Recurring concern

Unsafe emergency call handling

Get email alerts

Request correction

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
Individual concerns: 109
Date range: 2013–2026
Stated actions: 150

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

27 May2015
Inner North London
Concerns raised1
1. Failure of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Yusuf ABDISMAD · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance
Wider context from the report
“During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further. Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent. ”
Source location
Yusuf ABDISMAD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Mar2015
Inner North London
Concerns raised1
1. Failure to implement or consider automated call recategorisation
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Assess the clinical appropriateness and feasibility of automated call re-categorisation.
  Stated by London Ambulance Service NHS TrustStated completed
Respondent positions 2
1. Position
  Automated call recategorisation could increase risk by causing inappropriate ambulance dispatches and reducing protection for patients requiring eight-minute responses.
  Stated by London Ambulance Service NHS TrustDisputes the concern
1. Position
  Existing clinical hub staffing, standard operating procedures and surge-management processes are considered sufficient, removing the need for automated call-handling processes.
  Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficient
AI-generated summary

Sabrina Stevenson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to implement or consider automated call recategorisation
Wider context from the report
“(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS; ”
Source location
Sabrina Stevenson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Assess the clinical appropriateness and feasibility of automated call re-categorisation.

Verbatim wording from the response
“The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS imparts its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 5 · response
Published 30 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Automated call recategorisation could increase risk by causing inappropriate ambulance dispatches and reducing protection for patients requiring eight-minute responses.

Verbatim wording from the response
“The LAS has considered the aspect of automated re-categorisation. Whilst there is no current functionality in the CAD system to implement this, consideration has also been given as to whether or not this would be clinically appropriate to implement. Without the manual intervention and clinical review of 999 / Health Care Professional calls by a trained senior clinician, many calls would be re-categorised unsuitably where a clinical telephone assessment is more appropriate, based on the pertinent information recorded in the call record. As the LAS imparts its surge management processes to deal with any increase in demand, automatic re-categorisation would prove extremely difficult to manage, inappropriate ambulance dispatches would occur and the risk to patients who did require an 8 minute response would be increased, not reduced as a result.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 5 · response
Published 30 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing clinical hub staffing, standard operating procedures and surge-management processes are considered sufficient, removing the need for automated call-handling processes.

Verbatim wording from the response
“The Clinical Hub has refined and developed its processes, skill mix and staffing levels since its inception on 2 December 2013 and an increased level of staffing within the Clinical Hub in the Emergency Operations Centres has negated the need for any automated processes. Staff have clear standard operating procedures in place for the management of Held call, vulnerable patients and calls being held awaiting assessment. The demand management plan itself has been reviewed and replaced with the surge management plan, which has a number of criteria for allowing progression through the plan and a scored matrix to evidence and inform any decision made.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 5 · response
Published 30 March 2015
Open published response
18 Mar2015
County Durham and Darlington
Concerns raised3
1. Inadequate cross-boundary emergency call routing and inter-service dispatch systems
2. Failure to record key information during emergency call handling
3. Failure of emergency call location systems to accurately locate incidents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Review cross-border incident processes and systems.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
2. Action
  Review policies and procedures for liaising with adjoining emergency services when incidents occur on or near service borders.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
3. Action
  Review call-handling procedures for adjoining police and ambulance services and update direct control-room telephone access numbers.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
1. Action
  Send adjoining police forces and ambulance trusts letters explaining future call-processing changes.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
2. Action
  Discuss with the mobilising-system supplier how to deliver Direct Electronic Incident Transfer functionality.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated in progress
3. Action
  Review call-handling procedures, identify gaps, and act on them.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
4. Action
  Review the feasibility of increasing Gazetteer and map update frequency.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
5. Action
  Introduce a mobilising and communications system with integral caller-location mapping in the emergency control room.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
Respondent positions 6
1. Position
  Dispatching another ambulance service’s resource is undertaken by that service following a direct mutual-aid request, not through these systems.
  Stated by North East Ambulance Service NHS Foundation TrustRedirects responsibility
1. Position
  Emergency calls cannot technically be transferred directly between emergency services.
  Stated by County Durham and Darlington Fire and Rescue ServiceUnable to act
2. Position
  Direct electronic incident transfer is unavailable because emergency services’ computer systems are incompatible.
  Stated by County Durham and Darlington Fire and Rescue ServiceUnable to act
3. Position
  Resources cannot be directly dispatched from other fire services because their systems are disparate and resource-location protocols are absent.
  Stated by County Durham and Darlington Fire and Rescue ServiceUnable to act
4. Position
  Effective mutual assistance arrangements with adjoining fire services are considered sufficient despite the inability to dispatch their resources directly.
  Stated by County Durham and Darlington Fire and Rescue ServiceExisting arrangements considered sufficient
5. Position
  Existing call-handling procedures are considered robust, although they will be reviewed to identify and address any gaps.
  Stated by North East Ambulance Service NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Grant Thomas Benson and Gordon Nicky Davidson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Grant Thomas Benson and Gordon Nicky Davidson were travelling in a motor vehicle that crashed into a tree. The passenger died at the time of the collision or soon afterwards, while the driver survived the impact but died in the ensuing fire. The report identified shortcomings in emergency call handling and cross-boundary coordination, which delayed the dispatch of emergency services, although the evidence was that a prompt local response would not have changed the driver’s outcome in this case.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate cross-boundary emergency call routing and inter-service dispatch systems
Wider context from the report
“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”
Source location
Grant Thomas Benson and Gordon Nicky Davidson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record key information during emergency call handling
Wider context from the report
“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”
Source location
Grant Thomas Benson and Gordon Nicky Davidson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of emergency call location systems to accurately locate incidents
Wider context from the report
“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”
Source location
Grant Thomas Benson and Gordon Nicky Davidson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review cross-border incident processes and systems.

