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.
Mid Kent and Medway
Concerns raised2
Failure to establish and verify the correct address during emergency call handling
Failure to review the original emergency call recording to establish the correct address
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
Implement the 111-service requirement for callers to provide and confirm the ambulance address through an Operational Bulletin.
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 12 August 2021.
Action
Implement a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.
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 12 August 2021.
Manchester South
Concerns raised3
Failure of the call-handling script to support discussion of self-transport or provide a realistic ambulance-arrival timescale
Lack of provision in the call-handling script to specify an acute hospital with an A and E department
Failure of the call-handling script to emphasise further contact after deterioration for reassessment of urgency
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
Explore adding advice to ambulance call scripts to direct callers to the nearest hospital with an emergency department when appropriate.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 February 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Providing an accurate ambulance arrival time is impracticable because lower-priority responses may be diverted to higher-priority incidents.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Case exit scripts already routinely instruct callers to call 999 again if the patient's condition changes or deteriorates.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Ambulance services must resolve unclear deterioration instructions locally through call-handler training.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure of emergency caller scripts to positively persuade lone callers to contact someone when paramedic attendance is delayed
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
Amend closing instructions to advise callers to contact someone immediately if needed, then keep the telephone line free for ambulance-service callbacks.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS Pathways cannot mandate advice for delayed ambulance attendance because it lacks delay information held by 999 providers.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Each 111 and 999 provider manages demand and delayed-attendance procedures through its own operational systems and local procedures.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised2
Automatic categorisation of abandoned calls as category 3
Failure to provide call recordings or full medical information to categorisation decision-makers
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
Review the process for abandoned calls, including calls involving potential mental health concerns.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 November 2020.
Action
Introduce and revise the mental health abandoned-call procedure to guide Category 2 responses for patients actively at risk.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 November 2020.
Action
Develop, approve and release an abandoned-call procedure covering Category 2 escalation and mandatory Duty Manager checks, including call-recording review.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 November 2020.
Bedfordshire and Luton
Concerns raised2
Failure to code uncertain self-harm ingestion calls as Category 2
Failure to code uncertain self-harm ingestion calls as Category 2
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
Encourage ambulance trusts to implement early clinical review of calls involving patients threatening suicide.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 8 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mandating or instructing ambulance services is outside the organisation’s constitution and authority.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
ECPAG, an NHS England-led group, is responsible for approving changes to clinical code sets and response categories.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
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.3
Action
Change NHS Pathways ambulance categorisation so symptoms suggesting life-threatening anaphylaxis receive a category 1 response, and deploy the changes nationally.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Continue participating in ambulance user groups to share data, discuss cases, exchange learning, and support triage-system improvements through feedback mechanisms.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Work with NHS England and other partners, and request resolution of inconsistent anaphylaxis coding between AMPDS and NHS Pathways.
Stated by Association of Ambulance Chief ExecutivesStated 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.8
Position
Ambulance categorisation and alignment of NHS Pathways with MPDS are not NHS Digital’s responsibility or oversight function.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS England oversees both systems and must address ambulance categorisation or inconsistencies between MPDS and NHS Pathways.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Established NHS Pathways governance systems capture, review and resolve clinical coding issues, including those raised through Prevention of Future Deaths reports.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
ECPAG, acting for NHS England, controls ambulance categorisation and can identify inconsistencies between NHS Pathways and MPDS.
Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Changes to MPDS and NHS Pathways operation are matters for IAED and NHS Digital respectively.
Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
ECPAG has limited ability to align NHS Pathways and MPDS because the systems use different methodologies.
Stated by London Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
No remaining anaphylaxis categorisation inconsistency exists between NHS 111 and ambulance services because 111 incidents pass directly into ambulance dispatch.
Stated by Association of Ambulance Chief ExecutivesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
An independent body, rather than NHS Digital, should conduct the review of clinical triage systems because NHS Digital provides the NHS 111 Pathways system.
Stated by AdvancedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex
Concerns raised1
Lack of a facility for call handlers to pass calls directly to ambulance triage staff
This report raised 7 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 raised2
Failure to ask callers how long the patient has been fitting
Failure to consistently categorise non-maintenance of airways as a continuous red code
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing MPDS triage, clinical support and escalation arrangements are considered sufficient to prioritise healthcare professional calls appropriately.
Stated by Welsh Ambulance Services NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The existing pan-Wales CPAS governance framework and international MPDS system are considered sufficient for best-practice call categorisation without a separate hospital pathway.
Stated by Welsh Ambulance Services NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to provide ambulance crews with correct venue access directions
This report raised 11 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.
Hampshire
Concerns raised2
Failure of 999 call triage to quickly and effectively identify the appropriate emergency response agency
Failure to share information between emergency agencies without repeating caller screening
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 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.
