First reported 27 May 2016•Latest report 11 May 2026
Definition
What this concern includes
Includes failures dedicated to the telephone triage process, including unclear triage purpose, inadequate recording or information sharing, unreliable access, insufficient audit and delays in escalation or admission.
Not included
Excludes generic recordkeeping or communication failures not explicitly tied to telephone triage.
Excludes delays or access problems in services that do not form part of a telephone triage process.
Excludes unrelated staffing, training or system failures unless they directly impair telephone triage safety.
Reports
33
Distinct published reports
Individual concerns
46
A report can raise multiple concerns
Date range
2016–2026
First to latest report issue date
Stated actions
43
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 England16
Department of Health and Social Care7
NHS Pathways6
Royal College of General Practitioners4
Care Quality Commission3
NHS Greater Manchester Integrated Care Board3
Association of Ambulance Chief Executives2
Asthma + Lung UK2
DHU 111 (East Midlands) CIC2
North West Ambulance Service NHS Trust2
South East Coast Ambulance Service NHS Foundation Trust2
Yorkshire Ambulance Service NHS Trust2
Appello Limited1
Ashton Medical Centre1
Avon and Wiltshire Mental Health Partnership NHS Trust1
Executive non-departmental public body16
NHS trust15
Ministerial department7
Healthcare site6
Sub-organisation6
Integrated care board5
Health professional body4
Health and social care service regulator3
Type not available3
Community interest company2
Health-sector membership body2
Police force2
Registered charity2
Company1
Coronial office1
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.
Surrey
Concerns raised1
Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
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 concerns
Each 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
Position
A separate sepsis algorithm pathway is unnecessary because sepsis screening is embedded across multiple symptom-based NHS Pathways.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sunderland
Concerns raised2
Lack of guidance on conducting telephone contact to ameliorate the risk of suicide
Lack of guidance on maintaining telephone contact with patients expressing suicidal intent
Responses linked to these concerns
Each 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
Action
Provide mandatory NHS Pathways training on sensitive management of calls involving mental health conditions, including active listening and when to remain on the phone.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Whether health advisers remain on calls is an operational decision for each ambulance service, based on its real-time demand levels.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Coventry
Concerns raised1
Failure of NHS Pathways triage wording to be readily understood by callers in distress
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 concerns
Each 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
Action
Review ambulance triage outcome mapping and evidence, recommending changes to triage questions for implementation across providers.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.
Action
Update NHS Pathways wording and supporting information to improve recognition of clinical shock across different skin tones.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Add and maintain mandatory training on recognising skin-colour changes and using probing questions for patients with different skin colours.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NHS England will address the report’s other concerns in a separate response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Nationally approved triage systems, clinical support, oversight and regular script review provide the framework for consistent, safe 999 call handling.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NHS Pathways and ambulance-service concerns fall outside the Royal College of General Practitioners’ remit.
Stated by Royal College of General PractitionersOutside remitThe respondent said that this matter was outside its role or authority.
Coventry
Concerns raised1
Failure of NHS Pathways triage wording to be readily understood by callers in distress
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Sefton, St Helens and Knowsley
Concerns raised2
Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
Lack of national pathway guidance for call handlers on assessing how cold the body is
Responses linked to these concerns
Each 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
Action
Provide CPR Toolkit Training to NHS Pathways health advisors, including the ‘No, No, Go’ approach and telephone-guided CPR initiation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Devon, Plymouth and Torbay
Concerns raised1
Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
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 concerns
Each 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
Action
Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Continue refining and aligning the MPDS and NHS Pathways triage systems.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Action
Continue monitoring triage categorisation and strengthening clinical oversight.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South London
Concerns raised1
Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester West
Concerns raised1
Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor
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 concerns
Each 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
Action
Audit care navigator decisions and task-completion checks quarterly.
Stated by Ashton Medical Centre and SSP HealthStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Develop and share a learning document on safe, effective referrals to treating clinicians with Greater Manchester practices.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Action
Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Action
Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
Stated by Ashton Medical Centre and SSP HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The recorded request appears to have been for an alternative antibiotic, not an appointment requiring clinical assessment.
Stated by Ashton Medical Centre and SSP HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing pathways, triage guidance, staff training, policies and escalation procedures provide a clear and adequate response to urgent patient calls.
Stated by Ashton Medical Centre and SSP HealthExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Teesside and Hartlepool
Concerns raised2
Lack of triage guidance for responding when patients report prescribed steroid medication
Lack of triage guidance for establishing detailed steroid prescription information
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 concerns
Each 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
Action
Roll out a refresher bulletin for Health Advisors on adrenal insufficiency, Addison’s disease and adrenal crisis, and monitor staff completion and understanding.
Stated by North East Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
The respondent is not responsible for guidance or processes used to triage ambulance calls.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS ambulance services are responsible for processing 999 calls through approved triage systems.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Association of Ambulance Chief Executives is the appropriate organisation to provide further information on ambulance-service concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The North East and North Cumbria Integrated Care Board will respond directly to the Coroner regarding the concerns raised.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NEAS has limited ability to change NHS Pathways and defers the specific triage concern to NHS England, which delivers the system.
Stated by North East Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Health Advisors are not within the remit to understand complex medical issues such as steroid insufficiency during call triage.
Stated by North East Ambulance Service NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
NEAS cannot implement medication-detail questioning in NHS Pathways because it is a national system and recording errors could create additional risks.
Stated by North East Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure of the emergency call algorithm to identify symptoms consistent with an ongoing myocardial infarction
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 concerns
Each 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.3
Position
Concerns outside NHS England’s national policy or programme remit are not addressed in this response.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
NWAS, Tameside and Glossop Integrated Care NHS Foundation Trust, and the ICB should provide information on concerns assigned to them.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NWAS identified that the initial call was safely and appropriately triaged as Category 3 based on the symptoms provided.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes failures dedicated to the telephone triage process, including unclear triage purpose, inadequate recording or information sharing, unreliable access, insufficient audit and delays in escalation or admission.
