Recurring concern
Failure of emergency response leadership and coordination
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Request correctionFirst reported 7 Feb 2014•Latest report 26 Aug 2025
What this concern includes
Includes failures of leadership, command, role clarity or team coordination within an explicitly identified emergency or life-threatening emergency response.
Not included
- Excludes leadership or governance deficiencies unrelated to an emergency response.
- Excludes generic training, staffing or communication deficiencies unless the report directly ties them to leadership or coordination of the emergency response.
- Excludes failures specific to a separate operational process, hazard or non-emergency incident-management system.
- Reports
- 16
- Individual concerns
- 22
- Date range
- 2014–2025
- Stated actions
- 35
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure of staff to call emergency services for serious incidents
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 concernsEach 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
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Action
Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.
Stated by Beech Cliffe Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Staff were trained and authorised to contact doctors or emergency services directly, rather than being required to route medical issues through managers.
Stated by Beech Cliffe Limited
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Position
The evidence did not establish that staff encountered or recognised a faecal-vomit emergency requiring an immediate ambulance call.
Stated by Beech Cliffe Limited
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Concerns raised1
Unclear process for attending prisoners with life-threatening conditions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.
Stated by Care UK Limited -
Action
Review emergency care arrangements, including staff training and standardisation of emergency bags.
Stated by Care UK Limited
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Concerns raised1
Lack of clear guidance on calling emergency services and decision-making authority
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Lack of training for calm leadership during emergencies
Failure to designate clear emergency leadership
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 concernsEach statement is shown once, even when linked to more than one 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
Lack of a formal protocol for reporting and co-ordinating rescue in relation to life-threatening incidents in Portsmouth Harbour
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Formal protocols exist for alerting HM Coastguard to life-threatening incidents involving persons on land or at sea.
Stated by Maritime and Coastguard Agency
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Position
Existing HM Coastguard and harbour-authority communication, cooperation and rescue-coordination arrangements are sufficient within harbour limits.
Stated by Maritime and Coastguard Agency
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Concerns raised1
Failure of nursing staff to respond to collapses in a calm coordinated manner
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 concernsEach 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
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Action
Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.
Stated by North London NHS Foundation Trust -
Action
Introduce the step-by-step emergency-response guide in all other inpatient areas.
Stated by North London NHS Foundation Trust -
Action
Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.
Stated by North London NHS Foundation Trust
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Action
Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.
Stated by North London NHS Foundation Trust
Data last updated 7 September 2026