Verbatim wording from the response
“Following from the Regulation 28 report and recommendations sent to Yorkshire Ambulance Service and providing emergency services, I can confirm that the North East Ambulance Service has undertaken a review of our own processes and systems in respect of cross-border incidents.”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 1 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review policies and procedures for liaising with adjoining emergency services when incidents occur on or near service borders.

Verbatim wording from the response
“Following the Regulation 28 Report to Yorkshire Ambulance Service dated 19 March 2015, County Durham and Darlington Fire and Rescue Service (CDDFRS) have conducted a review of policies and procedures for liaising with the other border Blue Light Services when incidents occur on or near those adjoining borders.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 1 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review call-handling procedures for adjoining police and ambulance services and update direct control-room telephone access numbers.

Verbatim wording from the response
“7 Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Send adjoining police forces and ambulance trusts letters explaining future call-processing changes.

Verbatim wording from the response
“7 Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss with the mobilising-system supplier how to deliver Direct Electronic Incident Transfer functionality.

Verbatim wording from the response
“Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review call-handling procedures, identify gaps, and act on them.

Verbatim wording from the response
“All relevant information has been passed to our training department to review our call handling procedures and ensure any gaps are identified and acted on. We are however confident that the existing procedures are robust.”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the feasibility of increasing Gazetteer and map update frequency.

Verbatim wording from the response
“The Trust uses northings and eastings co-ordinates to map the location of calls alongside a Gazetteer pulling addresses from telephone landlines. Currently it is being reviewed as to the feasibility of increasing the frequency of Gazetteer and map updates for all Ambulance Trusts.”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 1 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a mobilising and communications system with integral caller-location mapping in the emergency control room.

Verbatim wording from the response
“1 Inability to Dispatch Resources without Identifying Exact Location on Mapping System In December 2014 CDDFRS introduced a new state of the art mobilising and communications system into their emergency control room. Prior to the introduction of this system control personnel would extract incident location information from callers using interrogation techniques given to them during initial training and induction.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 1 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Dispatching another ambulance service’s resource is undertaken by that service following a direct mutual-aid request, not through these systems.

Verbatim wording from the response
“6. Is it not possible for one ambulance service to dispatch an ambulance from another ambulance service?”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Emergency calls cannot technically be transferred directly between emergency services.

Verbatim wording from the response
“4 Transferring Calls from One Emergency Service to Another Currently it is not technically possible to transfer an emergency call from one emergency service to another. When calls are received in error for another Emergency Service, the Fire Service control room will log the call and take as many details from the caller as possible; at the same time another fire control operator will inform the relevant emergency service. Where necessary, and as appropriate, control operators will continue to speak to callers until it is known that assistance, from the attending emergency service, has arrived at the incident.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Direct electronic incident transfer is unavailable because emergency services’ computer systems are incompatible.

Verbatim wording from the response
“Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Resources cannot be directly dispatched from other fire services because their systems are disparate and resource-location protocols are absent.

Verbatim wording from the response
“6 Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Effective mutual assistance arrangements with adjoining fire services are considered sufficient despite the inability to dispatch their resources directly.

Verbatim wording from the response
“6 Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing call-handling procedures are considered robust, although they will be reviewed to identify and address any gaps.

