Recurring concern
Unreliable decisions about when ambulance attendance is required
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Request correctionFirst reported 30 Aug 2013•Latest report 18 Mar 2026
What this concern includes
Includes failures in the process for recognising when ambulance attendance is required, distinguishing ambulance use from an out-of-hours GP or other service, clarifying who must make the request, defining the information and urgency required, and enabling prompt escalation in hospitals, prisons, care settings and comparable services.
Not included
- Excludes delays in ambulance dispatch, attendance, travel or hospital handover after an appropriate ambulance request has been made.
- Excludes general emergency-call handling, ambulance capacity, triage or response-time failures where the decision to request ambulance attendance is not the deficient control.
- Excludes routine GP access, referral or clinical-assessment failures where no ambulance-escalation decision is involved.
- Excludes generic staff training, communication or role-clarity deficiencies unless they directly impair deciding when ambulance attendance is required or who must request it.
- Reports
- 12
- Individual concerns
- 14
- Date range
- 2013–2026
- Stated actions
- 20
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Unclear roles and responsibilities for requesting ambulance attendance at major hospital events
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Stated by Nuffield Health -
Action
Clarify ambulance-activation responsibilities during theatre emergencies in local standard operating policies and emergency guides.
Stated by Nuffield Health -
Action
Incorporate tertiary-referral criteria and senior clinician-to-ambulance communication into scenario-based training.
Stated by Nuffield Health
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Action
Reinforce ambulance-activation pathways through simulation covering deterioration recognition, escalation, intervention, ambulance arrival and SBARD handover.
Stated by Nuffield Health
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Regulation 28 concerns did not contribute to the patient’s death.
Stated by Nuffield Health
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Concerns raised1
Failure to prompt call assessors to consider repeated 999 calls over time when assessing urgency
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Implement a call-taking protocol requiring clinical review when three or more repeat calls are identified.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Treating callers with previous contacts differently could delay NHS Pathways assessment, ambulance dispatch, or life-saving advice.
Stated by NHS England
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Position
Established protocols treat repeat calls as requiring full retriage only when the patient's condition has changed or worsened.
Stated by West Midlands Ambulance Service University NHS Foundation Trust -
Position
A higher response category would not have been achieved because the patient was reported conscious and breathing regularly.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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Concerns raised1
Uncertainty about when medical professionals should call the ambulance service
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review the medical-emergency escalation process and reinforce it through resuscitation training.
Stated by Gloucestershire Health and Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The existing medical-emergency escalation process remains fit for purpose and is reinforced through training and induction.
Stated by Gloucestershire Health and Care NHS Foundation Trust
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Concerns raised1
Confusion over Police procedures for requesting Ambulance support
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Maintain and update the clinically informed ABD presentation covering recognition, management, emergency response and transfer options.
Stated by College of Policing and National Police Chiefs’ Council -
Action
Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
Stated by College of Policing and National Police Chiefs’ Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Chemical sedation and emergency-call categorisation are clinical matters for ambulance services, to which police officers defer.
Stated by College of Policing and National Police Chiefs’ Council
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Position
Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.
Stated by College of Policing and National Police Chiefs’ Council -
Position
Information-passage arrangements between Police and Ambulance control rooms should be determined locally because technologies and working practices differ.
Stated by Association of Ambulance Chief Executives
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Concerns raised2
Delays in calling an ambulance pending contact with the duty manager
Delays in calling an ambulance pending repeat observations regardless of initial results
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to consider and communicate ambulance involvement when clinically indicated
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
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.
Stated by South Central Ambulance Service NHS Foundation Trust -
Action
Disseminate the updated Standard Operating Procedure and Clinical Directive to all Emergency Operations Centre staff.
Stated by South Central Ambulance Service NHS Foundation Trust -
Action
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.
Stated by South Central Ambulance Service NHS Foundation Trust
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Action
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.
Stated by South Central Ambulance Service NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
An exhaustive list of time-critical transfer diagnoses and circumstances cannot be provided because medical care is complex.
Stated by South Central Ambulance Service NHS Foundation Trust
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Concerns raised1
Delays and uncertainty in calling an emergency ambulance and using the code blue call
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Verify current staff understanding of the Emergency Code Protocol and obtain signed confirmation.
Stated by Durham Prison -
Action
Issue pocket-sized Emergency Code Protocol cards to staff.
Stated by Durham Prison -
Action
Display Emergency Code Protocol posters prominently in all residential areas.
Stated by Durham Prison
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Action
Embed Emergency Code Protocol instruction, understanding checks, signed confirmation and card issuance in new-staff induction.
Stated by Durham Prison -
Action
Reinforce the Emergency Code Protocol through staff meetings, management briefings, notices, email, intranet publication and line-manager cascades.
Stated by Durham Prison
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Concerns raised1
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to ensure staff know to call an ambulance directly when required
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Communicate that the person discovering an incident must call emergency services when warranted, and embed this instruction in General Managers’ training for team members.
Stated by Sunrise Senior Living UK
Data last updated 7 September 2026