Recurring concern
Unreliable communication and understanding of emergency policies and procedures
- Reports that mention this concern
- 11
- Times this concern has been raised
- 11
- Stated actions linked to this concern
- 15
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 11 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Nuffield Health
Stated actions 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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Nuffield Health
Operate MyStaff as a centralised platform for accessible Group and local policies, update alerts and critical-policy readership analytics.
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Nuffield Health
Use policy-access and readership analytics to assure Consultant and staff engagement with critical emergency documentation.
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Nuffield Health
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
-
Nuffield Health
Update induction and practising-privileges renewal checklists to cover MyStaff access and locating local emergency policies.
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Nuffield Health
Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
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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Nuffield Health
The Regulation 28 concerns did not contribute to the patient’s death.
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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.
Linked response
- Serco Group plc
Stated actions 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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Serco Group plc
Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.
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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.
Linked response
- Somerset NHS Foundation Trust
Stated actions 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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Somerset NHS Foundation Trust
Launch and implement the OPEL Framework and Escalating Clinical Concerns Charter.
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Somerset NHS Foundation Trust
Implement the South West Labour Ward Framework.
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Somerset NHS Foundation Trust
Introduce a seven-day Flow Midwife service and Senior Midwife On Call support for acuity-related staffing risk and escalation.
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Somerset NHS Foundation Trust
Increase and refresh the midwifery and maternity support worker establishment to improve rota cover and workforce deployment.
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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.
Linked response
- HM Prison and Probation Service
Stated actions 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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HM Prison and Probation Service
Actively review the emergency-escort policy.
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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.
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.
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.
Linked response
- Highways & Transportation (Leeds City Council)
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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Highways & Transportation (Leeds City Council)
Ambulance crews do not need event-morning briefings because Emergency Operations Centre directions provide the most appropriate response information at the time.
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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.
Linked response
- Bannatyne Fitness Limited
Stated actions 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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Bannatyne Fitness Limited
Review emergency action procedures and conduct regular documented drills covering multiple emergencies.
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Bannatyne Fitness Limited
Centrally audit emergency procedures and documented drills quarterly.
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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Bannatyne Fitness Limited
Changes to policies and procedures were deferred pending the inquest and investigations by the Metropolitan Police and London Borough of Camden.
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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.
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.
Linked responses
- Care UK
- Pentonville Prison
Stated actions 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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Pentonville Prison
Continue working with the healthcare provider to ensure staff understand the steps required when responding to emergency calls.
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Care UK
Implement the emergency-procedure actions outlined in the action table for all healthcare staff.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026