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.
Liverpool and the Wirral
Concerns raised1
Delays in triaging emergency calls involving threats of overdose
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.1
Action
Deploy mental health professionals in 999 call centres and clinical assessment services to direct people in crisis to appropriate care.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.
Essex
Concerns raised1
Delays in calling emergency services and relaying basic emergency information
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.3
Action
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Cornwall and Isles of Scilly
Concerns raised1
Failure to answer or respond to calls within adequate timeframes
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.14
Action
Run recruitment campaigns to increase CMCU staffing and stabilise retention.
Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Regrade the RIMO role and increase its salary to support staff retention.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Use NICHE and Single Online Home to improve contact processing and public service delivery.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Introduce AACC7 to enable call-backs, a single voice queue and improved 101 answer times.
Stated by Devon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Introduce leaner processes to clarify responsibility and reduce call and follow-up work.
Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Analyse abandoned-call data to understand caller behaviour and contact-channel changes.
Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Transfer some incoming-contact management from Contact to local BCUs to increase RIMO capacity for 999 calls.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Provide dedicated Human Resources support for staff wellbeing, absence intervention, workplace adjustments and management effectiveness.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review shift patterns and move staffing towards peak-demand hours.
Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Implement the agreed new shift pattern for contact handlers.
Stated by Devon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Review identified Contact process improvements to improve service delivery.
Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Streamline nine Contact processes, including processes for missing people, Claire’s Law, Sarah’s Law and domestic abuse.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Operate a Demand Reduction team to identify repeat and vulnerable callers and reduce persistent or nuisance contact.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Open six additional police-station front offices and train staff to handle digital and non-urgent contact.
Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Liverpool and the Wirral
Concerns raised1
Failure of ambulance triage to identify a person who could check the caller’s safety
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.
Berkshire
Concerns raised1
Fragmented DNO emergency contact arrangements across ambulance service boundaries
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.2
Action
Share updated ambulance-service SOPs, including electricity-network maps and distribution-network-operator contact details, across NHS ambulance services.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 4 November 2022.
Action
Complete a review with each DNO and TNO confirming effective annual communication of regional network boundaries to local emergency services.
Stated by Electricity Networks AssociationStated plannedThe respondent said that this action was planned when they made their response on 4 November 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The membership organisation can provide guidance and collaboration but cannot mandate NHS ambulance services to implement safety action.
Stated by Association of Ambulance Chief ExecutivesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Preparing or overseeing local or national standard operating procedures and nationally overseeing 111 or 999 operations fall outside NHS Pathways’ remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Distribution and transmission network operators have suitable and effective arrangements with local emergency services for incidents involving electricity-network equipment.
Stated by Health and Safety ExecutiveExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to answer telecare fire calls as a priority
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
Commence development of a Fire Call Handling Pathway Decision Support Tool after completing the Ambulance tool, with NFCC and LFB support if available.
Stated by TEC Services Association C.I.C.Stated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Telecare and fire-service matters fall outside regulation, leaving no powers to prevent future deaths concerning those services.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The investigation found no evidence that involved TEC services were specifically at fault, while identifying disjointed agency working as significant.
Stated by TEC Services Association C.I.C.Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A Fire Call Handling Pathway Decision Support Tool is unlikely to be available until 2024 because development, testing, training and evaluation are required.
Stated by TEC Services Association C.I.C.Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure to automatically escalate disconnected ambulance calls from callers who are alone
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.
Surrey
Concerns raised1
Failure to make callbacks after dropped calls and at the two-hour mark
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Failure of call-processing protocols to incorporate overdose information into response categorisation
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.1
Action
Use Clinical Support Desk flags to identify overdose incidents and enable faster or out-of-order vehicle allocation.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2022.
South Wales Central
Concerns raised2
Failure of the prison control room to provide specific information to the ambulance service when an ambulance is required
Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support
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
Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
Stated by Cardiff PrisonStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.
Action
Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
Stated by Cardiff PrisonStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
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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.
