Recurring concern
Failure to initiate 999 calls promptly when life is at risk
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Request correctionFirst reported 15 Apr 2016•Latest report 26 May 2026
What this concern includes
Includes failures in arrangements for recognising when a 999 call is required and initiating it promptly, including staff or service switchboards directing service users or other unqualified callers to make the call when the responsible service should do so.
Not included
- Excludes ambulance call handling, dispatch, attendance and hospital handover failures after a 999 call has been initiated.
- Excludes decisions about whether ambulance attendance is required where the failure is not the initiation of the 999 call itself.
- Excludes non-emergency police or healthcare contact routes unless the report identifies a life-threatening situation requiring 999 initiation.
- Excludes the broader emergency response after the call has been made.
- Reports
- 7
- Individual concerns
- 8
- Date range
- 2016–2026
- Stated actions
- 7
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 contacting 999 and the on-call doctor during cardiac arrests
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.2
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Action
Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
Stated by SPFT -
Action
Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
Stated by SPFT
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
Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
Stated by SPFT
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Concerns raised1
Failure to make 999 calls immediately on discovering an unresponsive person
This report raised 7 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
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
Stated by Aspray House
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Concerns raised1
Lack of an outside line on the seclusion-room observation handset for direct 999 emergency calls
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
Adjust the Antelope House observation-room telephone line to enable external emergency calls.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Check seclusion-room telephones across inpatient mental-health units to confirm they can dial 999.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Concerns raised2
Failure to summon emergency medical assistance when required
Failure to apply the emergency-calling procedure consistently across practice staff
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.
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 written procedure for making a 999 emergency call
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
Intensive service switchboard inability to call 999 when life protection is required
This report raised 8 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.
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
The switchboard can call 999 when an emergency requires it, contrary to evidence that it lacked this ability.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
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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
Data last updated 7 September 2026