Recurring concern

Failure to ensure adequate supervision of emergency call handlers

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First reported 21 Jun 2017•Latest report 15 Apr 2026

Definition

What this concern includes

Includes failures of supervision arrangements for emergency call handlers, including supervisor availability, access to advice, oversight of calls, review of response decisions and escalation support for police, ambulance or comparable emergency call-handling functions.

Not included

  • Excludes general call-handler training, triage, recording, dispatch or algorithm deficiencies where supervision is not the shared unsafe condition.
  • Excludes failures of emergency-service staffing or response capacity that do not specifically impair supervision or oversight of call handlers.
  • Excludes clinical supervision of clinicians, care staff or other personnel who are not handling emergency calls.
  • Excludes failures occurring after a call has been safely handled when the remaining deficiency concerns downstream attendance, treatment or investigation.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2017–2026

First to latest report issue date

Stated actions
10

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 England2
Cheshire Constabulary1
South Western Ambulance Service NHS Foundation Trust1
Wiltshire Police1

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. Cheshire

    AI-generated summary

    Lisa Marie Elizabeth Beatrice TAYLOR-PENNY · 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

    Lisa Marie Elizabeth Beatrice Taylor-Penny was found deceased at home on 11 July 2025 after carers and social workers spent nearly seven hours trying to obtain emergency assistance to enter the property. The principal concern was that the rigid implementation of “Right care right person” did not provide sufficient scope for call handlers to escalate requests for senior professional judgment, including where other professionals expressed concern for life and limb and requested police attendance.

    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 sufficient scope for call handlers to escalate RCRP calls for senior professional judgment

    Wider context from the report

    “"Right care right person" (RCRP) is being implemented in a very rigid manner suggesting that call handlers may be using it as "tramlines not guidelines". I am concerned that it does not leave sufficient scope for call handlers to escalate calls for a senior member of staff to consider exercising professional judgment. In particular, where other professionals who are familiar with RCRP are nevertheless indicating a professional view that they need police attendance to secure entry and are expressing a concern for life and limb. ”

    Source location

    Lisa Marie Elizabeth Beatrice TAYLOR-PENNY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Train FCC staff, supervisors, managers and wider force personnel in RCRP law, procedures, toolkits, escalation and professional judgment.

    Verbatim wording from the response

    “This is supported by a policy document that explains the legal and statutory obligations, as well as the context and considerations that underpin Right Care Right Person implementation in Cheshire. Every member of staff in the FCC received detailed training in the law, the process and the application of RCRP prior to implementation. This included all Force Incident Sergeants (“FIS”), Force Incident Managers (“FIM”), FCC Supervisors and the Senior leadership team. Wider engagement and training were rolled out within the force to all departments. The training and supporting documents have also been shared with partner agencies to assist their own training and approach to RCRP (RCRP Legal and Escalation slides attached as Appendix three).”

    Source location

    Response from Cheshire Police
    Page 3 · response
    Published 29 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish a supervisor and Force Incident Manager escalation process for disputed, uncertain or exceptional deployment decisions.

    Verbatim wording from the response

    “3. Caller insists on deployment (after no deployment decision reached) and the matter thus requires escalation to a supervisor for review.”

    Source location

    Response from Cheshire Police
    Page 4 · response
    Published 29 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Employ trained RCRP floorwalkers and subject-matter support staff to assist call handlers during implementation and operational rollout.

    Verbatim wording from the response

    “During go live and throughout 2024 RCRP floorwalkers were employed to support staff in making decisions and answering questions. This was via experienced staff who received additional training and were selected for their knowledge of law and procedure and their ability to consistently apply RCRP to reported incidents. This was complemented by the FCC Supervisors on duty, and the RCRP project team who worked alongside staff in FCC Calls room. The training is as follows:”

    Source location

    Response from Cheshire Police
    Page 6 · response
    Published 29 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct live and retrospective quality assurance of concern-for-safety incidents, provide feedback and arrange further development where required.

    Verbatim wording from the response

    “Quality assurance is undertaken by the RCRP project and implementation team conducting live QA of incidents as they occur to ensure consistent application of RCRP in line with training. Direct feedback is given to FCC call handlers, and they can discuss decisions with the QA team as well as the FCC Supervisors. At the commencement of RCRP the FCC call handlers were all supported by RCRP subject matter experts (SME’s) and professionals from the mental health charity MIND who floor walked to assist call handlers become familiar with using the toolkits.”

