First reported 17 Apr 2014•Latest report 18 Jun 2025
Definition
What this concern includes
Includes failures in the dedicated ambulance-service information-transfer process where clinically important information from callers, hospitals, NHS 111, GPs or other relevant services is not conveyed to ambulance crews or treating clinicians in time for safe decision-making.
Not included
Excludes failures concerning information that is not clinically or operationally material to ambulance decision-making or patient transfer.
Excludes generic staffing, training, documentation or communication deficiencies that are not explicitly tied to the ambulance information-transfer process.
Excludes delays caused solely by hospital bed capacity, ambulance handover congestion or response-resource shortages when no information-transfer failure is identified.
Excludes failures in unrelated hospital, social-care or mental-health information systems.
Reports
12
Distinct published reports
Individual concerns
13
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
12
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.
East of England Ambulance Service NHS Trust3
Department of Health and Social Care2
Association of Ambulance Chief Executives1
College of Policing1
Devon & Cornwall Police1
Essex Partnership University NHS Foundation Trust1
Essex Police1
First Aid Cover Ltd1
HM Prison and Probation Service1
Joint Royal Colleges Ambulance Liaison Committee1
Medequip Assistive Technology Limited1
National Institute for Health and Care Excellence1
National Police Chiefs’ Council1
NHS Dorset Integrated Care Board1
NHS England1
NHS trust5
Executive non-departmental public body2
Ministerial department2
Police force2
Private limited company2
Company limited by guarantee1
Executive agency1
Health professional committee1
Health-sector membership body1
Integrated care board1
National policing body1
Prison or young offender institution1
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.
Suffolk
Concerns raised1
Failure of the Interoperability toolkit for information handover between 111 and 999 services
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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Manual transfer of information from 111 to 999 mitigates patient-safety risks when the electronic interoperability transfer fails.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Dorset
Concerns raised1
Unavailability of National Record Locator access for South West ambulance care in Dorset
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Continue participating in regional and national work to adopt National Record Locator information sharing.
Stated by NHS Dorset Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.
Action
Establish Dorset Care Record capability to share information through the National Record Locator and begin sharing records with other services.
Stated by NHS Dorset Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 March 2025.
Action
Continue working with Dorset Healthcare to transfer its information into the Dorset Care Record during 2025.
Stated by NHS Dorset Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The allegations about NHS Dorset’s involvement in National Record Locator work are not factually accurate.
Stated by NHS Dorset Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The system supplier has not delivered the technical capability needed to share Dorset Care Record information through the National Record Locator.
Stated by NHS Dorset Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Dorset Healthcare must share mental health care plans, while SWASFT must improve ambulance-crew uptake of its existing information-sharing system.
Stated by NHS Dorset Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
SWASFT’s prioritisation of the National Record Locator approach has delayed delivery of direct Dorset Care Record access.
Stated by NHS Dorset Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Solutions to information visibility across system partners lie with multiple organisations rather than solely within the Integrated Care Board.
Stated by NHS Dorset Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Failure to obtain and share complete contact information for ambulance disposition decisions
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 concerns
Each 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
Action
Train SWAST control-room staff to obtain accurate contact and incident information during calls with police.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
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 PoliceStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
Liverpool and the Wirral
Concerns raised1
Failure to communicate the limits of responders' diagnostic ability to ambulance services
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.
Suffolk
Concerns raised2
Lack of directly compatible ambulance and hospital IT systems for immediate availability of clinical information
Failure of patient handover processes to ensure significant clinical findings are available to receiving clinicians
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Develop IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2024.
Action
Roll out an ambulance dataset linking ambulance-service and emergency-department data through the emergency care data set.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Local process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Lack of sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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.
Berkshire
Concerns raised1
Failure of ambulance crews to have relevant information about fire service vehicle-lifting equipment
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.
Inner North London
Concerns raised1
Failure to provide a competent handover to ambulance services
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 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.
Suffolk
Concerns raised1
Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Consult other ambulance trusts to share best practices and solutions for recording and transmitting patient disposition information.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Action
Draft and issue dispatch instructions specifying pertinent information, including NHS 111 disposition descriptions, for transmission to attending resources.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The organisation is not constituted to mandate or instruct individual ambulance services on local information-sharing processes.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Norfolk
Concerns raised1
Failure to communicate arranged admission-bed information to ambulance crews
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Work with the CAD supplier to alter call duplication so pertinent destination information transfers into the active call.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Action
Require dispatch staff to transfer pertinent information manually into new calls until the technological solution is available.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Share CAD information-recording and transmission best practice and solutions with other ambulance services.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
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Includes failures in the dedicated ambulance-service information-transfer process where clinically important information from callers, hospitals, NHS 111, GPs or other relevant services is not conveyed to ambulance crews or treating clinicians in time for safe decision-making.
