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
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.
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.2
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Action
Train contact-centre staff, supervisors, and managers on Right Care Right Person and escalation procedures through peer training and updated training packages.
Stated by West Yorkshire Police -
Action
Implement and operate a widened WYP–YAS escalation process with approved procedures, digital documentation, daily review, and monthly partnership learning meetings.
Stated by West Yorkshire Police
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
West Yorkshire Police states RCRP did not change existing processes, which were already governed by established welfare and escalation policies.
Stated by West Yorkshire Police
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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.
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.2
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Action
Train officers requiring additional medical support to telephone 999 from the scene so operators can liaise directly and allocate resources.
Stated by Devon & Cornwall Police -
Action
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.
Stated by Devon & Cornwall Police
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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
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.2
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Action
Develop an alternative duplicate-call detection method using patient and caller demographic details beyond location-based matching.
Stated by West Midlands Ambulance Service University NHS Foundation Trust -
Action
Implement a call-taking protocol requiring clinical review when three or more repeat calls are identified.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
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Position
National policy on how ambulance services manage duplicate callers is outside NHS England’s remit.
Stated by NHS England
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Position
Ambulance services are responsible for adopting good practice and implementing local procedures for managing duplicate callers.
Stated by NHS England -
Position
Treating callers with previous contacts differently could delay NHS Pathways assessment, ambulance dispatch, or life-saving advice.
Stated by NHS England -
Position
Established protocols treat repeat calls as requiring full retriage only when the patient's condition has changed or worsened.
Stated by West Midlands Ambulance Service University NHS Foundation Trust -
Position
A higher response category would not have been achieved because the patient was reported conscious and breathing regularly.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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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.
Responses linked to these concernsEach 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.3
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Position
Concerns outside NHS England’s national policy or programme remit are not addressed in this response.
Stated by NHS England
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Position
NWAS, Tameside and Glossop Integrated Care NHS Foundation Trust, and the ICB should provide information on concerns assigned to them.
Stated by NHS England -
Position
NWAS identified that the initial call was safely and appropriately triaged as Category 3 based on the symptoms provided.
Stated by NHS England
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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.
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.2
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Action
Route overdose and poisoning calls through Clinical Navigation for timely clinician review, escalation, further triage and welfare action when specialist triage is delayed.
Stated by North West Ambulance Service NHS Trust -
Action
Provide extended overdose and poisoning training to clinicians in Clinical Navigation, the Clinical Support Desk and Clinical Coordination Desk, including use of TOXBASE.
Stated by North West Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
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Position
When patients do not answer return calls, existing arrangements provide ambulance dispatch and clinician-led judgement on whether categorisation should be upgraded.
Stated by North West Ambulance Service NHS Trust
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Position
Automatic upgrading of every unanswered patient call is not feasible because it would significantly burden ambulance capacity and response-time targets.
Stated by North West Ambulance Service NHS Trust -
Position
NWAS is best placed to respond on the specific local action addressing the concerns.
Stated by Department of Health and Social Care -
Position
The category 3 outcomes were appropriate based on NHS Pathways information and audits of both calls.
Stated by North West Ambulance Service NHS Trust -
Position
NHS Pathways, rather than the ambulance trust, ultimately determines categorisation of calls triaged through its system.
Stated by North West Ambulance Service NHS Trust
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Concerns raised1
Failure to ensure consistent ambulance call categorisation pathways across England
Responses linked to these concernsEach 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
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Position
Existing mapping and continual review of triage categorisation are considered sufficient to reduce unwarranted variation and support appropriate ambulance prioritisation.
Stated by Department of Health and Social Care
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Position
NHS England is responsible for overseeing ambulance services and maintaining, reviewing and revising the triage dataset through ECPAG.
Stated by Department of Health and Social Care
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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.
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
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.
Stated by J&K Partnership -
Action
Reissue care-home escalation guidance to staff and display it in key service areas.
Stated by J&K Partnership -
Action
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Stated by J&K Partnership
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
Appropriate escalation guidance was already available; staff contacted 111 rather than 999 because they panicked, not because guidance was absent.
Stated by J&K Partnership
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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.
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.2
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Action
Remodel Emergency Call Taker staffing to identify numbers required for reliable operational demand.
Stated by South Central Ambulance Service NHS Foundation Trust -
Action
Work with Isle of Wight NHS Trust to increase Emergency Call Taker numbers and availability.
Stated by South Central Ambulance Service NHS Foundation 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
The existing critical call process remains in place for time-critical 999 situations.
Stated by South Central Ambulance Service NHS Foundation Trust
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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.
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.2
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Action
Finalise the EOC clinician procedure for managing deteriorating patients.
Stated by North East Ambulance Service NHS Foundation Trust -
Action
Operate the Dispatch Clinical Risk Assessment procedure to prioritise Category 2 responses by clinical risk.
Stated by North East Ambulance Service NHS Foundation Trust
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
Responsibility for changes to NHS Pathways algorithms and system-generated response categories rests with NHS England and the Secretary of State.
Stated by North East Ambulance Service NHS Foundation Trust
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Position
The call handler followed NHS Pathways correctly, and the patient's conscious, breathing condition did not warrant a Category 1 response.
Stated by North East Ambulance Service NHS Foundation Trust -
Position
Even with further clinical information, a conscious patient with regular breathing would not necessarily have warranted a higher-priority Category 1 response.
Stated by North East Ambulance Service NHS Foundation Trust
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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.
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.
Data last updated 7 September 2026