First reported 19 Dec 2014•Latest report 16 Jun 2026
Definition
What this concern includes
Includes failures of dedicated audit, quality-assurance or review controls for emergency call handling, including audits of emergency service calls or Clinical Advisor calls, where required audit volumes, frequency, coverage, follow-up or use for identifying safety risks are not achieved.
Not included
Excludes generic care, clinical-record or organisational auditing deficiencies that are not specifically tied to emergency call handling.
Excludes failures in the substantive triage, advice, welfare-call or escalation process when no deficiency in auditing or assurance is identified.
Excludes generic staffing, training or governance deficiencies unless they directly impair the dedicated auditing of emergency call handling.
Excludes auditing of unrelated processes, including home leave, medication education, equipment checks or non-emergency communications.
Reports
5
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
9
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 England3
Association of Ambulance Chief Executives2
NHS West and North London Integrated Care Board2
South East Coast Ambulance Service NHS Foundation Trust2
Advanced Health And Care Limited1
Appello Careline Limited1
Bausch & Lomb U.K. Limited1
Care Quality Commission1
Department of Health and Social Care1
London Ambulance Service NHS Trust1
London Central & West Unscheduled Care Collaborative Limited1
Medicines and Healthcare products Regulatory Agency1
National Institute for Health and Care Excellence1
NHS Enfield Clinical Commissioning Group1
Sister of Kala Skinner1
NHS trust4
Executive non-departmental public body3
Health-sector membership body2
Integrated care board2
Private limited company2
Clinical commissioning group1
Health and social care service regulator1
Healthcare site1
Independent healthcare provider1
Medicines and medical devices regulator1
Ministerial department1
Professional membership body1
Type not available1
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, Brighton and Hove
Concerns raised1
Inadequate quality of the call auditing system
This report raised 8 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
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Reinforce information capture and communication through continuing operator training, call audits, supervision and operational reviews.
Stated by Appello Careline LimitedStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Strengthen QSF criteria for certified TEC monitoring organisations to improve call monitoring and emergency response quality.
Stated by TSAStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
NHS Pathways owns the national audit framework, so reviewing documentation weighting is its responsibility.
Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
Stated by TSAOutside remitThe respondent said that this matter was outside its role or authority.
Position
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure of 111 call audits to identify all significant call-handling failings
This report raised 20 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
Develop and apply an audit framework for NHS Pathways providers, including audit standards, frequencies, qualifications and training requirements.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Providers are responsible for operating the audit system and managing failed call audits within NHS Digital’s framework.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex
Concerns raised1
Failure to audit the required number of 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.
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
Provide dedicated, time-protected staffing for NHS Pathways audits.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.
Action
Introduce reporting and recording systems to monitor NHS Pathways audit performance.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.
Action
Introduce technology-based solutions to streamline the NHS Pathways audit process.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.
Action
Provide additional staff training to support the NHS Pathways audit function.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.
Avon
Concerns raised1
Failure to audit at least 3% of Clinical Advisor calls every month
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner West London
Concerns raised1
Lack of auditability of long and complex 999 and 111 calls
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.
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Includes failures of dedicated audit, quality-assurance or review controls for emergency call handling, including audits of emergency service calls or Clinical Advisor calls, where required audit volumes, frequency, coverage, follow-up or use for identifying safety risks are not achieved.
