Recurring concern

Failure to provide clear public information about accessing 999 and 111 emergency healthcare services

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First reported 8 Aug 2013•Latest report 20 Sep 2024

Definition

What this concern includes

Includes failures to provide clear, accurate and accessible public information about the role, capability, appropriate use and access routes for 999 and 111 emergency healthcare services, including information intended to prevent inappropriate use or unsafe underuse.

Not included

Excludes failures in emergency call handling, clinical triage, ambulance dispatch or response after a member of the public has contacted 999 or 111.
Excludes staff training or professional uncertainty about using 999 or 111 unless the assertion concerns information provided to the public.
Excludes public information about non-emergency police, fire or other services unless it is explicitly part of the same 999 or 111 emergency-healthcare access information.
Excludes general healthcare literacy or service-access problems without a specific deficiency in public information about 999 or 111.

Reports: 3
Individual concerns: 3
Date range: 2013–2024
Stated actions: 1

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 England2

Department of Health and Social Care1

NHS Lincolnshire Integrated Care Board1

South East Coast Ambulance Service NHS Foundation Trust1

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.

20 Sep2024
Berkshire
Concerns raised1
1. Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted
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.
Actions described in response 1
1. Action
  Run national public education campaigns on appropriate use of 999 and alternative NHS services.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  NHS England is responsible for responding on public education about when it is appropriate to call 999.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Susan Dear · 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

Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.

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
Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted
Wider context from the report
“(7) resources were being wasted due to ignorance of some of members of the public engaging with the service, and the inquest heard that it was unlikely this would improve substantially without a programme of public education regarding when it is appropriate to call 999, and when it is not. ”
Source location
Susan Dear · Prevention of Future Deaths report
Page 3 · 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
Run national public education campaigns on appropriate use of 999 and alternative NHS services.

Verbatim wording from the response
“There are national efforts underway to educate the public on when it is appropriate to call 999. NHS England runs a series of national public education campaigns signposting to the range of different services available. These also include resources around symptoms such as those which indicate a possible stroke or heart attack and require emergency treatment, as well as how and when to use NHS 111, a GP and pharmacist.”

Source location
Response from NHSE
Page 3 · response
Published 14 November 2024
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
NHS England is responsible for responding on public education about when it is appropriate to call 999.

Verbatim wording from the response
“In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand NHS England are writing to you regarding regional service improvements and actions being taken by SCAS. I am also informed they will respond to your concerns on appropriate public education about the circumstances in which it is appropriate to call 999.”

Source location
Response from DHSC
Page 1 · response
Published 14 November 2024
Open published response
4 Oct2021
West Sussex
Concerns raised1
1. Failure to provide the public with clear information about the 111 service role, capability and call-handler qualifications
This report raised 6 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 2
1. Position
  Responsibility for the national-policy matters concerning the 111 service’s role and Health Advisor naming rests with NHS England.
  Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibility
1. Position
  NHS England is responsible for responding to concerns about public understanding of 111's role and the use of the term health advisor.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Hannah Elizabeth ROYLE · 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

Hannah Elizabeth ROYLE, a 16-year-old girl with severe learning disability, developed diarrhoea and vomiting before suffering a cardiorespiratory arrest on the way to hospital. She was diagnosed with a massive gastric volvulus and later sustained an irreversible hypoxic brain injury; she was declared brainstem dead on 1 July 2020. The report raised concerns about inadequate 111 triage, insufficient accommodation of disabilities, the clinical advisor’s assessment, public understanding of the service, misleading terminology, and the abdominal pain 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 provide the public with clear information about the 111 service role, capability and call-handler qualifications
Wider context from the report
“4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service. There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed. Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different. ”
Source location
Hannah Elizabeth ROYLE · 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
Responsibility for the national-policy matters concerning the 111 service’s role and Health Advisor naming rests with NHS England.

Verbatim wording from the response
“4 & 5 – role and understanding of the 111 service; naming of Health Advisors”

Source location
2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published
Page 4 · response
Published 13 October 2021
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
NHS England is responsible for responding to concerns about public understanding of 111's role and the use of the term health advisor.

Verbatim wording from the response
“4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service. There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed. Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different.”

Source location
2021-0327-Response-from-NHS-Digital_Published
Page 4 · response
Published 13 October 2021
Open published response
8 Aug2013
South Lincolnshire
Concerns raised1
1. Lack of awareness among seasonal agricultural workers of 999 and 111 services
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.
AI-generated summary

Dimitar SHTYANOV · 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

Dimitar SHTYANOV, a Bulgarian seasonal agricultural worker with a history of asthma, became ill in August 2012 and attended hospital twice before arriving in cardiac arrest on 11 August; resuscitation was unsuccessful. The inquest recorded the medical cause of death as bilateral pneumothoraces due to acute asthma. Concerns included seasonal workers’ limited awareness of GP, 999 and 111 services, and uncertainty about whether Dimitar’s medicines from Bulgaria were shown to hospital staff.

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
Lack of awareness among seasonal agricultural workers of 999 and 111 services
Wider context from the report
“(2) They are often not aware of either the 999 service or the 111 service ”
Source location
Dimitar SHTYANOV · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted

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.1

Concerns raised1

Failure to provide the public with clear information about the 111 service role, capability and call-handler qualifications

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

Concerns raised1

Lack of awareness among seasonal agricultural workers of 999 and 111 services

Actions described in response 1

Respondent positions 1

Respondent positions 2