Includes failures in algorithms or algorithm-governed triage processes used to assess unwell patients where the system inadequately accounts for reported symptoms or emergency indicators, fails to identify serious deterioration, provides insufficient direction for clinical escalation, or encourages unsafe reliance without appropriate clinical input.
What is not included
Excludes failures in clinical assessment or treatment after the algorithm has appropriately identified the need for clinical input.
Excludes generic staffing, training, communication or service-capacity deficiencies unless they directly impair the algorithmic triage process.
Excludes named triage systems with a more specific established parent, such as NHS 111, MPDS, Manchester Triage System or ambulance call triage, when the assertion is confined to that system.
Excludes ordinary algorithm use where the algorithm reliably supports clinical judgement and no unsafe triage condition is identified.
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.
Department of Health and Social Care4
Barts Health NHS Trust1
Care Quality Commission1
East of England Ambulance Service NHS Trust1
NHS England1
North East Ambulance Service NHS Foundation Trust1
South Central Ambulance Service NHS Foundation Trust1
Welsh Ambulance Services NHS Trust1
Welsh Government1
NHS trust5
Ministerial department4
Devolved government1
Executive non-departmental public body1
Health and social care service regulator1
Reports and published responses 7 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised1
Lack of an algorithm for office call handlers to triage clients who appear unwell and determine a course of action
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
Existing CQC regulation and reasonable initial guidance are considered sufficient; further action is not considered likely to prevent a similar incident.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Care Quality Commission
The Department of Health and Social Care may be better placed to address concerns about call-handler triage algorithms.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Oxfordshire
Concerns raised2
Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems
Total reliance on an algorithm that does not direct early clinical input
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
South Central Ambulance Service 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
NHS England
Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.
South Central Ambulance Service NHS Foundation Trust
Log potential NHS Pathways system concerns with NHS England, including requests for information or change and anonymised patient-safety cases.
South Central Ambulance Service NHS Foundation Trust
Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
South Central Ambulance Service NHS Foundation Trust
Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
NHS England
The review concluded that the NHS Pathways algorithm functioned as intended in this case and required no changes.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Central Ambulance Service NHS Foundation Trust
NHS England, not the Trust, is responsible for altering the NHS Pathways algorithms.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Local services manage the availability of services matched to the NHS Pathways recommended outcome.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Central Ambulance Service NHS Foundation Trust
The Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Over-reliance on the NEWS algorithm in clinical assessment
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gwent
Concerns raised1
Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Eluned Morgan
Welsh Ambulance Services NHS 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.1
Welsh Ambulance Services NHS Trust
Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Eluned Morgan
Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of the ambulance call algorithm to direct exploration of concerning symptom responses
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Newcastle upon Tyne
Concerns raised1
Insufficient triage by algorithm when inadequate weight is given to reported symptoms and indicators of a medical emergency
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Lack of a neurological-deficit triage algorithm
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
EEAST
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
EEAST
Work with the IAED to improve triage standards and identify protocol gaps requiring clinical support.
EEAST
Meet the IAED, draft and submit a proposal for a neurological-deficit pathway in 999-call triage.
EEAST
Send the neurological-deficit pathway proposal to NASMeD for consideration and support.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
EEAST
The absence of a neurological-deficit protocol did not negatively affect the care provided or response assigned.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
EEAST
The IAED owns and designs the triage system, so protocol changes require its consideration and approval.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.