Verbatim wording from the response
“7. Review of call handling procedures”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015
Open published response
19 Dec2014
Inner West London
Concerns raised1
1. Failure to prevent call takers from downgrading calls to lower-acuity pathways
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ms Samia Yasmin Shara · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ms Samia Yasmin Shara, aged 15, died from acute heart failure caused by an aneurysm of the aortic sinus and a ruptured cusp of the aortic valve, following an undiagnosed congenital heart problem. Her brother made calls to 999 and 111, but the seriousness of her condition was not recognised until the final 999 call, delaying emergency ambulance services. Concerns included the audit of complex 999 and 111 calls and preventing call takers from downgrading calls to a lower-acuity pathway.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to prevent call takers from downgrading calls to lower-acuity pathways
Wider context from the report
“(2) That call takers should not be able to downgrade a call by moving to a pathway of lower acuity. ”
Source location
Ms Samia Yasmin Shara · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Jul2014
County Durham and Darlington
Concerns raised2
1. Delays in referring cases and dispatching ambulances after failure to obtain caller location information
2. Failure of ambulance service protocols to address caller-location and dispatch problems
This report raised 8 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.
AI-generated summary

Gary William Million · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in referring cases and dispatching ambulances after failure to obtain caller location information
Wider context from the report
“1. Once the 111 operator had failed to obtain detailed information about the callers location, there was a delay of some minutes before referring the matter to the Ambulance Trust and for the dispatch of an ambulance. ”
Source location
Gary William Million · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of ambulance service protocols to address caller-location and dispatch problems
Wider context from the report
“5. New revised North East Ambulance Service Trust protocols which are undated, and which were produced to the Senior Coroner only on the morning of the Inquest being resumed, do not deal with the problems identified in this case even though they were designed to address them. ”
Source location
Gary William Million · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Apr2014
Manchester City
Concerns raised1
1. Failure to assign an appropriately urgent code to a potentially fatal tablet ingestion
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The Green 2 code assigned to the overdose call was correct because no immediately life-threatening symptoms were reported.
  Stated by North West Ambulance Service NHS TrustDisputes the concern
AI-generated summary

Terence Norbert Dooley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Terence Norbert Dooley took a fatal overdose of medication and contacted the ambulance service, reporting his location and symptoms. Attendance was delayed by 2 hours and 38 minutes, and he was later found deceased by the canal. Concerns included the emergency call being coded green, the delay in response, poor communication, and misleading computer-generated codes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assign an appropriately urgent code to a potentially fatal tablet ingestion
Wider context from the report
“1. Despite the fact that each different tablet could be fatal on its own, let alone together, this call was given a code green. ”
Source location
Terence Norbert Dooley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Green 2 code assigned to the overdose call was correct because no immediately life-threatening symptoms were reported.

Verbatim wording from the response
“During the 999 call made by Mr Dooley on 28 October 2012 he advised that he had taken an overdose of medication. The Emergency Medical Dispatcher (EMD) confirmed that Mr Dooley was conscious and breathing and the system generated a Green 2 response code. MPDS is designed to elicit priority symptoms from a caller, for example, whether the patient is alert, conscious and breathing. If a patient has a compromised airway or is in cardiac arrest the system recognises that they require immediate, life sustaining, treatment and will generate a Red response code. Had Mr Dooley indicated any of these priority symptoms MPDS would have generated a higher response code.”

Source location
2014-0162-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 10 April 2014
Open published response
9 Jan2014
Bedfordshire and Luton
Concerns raised1
1. Emergency call protocols putting patients at risk
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 1
1. Action
  Continue clinical coordination in Health and Emergency Operations Centres to provide senior clinical review and adjust call priorities.
  Stated by East of England Ambulance Service NHS TrustStated completed
AI-generated summary

Albert James HAND · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Albert James Hand suffered a fall at the Arndale Shopping Centre in Luton on 1 November 2013 and experienced a delay of almost one and a half hours before arriving at hospital, during which his Glasgow Coma Scale fell from 11 to 7. The concerns identified were delays in conveying patients with head injuries, insufficient ambulance crews in the Luton and Bedfordshire area, and emergency-call protocols that may put patients at risk and result in future deaths.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Emergency call protocols putting patients at risk
Wider context from the report
“(3) That the Protocols in place for dealing with emergency calls are putting patients at risk and may result in future deaths. ”
Source location
Albert James HAND · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue clinical coordination in Health and Emergency Operations Centres to provide senior clinical review and adjust call priorities.

Verbatim wording from the response
“The organisational priorities outlined above will continue to be augmented with the clinical coordination function within the HEOCs. This function maintains a robust clinical review for those patients that require further interrogation via the telephone in order to gain a more detailed clinical picture of the patient’s condition. This enables the Trust to change the priority assigned to a call based on any significant changes in the patient’s condition. The clinical coordinators will continue to play a key role within the HEOCs to provide senior clinical presence within the rooms.”