    Source location

    Response from Cheshire Police
    Page 7 · response
    Published 29 April 2026

    Open published response

    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

    Existing RCRP toolkits, structured questions, training and escalation procedures provide consistent decision-making and adequate review where deployment decisions are disputed.

    Verbatim wording from the response

    “Whilst the RCRP process involves individual decision making, the toolkits and procedures ensure consistency and sound decision making to avoid differing interpretations of policy. The policy reflects decisions being made based on the information provided rather than decisions made based on who is providing the information.”

    Source location

    Response from Cheshire Police
    Page 9 · response
    Published 29 April 2026

    Open published response
  2. Plymouth, Torbay and South Devon

    AI-generated summary

    Sebastian · 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

    Sebastian was a six-year-old boy who became ill on 10 October 2015 and deteriorated over the following weekend. He suffered a cardiac arrest and was confirmed deceased at Derriford Hospital on 12 October 2015. The concerns included limitations in NHS Pathways questions and support arrangements that may have hindered recognition and escalation of an acutely unwell child, as well as the absence of a failsafe mechanism for repeated enquiries about the same complaint.

    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 review support arrangements for non-clinically qualified call advisors referring unusual cases to clinically qualified colleagues

    Wider context from the report

    “Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician. Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician. ”

    Source location

    Sebastian · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish and recirculate posters and updated guidance reminding call handlers how to recognise and respond to complex calls.

    Verbatim wording from the response

    “Actions in relation to complex calls following Sebastian’s death”

    Source location

    2019-0193-Response-by-NHS-Digital
    Page 8 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce a complex-calls training workshop for organisations using NHS Pathways, covering recognition, escalation and multidisciplinary support.

    Verbatim wording from the response

    “Finally, we have developed a training session which focuses on how we can support call handlers to recognise complex calls. This was introduced to all organisations that use NHS Pathways at the Training and Quality Forum on 25th June 2019.”

    Source location

    2019-0193-Response-by-NHS-Digital
    Page 8 · response
    Published 23 August 2019

    Open published response

    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

    Individual providers are responsible for training and supporting call handlers and creating infrastructure and clinical capacity for clinician transfers.

    Verbatim wording from the response

    “The training and support materials provided to sites are also under continual review as part of the NHS Pathways governance processes. Individual providers are responsible for training and supporting their staff as required by NHS Pathways and as appropriate to their local operating procedures.”

    Source location

    2019-0193-Response-by-NHS-Digital
    Page 7 · response
    Published 23 August 2019

    Open published response

    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

    Existing complex-call definitions and early-exit routes were considered sound for enabling non-clinical handlers to obtain clinical support.

    Verbatim wording from the response

    “Actions in relation to complex calls following Sebastian’s death”

    Source location

    2019-0193-Response-by-NHS-Digital
    Page 8 · response
    Published 23 August 2019

    Open published response
  3. Wiltshire and Swindon

    AI-generated summary

    Aidan David Ridley · 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

    Aidan David Ridley was struck by a car while crossing a road on 12 February 2016 and died three days later from hypoxic brain injury caused by how he landed, which obstructed his airway. Concerns included police call-handler advice not to turn him over, insufficient direction to seek ambulance advice or defer to medically trained bystanders, and inadequate call-handler training, guidance and supervision.

    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

    Inadequate supervision of Police call handlers

    Wider context from the report

    “(3) The guidance, training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively. ”

    Source location

    Aidan David Ridley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 intervene in or correct unsafe call-handler advice

    Wider context from the report

    “(4) There was a failure to intervene in or correct the advice given by the call handler not to turn Aidan over. ”

    Source location

    Aidan David Ridley · 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

    A minor road-traffic-collision report, as initially understood, would not require supervisor oversight under existing procedures.

    Verbatim wording from the response

    “This call was initially reporting a road traffic collision and this quickly developed into a medical emergency call that was not identified as such at the point the call came to the police. The training given to call handlers enables them to take control of the call and extract relevant information from the caller and remaining calm and reassuring. As information developed a call was made to ambulance by a colleague to ensure an ambulance was attending the scene which was within procedure.”

