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.
Liverpool and the Wirral
Concerns raised1
Delays in triaging emergency calls involving threats of overdose
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.1
Action
Deploy mental health professionals in 999 call centres and clinical assessment services to direct people in crisis to appropriate care.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.
Herefordshire
Concerns raised1
Failure to consider telephone call transcripts during triage
This report raised 4 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
Implement a process allowing clinicians to listen to the patient’s phone call when an online triage form is unavailable.
Stated by Hereford Medical GroupStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The telephone call contained nothing that would have influenced the GP’s triaging outcome.
Stated by Hereford Medical GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Liverpool and the Wirral
Concerns raised1
Failure of ambulance triage to identify a person who could check the caller’s safety
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Failure of the 999 emergency triage questionnaire to adequately measure clinical gravity
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
The prioritisation questions are not considered inappropriate; patient harm is attributed primarily to the Trust’s inability to respond promptly.
Stated by Welsh Ambulance Services NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Suffolk
Concerns raised1
Insufficient practitioner time to gather information and conduct triage and risk assessment
This report raised 4 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
Repurposed the First Response Service and transitioned access to NHS 111 option 2 to refocus crisis response.
Stated by NHS Suffolk and North East Essex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Continue working with NSFT to reduce team vacancies and improve the crisis-service offer in Suffolk.
Stated by NHS Suffolk and North East Essex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.
Action
Expand and diversify the types of mental health workforce roles available.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Invest £111 million in 2021/22 to grow the mental health workforce.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Funding did not directly determine recruitment capacity, and the service was adequately funded initially.
Stated by NHS Suffolk and North East Essex Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The service could not financially respond to the sudden increase in demand caused by its expanded remit.
Stated by NHS Suffolk and North East Essex Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Local commissioners are responsible for deciding service provision and ensuring services meet local population needs.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Central and South East Kent
Concerns raised2
Lack of a procedure or specific protocol for callers with learning disabilities
Failure of NHS Pathways triage to take account of callers with learning disabilities
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.2
Action
Train health advisors and clinicians to engage appropriately with people with learning disabilities.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Monitor NHS Pathways staff competency against the competency framework.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing NHS Pathways training, competency monitoring and adaptive triage, including clinician takeover, are considered sufficient for callers with learning disabilities.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Hull and East Riding of Yorkshire
Concerns raised2
Failure to consider the timing of requests for advice in 111 dispositions
Failure to accommodate prior direct general practitioner review in 111 dispositions
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.4
Position
NHS Digital develops and manages NHS 111 algorithms, so responsibility for their modification rests with NHS Digital.
Stated by Royal College of Paediatrics and Child HealthRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Dispositions should not be varied solely by time of day; assessing interference with usual activities is considered the safer objective approach.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Investment to enable primary-care and out-of-hours record sharing would require action by NHS England, NHS Improvement and the Department of Health and Social Care.
Stated by Royal College of General PractitionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Automatic clinician transfer after prior healthcare review is not considered appropriate because it could delay assessment and compromise patient safety.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised2
Early termination of 999 call triage before completion
NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
This report raised 12 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
Incorporate feedback about fluctuating consciousness into the ongoing NHS Pathways review and governance cycle.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 March 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing NHS Pathways early-exit options and clinical validation arrangements adequately manage complex or incompletely triaged calls.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing training and triage functions adequately address changing or fluctuating consciousness during calls.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Additional telephone triage causing delays in admission for elderly patients
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.2
Action
Review all calls to the Alternative to Transfer service to provide immediate assurance about service safety.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2021.
Action
Implement revised ATT visit criteria requiring Mastercall visits after telephone assessment, unless the patient’s GP elects to visit the same day.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 February 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing contract monitoring, eligibility guidance and senior-clinician triage were considered adequate, with no significant concerns identified.
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
Existing specifications, guidance and senior-clinician triage are considered sufficient to redirect inappropriate ATT calls to 999.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Western)
Concerns raised1
Failure to use a standard set of initial questions during clinical triage
This report raised 4 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
Replicating NHS 111’s standard questions for subsequent clinicians is considered unnecessary because the existing assessment and information-sharing process is sufficient.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
