First reported 9 Sep 2013•Latest report 19 May 2025
Definition
What this concern includes
Includes failures in the dedicated hospital pre-alert process, including deciding when a pre-alert is required, assigning responsibility for making it, conveying relevant clinical information to the hospital and auditing or assuring the system's effectiveness.
Not included
Excludes general ambulance, referral or clinical communication failures where no hospital pre-alert process is identified.
Excludes failures in hospital assessment, treatment or handover after the pre-alert has been reliably made and received.
Excludes generic audit, training or accountability deficiencies unless they directly impair the hospital pre-alert process.
Excludes routine notifications that do not function as a pre-alert for a seriously unwell patient.
Reports
5
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
13
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.
Ambulnz Community Partners Ltd.1
Department of Health and Social Care1
Dinnington Group Practice1
Kent Central Ambulance Service Ltd1
London Ambulance Service NHS Trust1
Northern Care Alliance NHS Foundation Trust1
North West Ambulance Service NHS Trust1
Welsh Ambulance Services NHS Trust1
Whittington Health NHS Trust1
Yorkshire Ambulance Service NHS Trust1
NHS trust4
Independent healthcare provider2
Healthcare site1
Ministerial department1
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.
North East Kent
Concerns raised1
Lack of clarity about responsibility for making pre-alert calls to hospital
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Mandate internal clinical escalation through the Clinical Support Line and empower crews to pre-alert hospitals independently when concerned or uncertain.
Stated by Kent Central Ambulance Service LtdStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Deliver refresher training for all crews on hospital pre-alert criteria and documentation.
Stated by Kent Central Ambulance Service LtdStated plannedThe respondent said that this action was planned when they made their response on 28 July 2025.
Action
Create and distribute a Medical Operational Plan for every event, covering staffing, response structure, communications and escalation pathways.
Stated by Kent Central Ambulance Service LtdStated plannedThe respondent said that this action was planned when they made their response on 28 July 2025.
Action
Distribute an event-readiness checklist covering equipment, clinical signs, contacts, escalation, hospital pre-alerts and documentation.
Stated by Kent Central Ambulance Service LtdStated plannedThe respondent said that this action was planned when they made their response on 28 July 2025.
North Wales (East and Central)
Concerns raised1
Failure to require pre-alerts for suspected sepsis in life-threatening time-critical situations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Implement pre-alert guidance for suspected sepsis, developed with Welsh Health Board clinical directors and the Royal College of Emergency Medicine Wales.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2020.
Action
Deliver mandatory training and a national education session to help emergency medical services staff recognise sepsis red flags and use pre-alerts.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
An exhaustive mandatory pre-alert policy is not feasible because clinical circumstances are too complex for an all-encompassing list.
Stated by Welsh Ambulance Services NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to include pregnancy information in pre-hospital alerts
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.6
Action
Complete an EOC observation session for the crew to support learning from the incident.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Review the crew’s learning from the EOC observation and confirm use of a structured information-sharing and handover approach.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Update pre-alert guidance to require the EOC to ask for other specific and critical information during information read-back.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Make operational staff aware of the updated pre-alert guidance.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Update joint maternity training to include EOC staff alongside operational, midwifery and maternity support staff.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Replace the Emergency Department priority-call information sheet with a version prompting staff to ask whether a relevant patient is pregnant.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The failure to communicate pregnancy information involved both the crew and emergency operations centre, not the emergency operations centre alone.
Stated by London Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised2
Absence of systems to audit the effectiveness and reliability of the pre-alert system
Lack of staff knowledge and training for reliable actioning of pre-alert requests
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Write to the Health and Safety Executive to bring the case to its attention regarding independent ambulance-service access to receiving emergency departments.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 January 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Local meetings among the ambulance provider, receiving Trust and ambulance service are considered sufficient to prevent a similar incident.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Licensing and medical-cover arrangements at public events are the responsibility of local authorities.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Amending the Purple Guide to specify independent ambulance access arrangements is ultimately for the HSE to decide.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NWAS should not and cannot act as gatekeeper for NHS hospital standby numbers.
Stated by North West Ambulance Service NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Hospitals and private ambulance providers must determine whether hospital standby numbers are shared.
Stated by North West Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in the dedicated hospital pre-alert process, including deciding when a pre-alert is required, assigning responsibility for making it, conveying relevant clinical information to the hospital and auditing or assuring the system's effectiveness.