Source location
2014-0010-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Page 3 · response
Published 9 January 2014
Open published response
16 Dec2013
Oxfordshire
Concerns raised1
1. Failure to allocate appropriate priorities to ambulance calls
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 1
1. Action
  Transition from AMPDS to the clinically focused NHS Pathways assessment system.
  Stated by South Central Ambulance Service NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.
  Stated by South Central Ambulance Service NHS Foundation TrustRedirects responsibility
AI-generated summary

Clive GOULD · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to allocate appropriate priorities to ambulance calls
Wider context from the report
“(1) The original call made by ████████ was allocated a priority green status which meant that should a higher priority call be received (a red status call) then an ambulance would be diverted, which is what happened on two occasions. An internal audit of that call suggests that a different priority could have been given to the original call and the presenting concerns of Mr Gould's status. ”
Source location
Clive GOULD · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Transition from AMPDS to the clinically focused NHS Pathways assessment system.

Verbatim wording from the response
“SCAS have recognised that AMPDS is a dispatch tool as opposed to a clinical decision software support tool. SCAS are currently transitioning, with full support from our Commissioners, from the AMPDS system to a more clinically focused assessment system called NHS Pathways which is also fully licensed by the Department of Health. The benefits of this change will be to quickly identify patients in a life threatening situation and dispatch accordingly for those patients who are more time critical and then to allocate remaining resources only if clinically required to do so. This transition will be completed by the end of autumn 2014.”

Source location
2013-0357-Response-by-South-Central-Ambulance-Service
Page 1 · response
Published 16 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.

Verbatim wording from the response
“SCAS response Currently SCAS operates the Department of Health licensed 999 triage software system called AMPDS. As this is a licensed tool all ambulance responses are determined at a national level. As a Trust we are required to maintain our AMPDS licence and ensure that call audits are carried out on a pre-determined percentage of inbound call volumes. The AMPDS product has been developed by Priority Dispatch Corporation with a comprehensive training programme that is prescriptive in nature and in order to be compliant all our Emergency Call Takers are required to meet the training standards and are audited on a monthly basis. As we currently use AMPDS our Call Takers are required to ask a pre-determined set of verbatim questions.”

Source location
2013-0357-Response-by-South-Central-Ambulance-Service
Page 1 · response
Published 16 December 2013
Open published response
6 Dec2013
Manchester South
Concerns raised1
1. Failure of ambulance call-takers to correctly assess breathing and triage calls
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 2
1. Action
  Provide all Emergency Medical Dispatchers with a six-week training course covering procedures, call taking, first aid, paediatric resuscitation and AMPDS.
  Stated by North West Ambulance Service NHS TrustStated completed
2. Action
  Require Emergency Medical Dispatchers to provide continuing-education and audit-review evidence to maintain certification.
  Stated by North West Ambulance Service NHS TrustStated completed
Respondent positions 1
1. Position
  Responsibility for selecting and training ambulance call-taking staff rests with the North West Ambulance Service Trust.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of ambulance call-takers to correctly assess breathing and triage calls
Wider context from the report
“During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances. It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating. The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated. I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit. ”
Source location
Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide all Emergency Medical Dispatchers with a six-week training course covering procedures, call taking, first aid, paediatric resuscitation and AMPDS.

Verbatim wording from the response
“All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years.”

Source location
2013-0356-Response-by-North-West-Ambulance-Service
Page 1 · response
Published 6 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require Emergency Medical Dispatchers to provide continuing-education and audit-review evidence to maintain certification.

Verbatim wording from the response
“All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years.”

Source location
2013-0356-Response-by-North-West-Ambulance-Service
Page 1 · response
Published 6 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for selecting and training ambulance call-taking staff rests with the North West Ambulance Service Trust.

Verbatim wording from the response
“I note that you have sent a copy of this Regulation 28 report to the Department for Education (DfE) and the North West Ambulance Service Trust (NWAS). The training of nursery staff is the responsibility of DfE whilst the selection and training of call taking staff at the NWAS is a matter for the NWAS Trust. I believe that these two issues should properly be addressed by the DfE and the NWAS.”

Source location
2013-0356-Response-by-Department-of-Health
Page 2 · response
Published 6 December 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance

Concerns raised1

Failure to implement or consider automated call recategorisation

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised3

Inadequate cross-boundary emergency call routing and inter-service dispatch systems

Failure to record key information during emergency call handling

Failure of emergency call location systems to accurately locate incidents

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.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6

Concerns raised1

Failure to prevent call takers from downgrading calls to lower-acuity pathways

Concerns raised2

Delays in referring cases and dispatching ambulances after failure to obtain caller location information

Failure of ambulance service protocols to address caller-location and dispatch problems

Concerns raised1

Failure to assign an appropriately urgent code to a potentially fatal tablet ingestion

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 2

Actions described in response 8

Respondent positions 6

Respondent positions 1