Recurring concern
Unreliable decisions about when ambulance attendance is required
- Reports that mention this concern
- 12
- Times this concern has been raised
- 14
- Stated actions linked to this concern
- 20
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 12 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Nuffield Health
Stated actions 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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Nuffield Health
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
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Nuffield Health
Clarify ambulance-activation responsibilities during theatre emergencies in local standard operating policies and emergency guides.
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Nuffield Health
Incorporate tertiary-referral criteria and senior clinician-to-ambulance communication into scenario-based training.
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Nuffield Health
Reinforce ambulance-activation pathways through simulation covering deterioration recognition, escalation, intervention, ambulance arrival and SBARD handover.
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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Nuffield Health
The Regulation 28 concerns did not contribute to the patient’s death.
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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.
Linked responses
- NHS England
- West Midlands Ambulance Service University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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West Midlands Ambulance Service University NHS Foundation Trust
Implement a call-taking protocol requiring clinical review when three or more repeat calls are identified.
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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NHS England
Treating callers with previous contacts differently could delay NHS Pathways assessment, ambulance dispatch, or life-saving advice.
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West Midlands Ambulance Service University NHS Foundation Trust
Established protocols treat repeat calls as requiring full retriage only when the patient's condition has changed or worsened.
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West Midlands Ambulance Service University NHS Foundation Trust
A higher response category would not have been achieved because the patient was reported conscious and breathing regularly.
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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.
Linked response
- Gloucestershire Health and Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Gloucestershire Health and Care NHS Foundation Trust
Review the medical-emergency escalation process and reinforce it through resuscitation training.
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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Gloucestershire Health and Care NHS Foundation Trust
The existing medical-emergency escalation process remains fit for purpose and is reinforced through training and induction.
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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.
Linked responses
- Association of Ambulance Chief Executives
- College of Policing
- National Police Chiefs’ Council
Stated actions 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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College of Policing and National Police Chiefs’ Council
Maintain and update the clinically informed ABD presentation covering recognition, management, emergency response and transfer options.
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College of Policing and National Police Chiefs’ Council
Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
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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College of Policing and National Police Chiefs’ Council
Chemical sedation and emergency-call categorisation are clinical matters for ambulance services, to which police officers defer.
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College of Policing and National Police Chiefs’ Council
Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.
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Association of Ambulance Chief Executives
Information-passage arrangements between Police and Ambulance control rooms should be determined locally because technologies and working practices differ.
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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
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- South Central Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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South Central Ambulance Service NHS Foundation Trust
Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.
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South Central Ambulance Service NHS Foundation Trust
Disseminate the updated Standard Operating Procedure and Clinical Directive to all Emergency Operations Centre staff.
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South Central Ambulance Service NHS Foundation Trust
Provide Emergency Operations Centre staff with guidance on diagnoses and circumstances indicating a time-critical transfer, including escalation to the Clinical Support Desk when needed.
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South Central Ambulance Service NHS Foundation Trust
Audit inter-hospital time-critical transfer requests and provide feedback to acute trusts and commissioners when request information conflicts with the patient’s clinical condition.
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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South Central Ambulance Service NHS Foundation Trust
An exhaustive list of time-critical transfer diagnoses and circumstances cannot be provided because medical care is complex.
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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.
Linked response
- Durham Prison
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Durham Prison
Verify current staff understanding of the Emergency Code Protocol and obtain signed confirmation.
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Durham Prison
Issue pocket-sized Emergency Code Protocol cards to staff.
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Durham Prison
Display Emergency Code Protocol posters prominently in all residential areas.
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Durham Prison
Embed Emergency Code Protocol instruction, understanding checks, signed confirmation and card issuance in new-staff induction.
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Durham Prison
Reinforce the Emergency Code Protocol through staff meetings, management briefings, notices, email, intranet publication and line-manager cascades.
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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.
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.
Linked response
- Sunrise Senior Living UK
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Sunrise Senior Living UK
Communicate that the person discovering an incident must call emergency services when warranted, and embed this instruction in General Managers’ training for team members.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026