Ambulance procedures to change after Berkshire woman dies
Sandra Millard, 81, died alone at home after calling 111 and being unable to move from her chair, prompting a review of ambulance call handling across the country
Last updated 14th Apr 2025
Ambulance services across England are considering a change in their procedures after a woman in Berkshire died waiting for help following a call to 111.
Sandra Millard, aged 81, called 111 on 19 May 2024 to say she was unable to get out of her chair. A clinician attempted to call her back four times, but each time the line was engaged. No further action was taken, and no ambulance was sent.
She was found dead by a neighbour the following day.
At her inquest, the coroner concluded that she died from sepsis caused by infected leg ulcers. Other contributing factors included ischaemic heart disease and chronic kidney disease.
Robert Simpson, Assistant Coroner for Berkshire, issued a Regulation 28 report to prevent future deaths. He raised concerns about a gap in how the NHS Pathways triage system handles cases where a person is stuck in one position but not necessarily lying on the floor.
“When SCAS call takers using the NHS Pathways triage tool exit a module indicating a person is lying on the floor with no reported injuries they are prompted to ask additional questions,” the coroner wrote. “This same procedure is not applied when someone reports that they are stuck in situ, for example they are unable to move from their chair.”
He added: “My concern is that the additional risks of a long lie, for example rhabdomyolysis, may well apply when someone is unable to move from any position.”
The South Central Ambulance Service (SCAS) has now agreed to update its procedures to ensure call handlers ask further questions when a person is immobile, even if they are not on the floor. These include checking if someone is with the caller or if a family member can attend while waiting for an ambulance.
The coroner welcomed this change but noted that the issue could apply to other ambulance services using the NHS Pathways system.
His report was also sent to NHS England and the Association of Ambulance Chief Executives for wider consideration.