection tool in emergency call handling
NHS England received 2 coroners' reports about this hazard between 3 May 2024 and 11 May 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
Ambulance Response Programme (ARP) Impact Assessment ↗- 2 years laterClosely relatedConfidence 0.90 · higha different coroner
“The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls”
Original on judiciary.uk ↗ Repeated from the earlier report:sepsispathway
NHS England responded.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.
2024 → 2026Oliver Shelley2 years after Michael Clarke · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify a missing sepsis detection tool in emergency call handling that could delay appropriate response.
Michael Clarke · 3 May 2024
“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”
Original on judiciary.uk ↗ Oliver Shelley · 11 May 2026
“The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls”
Original on judiciary.uk ↗
Stated action · timescale: 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”
What happened next: No evidence found either way
NHS England has prioritised improving ambulance performance during 2023/24, as outlined in its recovery plan for urgent and emergency care published in January 2023.
“ARP is now a specific work stream within the wider Ambulance Improvement Programme, led by NHS England and NHS Improvement.”
No evidence found does not mean the action did not happen.
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 |
|---|---|---|---|---|
| 2024 → 2026 | 0.78 | 0.21 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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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.