Recurring concern
Unsafe emergency call handling
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Request correctionFirst reported 6 Dec 2013•Latest report 16 Jun 2026
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
- Individual concerns
- 109
- Date range
- 2013–2026
- Stated actions
- 150
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to grade calls correctly
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 concernsEach 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
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Action
Ask Home Office officials to contact West Midlands Police to identify remedial or additional measures for appropriate 101 call handling.
Stated by Kit Malthouse MP -
Action
Provide ongoing further training to all control room staff to reduce call-grading errors.
Stated by West Midlands Police -
Action
Capture learning from the incident and provide training to the involved call handlers.
Stated by West Midlands Police
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Action
Review THRIVE+ training for staff using learning from the incident.
Stated by West Midlands Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Police and Crime Commissioners and Chief Constables are responsible for deciding public communications and incident responses in their forces.
Stated by Kit Malthouse MP
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Position
The incorrect call grading made no difference because limited resources meant a correctly graded P2 call would also not have received a response.
Stated by Police and Crime Commissioner for West Midlands
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Concerns raised2
Lack of safety-critical communication training for emergency call takers
Failure to escalate emergency calls from initial call takers to team leaders
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 concernsEach 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
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Action
Include safety-critical communications training in the Customer Ambassador competency standard.
Stated by Govia Thameslink Railway Limited
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Concerns raised1
Insufficient resources for triage of all non-category 1 emergency 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to obtain riverfront coastguard location references during emergency calls
Failure to promptly triage river emergencies and involve appropriate waterborne assets
Responses linked to these concernsEach 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
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Action
Review OP61 to remove ambiguity about directly informing the Maritime Coastguard Agency.
Stated by London Ambulance Service NHS Trust -
Action
Remind all Emergency Operations Centre staff of the correct OP61 process for informing the Maritime Coastguard Agency.
Stated by London Ambulance Service NHS Trust -
Action
Develop Multi-Agency Incident Transfer data transmission to speed transfer of incident details between emergency services.
Stated by 999/112 Liaison Committee (999LC
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing advice to seek nearby help, roads and landmarks is considered sufficient; mandatory coastguard-signage requests could delay dispatch.
Stated by London Ambulance Service NHS Trust
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Position
Existing location systems and backup methods are considered sufficient, so callers are not routinely required to provide additional landmarks.
Stated by 999/112 Liaison Committee (999LC -
Position
Existing emergency-service information-sharing arrangements are considered sufficient, so callers should not be required to alert multiple services themselves.
Stated by 999/112 Liaison Committee (999LC
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Concerns raised1
Failure by call handlers to escalate worsening conditions
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 concernsEach 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
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Action
Reinforce call-handler escalation through initial training and one-to-one sessions with existing staff.
Stated by EEAST
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Concerns raised1
Lack of capacity to link repeat emergency calls concerning the same patient at the same 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 concernsEach 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
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Action
Extend duplicate-call alert checking toward a 12-hour window while reviewing CAD feasibility and system-performance impact.
Stated by East Midlands Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Extending duplicate-call checking requires assurance that increased CAD processing will not detrimentally affect the system’s ability to handle incoming calls.
Stated by East Midlands Ambulance Service NHS Trust
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Concerns raised1
Omission of second adrenaline auto-injector guidance from the emergency call algorithm
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 concernsEach 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
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Action
Raise the recommendation with IAED-MPDS governance bodies for consideration of a second EpiPen prompt.
Stated by London Ambulance Service NHS Trust -
Action
Share the PFD recommendation with NASMED leadership for consideration and wider ambulance-service escalation.
Stated by London Ambulance Service NHS Trust -
Action
Raise the PFD recommendation with NHS Pathways clinical governance leadership.
Stated by London Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Trust lacks authority to amend MPDS call-taking protocols unilaterally under its licence.
Stated by London Ambulance Service NHS Trust
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Position
Requests to change MPDS call-taking protocols must be submitted to the IAED Standards Committee.
Stated by London Ambulance Service NHS Trust
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Concerns raised3
Inadequate supervision of Police call handlers
Limited use of three-way calls between the public, Police call handlers and the ambulance service
Failure to intervene in or correct unsafe call-handler advice
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 concernsEach 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
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Action
Train new call handlers, issue staff briefings and reminders, and regularly test the three-way police-ambulance conferencing process.
Stated by Wiltshire Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
A minor road-traffic-collision report, as initially understood, would not require supervisor oversight under existing procedures.
Stated by Wiltshire Police
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Position
Routine monitoring of every call is not achievable because supervisors have other responsibilities and the control room manages numerous live incidents.
Stated by Wiltshire Police
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Concerns raised3
Lack of call-handling provision for identifying unrecognised ED/ABD presentations
Contradictory ambulance call-handling instructions
Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to manage support arrangements safely for callers who are alone
Failure to establish whether an emergency caller is alone and whether another person can be spoken to
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 concernsEach 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
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Action
Review the closing instruction for callers alone, consider adding advice to call someone else, and work with 999 services on its development.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
The service cannot add contradictory instructions to its own script because it must follow NHS Pathways and this could confuse callers.
Stated by South East Coast Ambulance Service NHS Foundation Trust
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Position
NHS Pathways is responsible for amending the script to ask whether patients are alone and provide corresponding instructions.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Position
The instruction not to contact others after ambulance dispatch remains necessary because ambulance services may need to call patients back.
Stated by NHS England -
Position
The decision to require call handlers to ask whether another person is present is an operational matter for South East Coast Ambulance Service.
Stated by NHS England
Data last updated 7 September 2026