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.
North Northumberland
Concerns raised3
Failure to recognise location information from 999 calls
Failure to identify location from mobile 999 calls
Failure to immediately alert police and other emergency services from 999 call information
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.8
Action
Consider sourcing Mountain Rescue expertise and using SARLOC to improve location identification in relevant incidents.
Stated by North East Ambulance Service NHS Foundation Trust and Northumbria PoliceStated plannedThe respondent said that this action was planned when they made their response on 2 December 2016.
Action
Dual-monitor emergency calls and immediately review confirmed or suspected missing-person calls independently of the call handler.
Stated by Northumberland Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 2 December 2016.
Action
Confirm Fire Control procedures for mobilising to EISEC locations that include sea or water areas.
Stated by Northumberland Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 2 December 2016.
Action
Issue updated operational guidance addressing the identified emergency communications limitation.
Stated by Maritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 2 December 2016.
Action
Modify training packages to reflect the updated operational guidance.
Stated by Maritime and Coastguard AgencyStated completedThe respondent said that this action was complete when they made their response on 2 December 2016.
Action
Deliver THRIVE training to NEAS call handlers to improve identification of triggers requiring other emergency services.
Stated by North East Ambulance Service NHS Foundation Trust and Northumbria PoliceStated plannedThe respondent said that this action was planned when they made their response on 2 December 2016.
Action
Provide Tactical Advisors to support faster tactical responses and improve inter-agency communication.
Stated by North East Ambulance Service NHS Foundation Trust and Northumbria PoliceStated completedThe respondent said that this action was complete when they made their response on 2 December 2016.
Action
Finalise, approve and use the revised procedure for responding to 999 calls concerning water-based incidents.
Stated by North East Ambulance Service NHS Foundation Trust and Northumbria PoliceStated completedThe respondent said that this action was complete when they made their response on 2 December 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NEAS cannot remove closed questioning because Call Handlers must comply with NHS Pathways licence requirements and maintain clinical focus.
Stated by North East Ambulance Service NHS Foundation Trust and Northumbria PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Hertfordshire
Concerns raised1
Failure to manage outstanding emergency calls and waiting times within target response times
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
Increase clinician staffing in Emergency Operations Centres to treat more patients by telephone and refer them to appropriate pathways.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2017.
Action
Release ambulance crews from hospital emergency-department queues to attend patients with life-threatening community conditions.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2017.
Action
Negotiate with regulators and commissioners regarding funding needed to address the Trust’s capacity gap.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2017.
Action
Recruit hundreds of patient-facing staff within the available financial envelope.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust lacks capacity to deliver national NHS response-time targets amid rising demand and an acknowledged capacity gap.
Stated by East of England Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised3
Failure to contact the manager for emergency callers where a manager is available
Failure to obtain further information or reassess when directed by emergency services or relevant professionals
Failure to pass requested further information back to the requesting agency or professional
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cornwall and Isles of Scilly
Concerns raised1
Failure to appropriately triage and manage emergency 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.1
Action
Participate as a trial site in the Ambulance Response Programme’s new call-coding system.
Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 June 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The original emergency call was triaged correctly, achieving 97% compliance against the applicable 86% pass rate.
Stated by South Western Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Delay in providing the ambulance with the prison gate location
This report raised 15 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
Require prison control rooms to provide the gate location at the beginning of ambulance calls and brief staff on the requirement.
Stated by Pentonville PrisonStated completedThe respondent said that this action was complete when they made their response on 19 May 2016.
Action
Update the Computerised Gazetteer with both HMP Pentonville vehicular entrances and their postal addresses.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2016.
Action
Request HMP Pentonville staff to state the required ambulance entrance at the beginning of every 999 call.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2016.
Action
Deliver refresher training requiring emergency medical dispatchers to confirm the HMP Pentonville entrance at the start of each call.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2016.
Manchester South
Concerns raised1
Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
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.2
Action
Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2016.
Action
Trial a new ambulance coding system.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.
Stated by North West Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure of ward staff to call 999 directly
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.2
Action
Replace Reaside Clinic’s telephony system with the Trust’s standard system.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 April 2016.
Action
Extend ward medical-emergency simulations to test ambulance-call connection and availability of patient information and observations.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 April 2016.
Manchester (North)
Concerns raised1
Absence of protocol or guidance for inpatient contact with emergency services
This report raised 10 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 agreed staff protocol and guidance for responding when service users contact emergency services via 999, including risk review and safeguarding actions.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 February 2016.
Liverpool and the Wirral
Concerns raised1
Failure to advise doctors or emergency services of changes in circumstances after the first call
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.4
Action
Require call handlers to update emergency services about changes in a client’s circumstances and maintain contact until key holders or emergency services arrive.
Stated by Magenta LivingStated completedThe respondent said that this action was complete when they made their response on 28 January 2016.
Action
Brief all trained community alarm call handlers on the revised procedures, record their understanding, and provide the updated procedure.
Stated by Magenta LivingStated completedThe respondent said that this action was complete when they made their response on 28 January 2016.
Action
Address the revised procedures with new call-handling staff through the normal induction programme.
Stated by Magenta LivingStated plannedThe respondent said that this action was planned when they made their response on 28 January 2016.
Action
Monitor staff implementation of procedural changes through spot audits, call-recording reviews, data checks, and performance improvement measures.
Stated by Magenta LivingStated completedThe respondent said that this action was complete when they made their response on 28 January 2016.
Inner North London
Concerns raised3
Failure to provide the attending ambulance service with the prison gate location
Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers
Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons
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
Request that prison staff state the ambulance access gate at the beginning of emergency calls.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.
Action
Disseminate learning to emergency operations centre staff through the November Control Services Team Talk, requiring confirmation of the prison address to attend.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.
Action
Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.
Action
Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.
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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.
