First reported 6 Dec 2013•Latest report 16 Jun 2026
Definition
What this concern includes
Includes failures of the emergency call-handling process that impair location identification, information transfer, triage, escalation, reassessment, caller advice or appropriate resource deployment, including the anchor's failure to obtain riverfront coastguard location references and the delayed provision of a prison gate location.
Not included
Excludes deficiencies in coastguard staffing or service coverage that are not failures of emergency call handling.
Excludes clinical assessment, treatment or other downstream response failures after the call-handling process has ended.
Excludes generic staffing, training, policy or information-system deficiencies unless they are specifically tied to unsafe emergency call handling.
Excludes failures in non-emergency communication processes that do not concern handling an emergency call.
Reports
79
Distinct published reports
Individual concerns
109
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
150
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 England17
Department of Health and Social Care13
Association of Ambulance Chief Executives7
London Ambulance Service NHS Trust7
South East Coast Ambulance Service NHS Foundation Trust7
North West Ambulance Service NHS Trust6
Devon & Cornwall Police4
East Midlands Ambulance Service NHS Trust4
East of England Ambulance Service NHS Trust4
NHS Pathways4
South Central Ambulance Service NHS Foundation Trust4
Greater Manchester Police3
National Ambulance Service Medical Directors3
North East Ambulance Service NHS Foundation Trust3
Welsh Ambulance Services NHS Trust3
NHS trust49
Executive non-departmental public body17
Ministerial department16
Police force15
Health-sector membership body7
Private limited company6
Integrated care board5
Sub-organisation5
Type not available5
Health professional body4
Company limited by guarantee3
English metropolitan district council3
National policing body3
Other public body3
Prison or young offender institution3
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
Failure to obtain or provide basic clinical advice during careline emergency calls
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.5
Action
Amend failed-callback procedures to require Careline re-contact and consideration of three-way clinician communication when direct contact cannot be established.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Review use of Careline functionality during initial 999 calls to improve communication pathways and maximise available technology.
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 and strengthen access to clinical inline support by relaunching staff guidance and formalising expectations in the call-handling procedure.
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
Share and discuss the PFD learning with the ambulance service medical directors group.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Recommend that each ambulance service review local procedures for handling calls from telecare providers and assess three-way calling availability.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete 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
Routine three-way conference calling will not be introduced because operational complexity and variable call scenarios make it disproportionate or ineffective.
Stated by Appello Careline LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant 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
The organisation cannot mandate or instruct ambulance services, whose local procedures and implementation decisions remain their responsibility.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
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
Operational concerns about ambulance care are the responsibility of SECAMB, which is best placed to respond directly.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex, Brighton and Hove
Concerns raised1
Failure to inform callers when no ambulance is being arranged
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
Work with ambulance services to develop standard scripts for situations where Ambulance Response Programme standards will not be met.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Surrey
Concerns raised1
Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A separate sepsis algorithm pathway is unnecessary because sepsis screening is embedded across multiple symptom-based NHS Pathways.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Sussex
Concerns raised1
Delays in routing emergency calls concerning apparently deceased persons to ambulance services
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
Engage operational partners to consider the proposed change and decide whether to adopt it as standard practice.
Stated by Department for Science, Innovation and TechnologyStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2026.
Action
Continue working with operational partners to reflect any agreed improvements appropriately in the PECS Code of Practice.
Stated by Department for Science, Innovation and TechnologyStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2026.
Action
Engage ambulance services and the 999 Liaison Committee to consider default ambulance routing for uncertain reports of apparently deceased people.
Stated by UK policingStated plannedThe respondent said that this action was planned when they made their response on 21 May 2026.
Action
Reinforce expectations that police control rooms immediately notify ambulance services when life extinction is uncertain, using guidance and assurance activity.
Stated by UK policingStated plannedThe respondent said that this action was planned when they made their response on 21 May 2026.
Action
Support development of rapid call-transfer functionality between police and ambulance services to address identified mis-routing without caller re-dialling.
Stated by UK policingStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Operational delivery of emergency services, including police and ambulance response and control-room decisions, is outside the department’s responsibility.
Stated by Department for Science, Innovation and TechnologyOutside remitThe respondent said that this matter was outside its role or authority.
Position
BT and emergency services develop and implement the detailed operational policies and processes for handling emergency calls.
Stated by Department for Science, Innovation and TechnologyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Operational partners decide whether the proposed change should be adopted into standard practice.
Stated by Department for Science, Innovation and TechnologyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for developing and adopting rapid call-transfer functionality does not sit with policing.
