Recurring concern

Telephone triage that is unreliable and can delay necessary care

First to latest report 27 May 2016 — 11 May 2026

Reports that mention this concern: 33
Times this concern has been raised: 46
Stated actions linked to this concern: 43

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Reports and published responses 33 reports

See individual reports that have raised this concern, and the actions taken in response

13 Sep2016
West Yorkshire (Western)
Concerns raised1
1. Failure of telephone operator protocols to require comprehensive enquiries about long lays, particularly for obese patients
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Keith William Rushton · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Keith William Rushton slid from his bed at home on 15 December 2015 and was unable to get up, remaining there until he was found on 16 December. An ambulance arrived approximately two hours after it was called, and he died later that day from multi-organ failure and rhabdomyolysis associated with crush injuries to his legs. The concerns focused on ambulance response times and telephone protocols for identifying prolonged lies, particularly involving obese patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of telephone operator protocols to require comprehensive enquiries about long lays, particularly for obese patients
Wider context from the report
“• To review existing protocols governing the allocation of information by telephone operators to incorporate more comprehensive enquiries with respect to long lays, particularly in the case of obese patients, in order to ensure adequate delivery of appropriate ambulance response times. ”
Source location
Keith William Rushton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Aug2016
Avon
Concerns raised1
1. Failure to include risk assessment in telephone triage
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Avon and Wiltshire Mental Health Partnership NHS Trust
Stated actions 1
1. Avon and Wiltshire Mental Health Partnership NHS Trust
  Use the Access Trigger Tool across telephone triage to require clinicians to assess risk and determine response urgency.
AI-generated summary

Oliver Hamlin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Oliver was found dead hanging from a tree at Norton Wood, Clevedon, after expressing paranoid thoughts and being triaged by the Primary Care Liaison Service. The concerns raised were that no risk assessment was carried out during triage, risk assessments should be documented, and weekend cover for the service should be considered.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to include risk assessment in telephone triage
Wider context from the report
“1. That there is a further review of the telephone triage process to specifically consider including a risk assessment. I was made aware that the triaging process has been reviewed but was not advised of any review to the risk assessment process itself. ”
Source location
Oliver Hamlin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use the Access Trigger Tool across telephone triage to require clinicians to assess risk and determine response urgency.

Verbatim wording from the response
“1. Following the review, the telephone triage process now includes the access trigger tool which is a trust wide tool that requires every clinician to ask in depth questions about risk. In essence it is a risk assessment which will indicate an immediacy of response.”

Source location
2016-0306-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 15 August 2016
Open published response
27 May2016
Cornwall and Isles of Scilly
Concerns raised1
1. Maternity Helpline triage by unregistered, inadequately trained and unqualified staff
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Charlie Mark Jermyn · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Maternity Helpline triage by unregistered, inadequately trained and unqualified staff
Wider context from the report
“7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff, who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice. ”
Source location
Charlie Mark Jermyn · Prevention of Future Deaths report
Page 2 · concerns
Open source report