Recurring concern

Telephone triage that is unreliable and can delay necessary care

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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

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.

  1. West Yorkshire (Western)

    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

  2. Avon

    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

  3. Cornwall and Isles of Scilly

    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
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Data last updated 7 September 2026