Stated by UK policingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Policing cannot unilaterally change BT routing practices or default routing rules because PECS amendments require multi-agency agreement.
Stated by UK policingUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Police and BT call handlers will not undertake enhanced clinical triage because it risks further delay and unintended harm.
Stated by UK policingUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Cumbria
Concerns raised2
Failure to return calls from CHOC to NWAS after the third failed contact attempt
Failure to pass full and accurate information between NWAS and CHOC
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
Review the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Hampshire, Portsmouth and Southampton
Concerns raised1
Insufficient understanding of Category 1 response criteria for hanging incidents
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
Request national review of whether Category 1 disposition is appropriate for patients threatening to hang themselves.
Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Deliver mandatory refresher training and updated materials on suicidal-patient call management, escalation, response categories, information gathering, and risk assessment.
Stated by Isle of Wight NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Action
Continue working with national bodies to strengthen guidance and NHS Pathways for risks involving suicidal patients and potential hanging.
Stated by Isle of Wight NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
National NHS Pathways bodies are responsible for deciding whether Category 1 responses are appropriate for potential hanging incidents.
Stated by Isle of Wight NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
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
Require clinicians to review available information and make all Category 3 transfers through a clinical-only process, ending manual pushes to NEMS.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The manual push pathway will remain paused, with no reinstatement planned while agreed safety actions remain incomplete.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Concerns other than concern three are better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
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.5
Action
Keep the manual push pathway paused pending completion of all agreed safety actions.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Review automatic transfer codes with comparable East Midlands services to assess whether wider removal is appropriate.
Stated by NHS Nottingham and Nottinghamshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2026.
Action
End manually pushed calls and route referrals through Directory of Services or automated ITK pathways.
Stated by NEMS Community Benefit ServicesStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Strengthen governance, clinical oversight and operational boundaries for urgent care pathway referrals.
Stated by NEMS Community Benefit ServicesStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Require clinicians to review available information and make all Category 3 transfers through the clinical push model.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Concerns about the urgent care pathway, CAD information, Category 3 call handling and transfer criteria should be addressed by EMAS, NEMS and the ICB.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to correctly distinguish between missing-person reporting and the Right Person Right Care initiative
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.3
Action
Review Missing Person and RCRP policies, consult stakeholders, and progress senior-officer sign-off to clarify their distinction and reduce operational confusion.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025.
Action
Deliver enhanced call-handler and supervisor training on vulnerability assessment, complex cases, escalation decisions, and supervisory quality assurance.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025.
Action
Update the FCCO Sherlock guidance system with revised instructions for distinguishing Missing Person and RCRP procedures.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 3 December 2025.
Manchester West
Concerns raised2
Sub-optimal information gathering and evaluation of emergency category
Failure to accurately evaluate concern-for-welfare emergencies requiring forced entry
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.9
Action
Deliver targeted training briefs on Concern for Welfare criteria.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Host GMP supervisor and manager visits to the NWAS control room to observe triage and decision-making.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Review and update national RCRP guidance to clarify risk assessment and address emerging learning.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025.
Action
Provide continuing THRIVE training, refresher training and monitoring to improve risk assessment and decision-making.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Establish enhanced FCCO scrutiny, performance audits, dip sampling, performance plans and dashboard monitoring for RCRP compliance and signposting accuracy.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Develop and test an upgraded RCRP assessment tool integrating thematic pathways and presenting relevant guidance during questioning.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025.
Action
Review and amend the existing RCRP assessment tools, including question wording, ordering and NWAS definitions, to improve information gathering and risk identification.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025.
Action
Monitor the impact of RCRP and refine guidance using operational feedback and case reviews.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025.
Action
Implement and operate the RCRP policy and partner-agency pathways for assessing concern-for-welfare calls and directing responses.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
NWAS requires a confirmed location and clear medical need before deploying an ambulance under its Concern for Welfare procedure.
Stated by North West Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Despite inadequate questioning, signposting the caller to NWAS was consistent with Right Care, Right Person principles.
Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NWAS is not the expected primary responder to welfare calls involving no confirmed medical need, given its ambulance function.
Stated by North West Ambulance Service NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
NWAS is responsible for remotely assessing physical-health concerns and ordinarily providing the appropriate response.
Stated by Greater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of the emergency call-handling process that impair location identification, information transfer, triage, escalation, reassessment, caller advice or appropriate resource deployment, including the anchor's failure to obtain riverfront coastguard location references and the delayed provision of a prison gate location.
