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.
West Sussex
Concerns raised1
Different ambulance-call handling for third-party callers
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 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.
Birmingham and Solihull
Concerns raised1
Failure of NHSP overdose triage to account for drug type and sudden-collapse risk
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.3
Action
Introduce and ratify disposition code Dx0124 to identify higher-risk suicidal patients for early clinical review.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Deploy NHS Pathways Release 18 across NHS 111 and participating ambulance services, including staff updates and system implementation.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Develop a proposed disposition code to identify symptomatic, non-suicidal overdose patients for urgent clinical assessment.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Automated identification of higher-risk overdose patients is not currently possible because patients may inaccurately identify the substance or quantity taken.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Reclassifying every overdose case as a Category 2 ambulance response would create wider clinical risks and delay responses to patients with greater need.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Automatically identifying higher-risk overdose patients from drugs taken is not possible because telephone triage has too many variables for non-clinical call handlers.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Re-categorising all suicidal cases for faster ambulance responses would offer little benefit and could introduce wider clinical risks.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Lack of a neurological-deficit triage algorithm
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.3
Action
Work with the IAED to improve triage standards and identify protocol gaps requiring clinical support.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Action
Meet the IAED, draft and submit a proposal for a neurological-deficit pathway in 999-call triage.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Send the neurological-deficit pathway proposal to NASMeD for consideration and support.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The absence of a neurological-deficit protocol did not negatively affect the care provided or response assigned.
Stated by EEASTDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The IAED owns and designs the triage system, so protocol changes require its consideration and approval.
Stated by EEASTRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised2
Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
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.
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 the vomiting question to address callers’ unfamiliarity with the term “coffee-grounds”.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.
Action
Add “soil” to the supporting information for the question about vomiting blood.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.
Action
Review the gastrointestinal pathways, including diarrhoea and vomiting, clinical evidence on haematemesis, and whether user research could improve triage questions.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Communication training, monthly audits, adaptable questioning and clinician transfer routes provide sufficient support for young or vulnerable callers.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The coffee-ground description is clinically specific and supported by explanatory text; removing it could cause inappropriate over-referral.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to provide reliable telephone access to the IAPT team for initial triage
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.
Northamptonshire
Concerns raised2
Lower priority allocation by the ‘111’ Pathway triaging system than by the ‘999’ AMPDS system
Failure of ‘111’ and EMAS call handling systems to treat neurological signs as urgent
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
Share concerns about NHS Pathways’ ability to identify possible sepsis with the software developers.
Stated by DHU 111 (East Midlands) CICStated completedThe respondent said that this action was complete when they made their response on 11 April 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The triage systems would not have warranted a Category 2 ambulance without both severe illness and new marks being present.
Stated by DHU 111 (East Midlands) CICDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised1
Mental-health telephone triage by staff with insufficient mental-health training
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 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
Operate a 24/7 control-room triage service staffed by mental health professionals alongside police communications staff.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 28 December 2018.
Warwickshire
Concerns raised5
Failure to retain staff recollection of telephone triage
Lack of contemporaneous records of telephone triage
Failure to update the RIO system with telephone triage information
Lack of subsequent notes of telephone triage
Lack of clarity about the purpose and scope of telephone triage
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 South
Concerns raised1
Failure of the practice information system to reliably communicate telephone triage information to the subsequent face-to-face clinician
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.5
Action
Record reception and triage information in patients’ clinical notes using the EMIS triage template.
Stated by Stockport Medical GroupStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
Action
Train reception supervisors to use the new EMIS triage template.
Stated by Stockport Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Action
Have reception supervisors train staff across all three sites to use the EMIS triage template as the standard booking format.
Stated by Stockport Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Action
Request EMIS software changes to automate transfer of triage information into clinical notes.
Stated by Stockport Medical GroupStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
Action
Adhere to the policy of recording reception and triage information in clinical notes pending suitable EMIS software adaptation.
Stated by Stockport Medical GroupStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Automating transfer of triage information into clinical notes depends on EMIS adding the required software capability.
Stated by Stockport Medical GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised2
Failure to provide advice to return to hospital after reported high temperature following a burn
Failure to record reported high temperature in telephone notes
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.1
Action
Alert the Paediatric Burns Network to the advice so that improvements can be made more widely.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
There was no suggestion that a temperature spike was mentioned during the telephone call and then not recorded or acted upon.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The existing national leaflet already provides nationally accepted burns advice, correct warning signs, and appropriate instructions for parents seeking further care.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The burns unit can already be contacted by telephone 24 hours a day, every day.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting 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.