    Source location

    2019-0173-Response-by-Wiltshire-Police
    Page 2 · response
    Published 2 August 2019

    Open published response

    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

    Routine monitoring of every call is not achievable because supervisors have other responsibilities and the control room manages numerous live incidents.

    Verbatim wording from the response

    “As mentioned, incoming calls are not all routinely monitored by supervisors. The layout of the call center means the Force Incident Manager (Inspector) has responsibility for up to seventeen members of staff who are either taking calls or dispatching units. The inspector may hear one half of the conversation as the operator is speaking. The inspector and supervisors have the ability to dip sample calls of call handlers but also have other roles and responsibilities which include assessing the current active logs across the county. A supervisor could review or monitor the call requested by the call handler. It is routine within the Crime & Communication Centre to have up to 30 live incidents across the county over five different radio channels which places demands on all the staff.”

    Source location

    2019-0173-Response-by-Wiltshire-Police
    Page 2 · response
    Published 2 August 2019

    Open published response
  4. Exeter and Greater Devon

    AI-generated summary

    Colin James SLUMAN · 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

    Colin James SLUMAN suffered a burst varicose vein and exsanguinated before emergency services attended. Concerns included that the NHS Pathways protocol did not treat dizziness and being alone as triggers for a rapid response to catastrophic haemorrhage, that call handlers were not clinically trained and relied on the protocol, and that clinical supervision was not continuously available.

    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

    Insufficient availability of Clinical Supervisors to advise call handlers on appropriate responses

    Wider context from the report

    “(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports. ”

    Source location

    Colin James SLUMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 constant clinical oversight of all emergency reports

    Wider context from the report

    “(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports. ”

    Source location

    Colin James SLUMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Put funding in place to recruit ten additional clinicians.

    Verbatim wording from the response

    “One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 5 · response
    Published 28 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review clinicians’ rota arrangements to align availability with demand by time and day.

    Verbatim wording from the response

    “One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 5 · response
    Published 28 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce a cross-hub hunt group enabling EMAs to obtain support from available clinicians.

    Verbatim wording from the response

    “In response to continual increases in call volume, the Trust has implemented a virtual telephony system to ensure an available call handler, irrespective of location, will take a 999 call on either NHS Pathways or MPDS. To further ensure accessibility of clinical support for EMAs, a ‘hunt group’ was introduced in November 2016 whereby EMAs are able to seek clinical support from available clinicians irrespective of their hub location, thereby maximising the clinical support available to call handling staff.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 6 · response
    Published 28 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Add major blood loss categories to the Clinical Supervisors’ Escalation Report.

    Verbatim wording from the response

    “A further system utilised by clinicians within the hub is the Escalation Report. This is a tool on the administrative computers on each Clinical Supervisor’s desk and is designed to assist clinicians to identify incidents that have been triaged to an ‘Amber’ disposition but may be in need of a higher level of urgency. It only includes those incidents where an ambulance has yet to be allocated and relates to those categories of call that have the potential to be life-threatening, as in this instance. A Clinical Supervisor can then review the incidents highlighted by this report and decide whether to call the patient for further triage and upgrade the call where required. Before this incident, ‘major blood loss’ (without other symptoms) did not appear as a category identified on the Escalation report.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 6 · response
    Published 28 July 2017

    Open published response

    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

    EMAs are not completely reliant on NHS Pathways because clinical escalation, local guidance and supervisory review provide additional safeguards.

    Verbatim wording from the response

    “In terms of whether EMAs are completely reliant on NHS Pathways to reach a disposition, as the Pathways are meticulously devised by a panel of clinical experts, EMAs are for the most part, able to rely on the disposition reached. However, there are occasions where the Trust does not consider a particular disposition (as would be generated by NHS Pathways) for a specific patient presentation to be appropriate despite being clinically safe. On those occasions, the issues are escalated to NHS Pathways for review. Although the Pathways may be revised as a result, if change is not felt to be clinically necessary, it is for the Trust to determine whether local guidance or SOPs should be implemented to govern a particular situation and accordingly any policies would need to be ratified through internal governance procedures.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 4 · response
    Published 28 July 2017

    Open published response
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Data last updated 7 September 2026