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
Suffolk
Concerns raised2
Failure to provide the police with the correct identity of the person involved in a welfare call
Failure to share the informant's contact details and ambulance service CAD information with the police
This report raised 2 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.
Northamptonshire
Concerns raised1
Failure to escalate calls when a urinary tract infection is suspected
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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
East Midlands Ambulance Service NHS Trust
The information provided did not warrant escalation, so the call was appropriately categorised without a higher-priority response.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Western)
Concerns raised1
Failure to pass updated information to third-party call-handling contractors
This report raised 3 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.
West Yorkshire Eastern
Concerns raised1
Failure to escalate repeated requests for an ambulance in the control room
This report raised 4 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.
South Wales Central
Concerns raised1
Failure to re-categorise incidents when welfare-call information indicates increased risk
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cardiff & Vale University LHB
Welsh Ambulance Services 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.1
Cardiff & Vale University LHB and Welsh Ambulance Services NHS Trust
Remind clinical contact centre leads to handle Protocol 23 overdose cases promptly.
Portsmouth and South East Hampshire
Concerns raised2
Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request
Vagueness of the Use of Standby Points policy for probing emergency requests
This report raised 10 other concerns. 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.5
South Central Ambulance Service NHS Foundation Trust
Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.
South Central Ambulance Service NHS Foundation Trust
Disseminate the updated Standard Operating Procedure and Clinical Directive to all Emergency Operations Centre staff.
South Central Ambulance Service NHS Foundation Trust
Provide Emergency Operations Centre staff with guidance on diagnoses and circumstances indicating a time-critical transfer, including escalation to the Clinical Support Desk when needed.
South Central Ambulance Service NHS Foundation Trust
Audit inter-hospital time-critical transfer requests and provide feedback to acute trusts and commissioners when request information conflicts with the patient’s clinical condition.
South Central Ambulance Service NHS Foundation Trust
Amend and finalise the Use of Standby Points policy to clarify that crews dispatched to Time Critical or Category 1 calls cannot reasonably request facilities use.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
South Central Ambulance Service NHS Foundation Trust
An exhaustive list of time-critical transfer diagnoses and circumstances cannot be provided because medical care is complex.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Central Ambulance Service NHS Foundation Trust
Changes to the standby-points policy require review by staff union representatives and senior operational staff before finalisation.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Black Country
Concerns raised1
Failure to accurately triage emergency calls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
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.1
West Midlands Ambulance Service University NHS Foundation Trust
Deliver further education and refresher training on head injuries through the NHS Pathways update.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
West Midlands Ambulance Service University NHS Foundation Trust
It is unclear whether the call was incorrectly categorised because the caller’s answers may not have supported a Category 2 response.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Failure of police call handlers to assess whether an individual is objectively at immediate risk
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex 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.1
Essex Police
Supplement Force Control Room call-handler training with guidance on assessing immediacy, welfare risks, and when to seek advice.
Exeter and Great Devon District
Concerns raised1
Failure to grade calls correctly where there is a clear danger to life
This report raised 3 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.1
Devon & Cornwall Police
Review and update policy D051 to align grading and deployment decisions with national incident-recording and call-handling standards, incorporating the THRIVE risk-assessment tool.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Devon & Cornwall Police
Existing grading and deployment policies, audits and working practices are considered sufficient to ensure compliance with national incident-recording and call-handling standards.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Eastern)
Concerns raised1
Lack of an effective system for managing multiple calls regarding the same incident
This report raised 6 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.