Recurring concern

Unreliable communication of ambulance dispatch status and expectations

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First reported 16 Dec 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of communication dedicated to ambulance dispatch and response status, including misleading dispatch wording, unclear response expectations and inadequate updates after a call has been placed.

Not included

  • Excludes delays caused solely by ambulance resource shortages, staffing or hospital handover congestion where communication reliability is not the identified unsafe condition.
  • Excludes failures in clinical, mental-health, social-care or other discharge and referral communications not specifically tied to ambulance dispatch status or expectations.
  • Excludes failures of emergency call assessment or clinical prioritisation where the concern is the decision itself rather than communicating dispatch status or expectations.
Reports
13

Distinct published reports

Individual concerns
16

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
12

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.

NHS England5
South East Coast Ambulance Service NHS Foundation Trust3
Department of Health and Social Care2
East Midlands Ambulance Service NHS Trust2
NEMS Community Benefit Services Limited2
NHS Nottingham and Nottinghamshire Integrated Care Board2
North West Ambulance Service NHS Trust2
Aneurin Bevan University LHB1
Brother and next of kin1
Counsel1
NHS Pathways1
Rye Hill Prison1
South Central Ambulance Service NHS Foundation Trust1
Welsh Ambulance Services NHS Trust1

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.

  1. Brighton and Hove

    AI-generated summary

    Kevan FUNNELL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kevan Funnell, described as an older man with a head injury, was found lying in a public highway on a freezing night in October 2017. The principal concern was the ambulance service’s delayed response, including concerns that the first two calls were not appropriately progressed or escalated and that the call-handling system was not fit for purpose in this case.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide an estimated arrival time and proactive safety follow-up for waiting callers

    Wider context from the report

    “At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1 then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00:51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term “abandoned” however, it seems to me that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were coming and going about their business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need for a clinician. If that is not done, ████████ explained that during each shift a clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. ████████ agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service. ”

    Source location

    Kevan FUNNELL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester City

    AI-generated summary

    Terence Norbert Dooley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Terence Norbert Dooley took a fatal overdose of medication and contacted the ambulance service, reporting his location and symptoms. Attendance was delayed by 2 hours and 38 minutes, and he was later found deceased by the canal. Concerns included the emergency call being coded green, the delay in response, poor communication, and misleading computer-generated codes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate emergency response dispatch expectations

    Wider context from the report

    “3. There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes. ”

    Source location

    Terence Norbert Dooley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There was no lack of communication because the dispatcher explained the high demand and advised calling back if the patient's condition worsened.

    Verbatim wording from the response

    ““There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes.””

    Source location

    2014-0162-Response-by-North-West-Ambulance-Service
    Page 3 · response
    Published 10 April 2014

    Open published response

  3. Oxfordshire

    AI-generated summary

    Clive GOULD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide callers with accurate information about ambulance arrival delays

    Wider context from the report

    “(3) The evidence from the family at the inquest was that they were informed that an ambulance would be arriving shortly. Had they known that there was to be the delays that occurred because other calls had been given priority, they informed me that they could have used first aid resources available to them within the village, such as locally trained first aiders etc. ”

    Source location

    Clive GOULD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No estimated response times are communicated because dynamic priorities may require resources to be diverted to more time-critical incidents.

    Verbatim wording from the response

    “SCAS response SCAS has reviewed this point and conclude that as our 999 service is a dynamic response service, situations and priorities can change and diverting of resources to a more time critical incident can happen and must take priority. Currently no ambulance service communicates at the time of a call what their response time will be for this reason. SCAS have recognised that on occasions patients may experience a delay in response due to high levels of demand. In order to support patients SCAS have developed a Clinical Support Desk (CSD) within Emergency Operations Centre who will call back and support patients with further clinical advice until a response is on scene. The CSD are very experienced nurses and can support these patients and their families.”

    Source location

    2013-0357-Response-by-South-Central-Ambulance-Service
    Page 2 · response
    Published 16 December 2013

    Open published response
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Data last updated 7 September 2026