Recurring concern
Failure to ensure care staff can initiate appropriate emergency calls
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Request correctionFirst reported 15 Dec 2014•Latest report 27 Feb 2023
What this concern includes
Includes failures of training, competence, guidance or access arrangements that directly prevent care staff from recognising which emergency number to use or promptly initiating an appropriate 999 or 111 call.
Not included
- Excludes ambulance or police dispatch, call-handler triage, response-time and hospital-handover failures after the emergency call has been initiated.
- Excludes CPR, choking treatment, clinical assessment or other first-aid competence failures unless they also directly impair the initiation of the emergency call.
- Excludes generic staff-training deficiencies without a direct connection to care staff initiating an appropriate emergency call.
- Excludes emergency calls made by patients, relatives or members of the public where care-staff capability is not the deficient control.
- Reports
- 9
- Individual concerns
- 9
- Date range
- 2014–2023
- Stated actions
- 13
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
Delays in calling emergency services and relaying basic emergency information
This report raised 15 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.3
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Action
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to train staff to call emergency services immediately
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 ward staff awareness of telephone restrictions affecting 111 calls
This report raised 13 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
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
Failure to train care staff in basic emergency call processes
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.3
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Action
Implement an additional action plan and timetable responding to the inquest findings.
Stated by Avery Healthcare Group -
Action
Continue embedding all organisational policies and procedures at Aran Court.
Stated by Avery Healthcare Group -
Action
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The orientation checklist is considered sufficient to ensure staff understand telephone, nurse-call and emergency procedures.
Stated by Avery Healthcare Group
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Position
Existing emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.
Stated by Care Quality Commission -
Position
Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.
Stated by NHS England
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Concerns raised1
Lack of staff knowledge about obtaining an outside telephone line to emergency services
This report raised 1 other concern. 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
Remove the requirement to dial 9 for an outside telephone line.
Stated by Independence Homes -
Action
Communicate the changed outside-line procedure to staff verbally, by email and in the communications book.
Stated by Independence Homes
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Clear guidance on obtaining an outside telephone line was already provided at the time of the death.
Stated by Independence Homes
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Concerns raised1
Failure of ward staff to call 999 directly
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.
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
Replace Reaside Clinic’s telephony system with the Trust’s standard system.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Extend ward medical-emergency simulations to test ambulance-call connection and availability of patient information and observations.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Lack of staff training in appropriate use of 999 or 111
This report raised 11 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
Provide refresher training on the appropriate use of 999 and 111.
Stated by MERIDIAN HEALTHCARE LIMITED
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Concerns raised1
Failure to ensure staff know to call an ambulance directly when required
This report raised 11 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
Communicate that the person discovering an incident must call emergency services when warranted, and embed this instruction in General Managers’ training for team members.
Stated by Sunrise Senior Living UK
Data last updated 7 September 2026