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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 79 reports
See individual reports that have raised this concern, and the actions taken in response
West Yorkshire (Western)
Concerns raised1
Reliance on call takers to bring cross-agency welfare concerns to operational managers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
West Yorkshire Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
West Yorkshire Police
Train contact-centre staff, supervisors, and managers on Right Care Right Person and escalation procedures through peer training and updated training packages.
West Yorkshire Police
Implement and operate a widened WYP–YAS escalation process with approved procedures, digital documentation, daily review, and monthly partnership learning meetings.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
West Yorkshire Police
West Yorkshire Police states RCRP did not change existing processes, which were already governed by established welfare and escalation policies.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Failure to call an ambulance promptly following a concern for welfare call
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Devon & Cornwall Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Devon & Cornwall Police
Train officers requiring additional medical support to telephone 999 from the scene so operators can liaise directly and allocate resources.
Devon & Cornwall Police
Require officers using the police control room to explain why they cannot call 999 directly, and train police and ambulance personnel to record relevant information when liaising.
Birmingham and Solihull
Concerns raised2
Failure of the automated duplicate checker to identify repeat calls when the patient changes location
Failure to prompt call assessors to consider repeated 999 calls over time when assessing urgency
Linked responses
NHS England
West Midlands Ambulance Service University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
West Midlands Ambulance Service University NHS Foundation Trust
Develop an alternative duplicate-call detection method using patient and caller demographic details beyond location-based matching.
West Midlands Ambulance Service University NHS Foundation Trust
Implement a call-taking protocol requiring clinical review when three or more repeat calls are identified.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
NHS England
National policy on how ambulance services manage duplicate callers is outside NHS England’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Ambulance services are responsible for adopting good practice and implementing local procedures for managing duplicate callers.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Treating callers with previous contacts differently could delay NHS Pathways assessment, ambulance dispatch, or life-saving advice.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Midlands Ambulance Service University NHS Foundation Trust
Established protocols treat repeat calls as requiring full retriage only when the patient's condition has changed or worsened.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Midlands Ambulance Service University NHS Foundation Trust
A higher response category would not have been achieved because the patient was reported conscious and breathing regularly.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure of the emergency call algorithm to identify symptoms consistent with an ongoing myocardial infarction
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
Concerns outside NHS England’s national policy or programme remit are not addressed in this response.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
NWAS, Tameside and Glossop Integrated Care NHS Foundation Trust, and the ICB should provide information on concerns assigned to them.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
NWAS identified that the initial call was safely and appropriately triaged as Category 3 based on the symptoms provided.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised2
Failure to escalate calls when repeated non-response may indicate loss of consciousness
Failure to assign an appropriately urgent category to calls indicating a medication overdose and suicidal intent
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
North West Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
North West Ambulance Service NHS Trust
Route overdose and poisoning calls through Clinical Navigation for timely clinician review, escalation, further triage and welfare action when specialist triage is delayed.
North West Ambulance Service NHS Trust
Provide extended overdose and poisoning training to clinicians in Clinical Navigation, the Clinical Support Desk and Clinical Coordination Desk, including use of TOXBASE.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
North West Ambulance Service NHS Trust
When patients do not answer return calls, existing arrangements provide ambulance dispatch and clinician-led judgement on whether categorisation should be upgraded.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North West Ambulance Service NHS Trust
Automatic upgrading of every unanswered patient call is not feasible because it would significantly burden ambulance capacity and response-time targets.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Department of Health and Social Care
NWAS is best placed to respond on the specific local action addressing the concerns.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North West Ambulance Service NHS Trust
The category 3 outcomes were appropriate based on NHS Pathways information and audits of both calls.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
North West Ambulance Service NHS Trust
NHS Pathways, rather than the ambulance trust, ultimately determines categorisation of calls triaged through its system.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to ensure consistent ambulance call categorisation pathways across England
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
Existing mapping and continual review of triage categorisation are considered sufficient to reduce unwarranted variation and support appropriate ambulance prioritisation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
NHS England is responsible for overseeing ambulance services and maintaining, reviewing and revising the triage dataset through ECPAG.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Coventry
Concerns raised1
Failure to identify emergencies and contact the appropriate emergency service
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
J&K Partnership
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
J&K Partnership
Provide face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
J&K Partnership
Reissue care-home escalation guidance to staff and display it in key service areas.
J&K Partnership
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
J&K Partnership
Appropriate escalation guidance was already available; staff contacted 111 rather than 999 because they panicked, not because guidance was absent.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Oxfordshire
Concerns raised1
Delays in connecting 999 calls to an Emergency Call Taker
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
South Central Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
South Central Ambulance Service NHS Foundation Trust
Remodel Emergency Call Taker staffing to identify numbers required for reliable operational demand.
South Central Ambulance Service NHS Foundation Trust
Work with Isle of Wight NHS Trust to increase Emergency Call Taker numbers and availability.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
South Central Ambulance Service NHS Foundation Trust
The existing critical call process remains in place for time-critical 999 situations.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Teesside and Hartlepool
Concerns raised1
Failure to escalate Category 2 calls to Category 1 when conditions worsen
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North East Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
North East Ambulance Service NHS Foundation Trust
Finalise the EOC clinician procedure for managing deteriorating patients.
North East Ambulance Service NHS Foundation Trust
Operate the Dispatch Clinical Risk Assessment procedure to prioritise Category 2 responses by clinical risk.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
North East Ambulance Service NHS Foundation Trust
Responsibility for changes to NHS Pathways algorithms and system-generated response categories rests with NHS England and the Secretary of State.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North East Ambulance Service NHS Foundation Trust
The call handler followed NHS Pathways correctly, and the patient's conscious, breathing condition did not warrant a Category 1 response.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
North East Ambulance Service NHS Foundation Trust
Even with further clinical information, a conscious patient with regular breathing would not necessarily have warranted a higher-priority Category 1 response.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised1
Unclear procedure for relaying emergency information to the ambulance service
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.