Recurring concern
Unreliable communication and understanding of emergency policies and procedures
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Request correctionFirst reported 8 Jan 2016•Latest report 18 Mar 2026
What this concern includes
Includes failures of the dedicated process for communicating, acknowledging, maintaining understanding of and applying emergency policies and procedures, including local variation, staff receipt and comprehension, acknowledgement controls and assurance that personnel know which emergency procedures apply.
Not included
- Excludes generic staff training, communication or documentation deficiencies unless they directly concern emergency policies and procedures.
- Excludes failures in the substantive design or clinical adequacy of an emergency procedure where communication, understanding or application is not the shared unsafe condition.
- Excludes non-emergency policies and procedures unless the report explicitly links them to the same emergency-policy communication and understanding process.
- Excludes operational failures occurring after personnel have reliably received, understood and applied the applicable emergency policies and procedures.
- Reports
- 11
- Individual concerns
- 11
- Date range
- 2016–2026
- Stated actions
- 15
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to ensure consultants understand locally varying emergency policies and procedures
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Operate MyStaff as a centralised platform for accessible Group and local policies, update alerts and critical-policy readership analytics.
Stated by Nuffield Health -
Action
Use policy-access and readership analytics to assure Consultant and staff engagement with critical emergency documentation.
Stated by Nuffield Health -
Action
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Stated by Nuffield Health
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Action
Update induction and practising-privileges renewal checklists to cover MyStaff access and locating local emergency policies.
Stated by Nuffield Health -
Action
Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
Stated by Nuffield Health
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Regulation 28 concerns did not contribute to the patient’s death.
Stated by Nuffield Health
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Concerns raised1
Failure to operate and provide clear guidance on emergency button procedures
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.
Stated by Serco Group plc
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Concerns raised1
Lack of understanding and implementation of policies for additional staffing during high acuity or emergency situations
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Launch and implement the OPEL Framework and Escalating Clinical Concerns Charter.
Stated by Somerset NHS Foundation Trust -
Action
Implement the South West Labour Ward Framework.
Stated by Somerset NHS Foundation Trust -
Action
Introduce a seven-day Flow Midwife service and Senior Midwife On Call support for acuity-related staffing risk and escalation.
Stated by Somerset NHS Foundation Trust
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Action
Increase and refresh the midwifery and maternity support worker establishment to improve rota cover and workforce deployment.
Stated by Somerset NHS Foundation Trust
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Concerns raised1
Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Actively review the emergency-escort policy.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to apply the emergency-calling procedure consistently across practice staff
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of ride operators to understand water-entry emergency procedures
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to ensure ambulance crews understand emergency authority to cross road closure signs
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Ambulance crews do not need event-morning briefings because Emergency Operations Centre directions provide the most appropriate response information at the time.
Stated by Highways & Transportation (Leeds City Council)
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Concerns raised1
Failure to ensure the duty manager reads the standard operating procedures and emergency action plan
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Review emergency action procedures and conduct regular documented drills covering multiple emergencies.
Stated by Bannatyne Fitness Limited -
Action
Centrally audit emergency procedures and documented drills quarterly.
Stated by Bannatyne Fitness Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Changes to policies and procedures were deferred pending the inquest and investigations by the Metropolitan Police and London Borough of Camden.
Stated by Bannatyne Fitness Limited
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Concerns raised1
Failure to verify receipt and understanding of critical policies and procedures
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inconsistent understanding of prison healthcare emergency procedures
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Continue working with the healthcare provider to ensure staff understand the steps required when responding to emergency calls.
Stated by Pentonville Prison -
Action
Implement the emergency-procedure actions outlined in the action table for all healthcare staff.
Stated by Care UK
Data last updated 7 September 2026