Recurring concern

Unreliable ambulance dispatch and resource-allocation controls

First to latest report 24 Feb 2014 — 30 Jan 2025

Reports that mention this concern
17
Times this concern has been raised
19
Stated actions linked to this concern
26

What this concern includes

Includes failures in the ambulance dispatch and resource-allocation process, including adherence to dispatch protocols, selection and allocation of appropriate resources, destination accuracy, post-allocation resource decisions, traceability and control-centre oversight.

What is not included
  • Excludes ambulance capacity shortages where the dispatch and resource-allocation process itself is not deficient.
  • Excludes ambulance call triage, response-time communication, hospital handover and clinical treatment failures unless they directly concern dispatch or resource allocation.
  • Excludes generic emergency-call handling or information-system deficiencies where no ambulance dispatch or resource-allocation control failure is identified.
  • Excludes failures occurring after an ambulance has been correctly dispatched, unless they concern a dispatch or resource-allocation decision.

Reports and published responses 17 reports

See individual reports that have raised this concern, and the actions taken in response

  1. South Yorkshire (Eastern)

    AI-generated summary

    Barry Stuart Hodges · 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

    Barry Stuart Hodges, a 69-year-old man, collapsed with chest pains at a tennis club on 23 August 2016 and died after being transferred to hospital following cardiac arrest. The report identified failures to follow ambulance dispatch and resource-review protocols, insufficient safety-netting and apparent gaps in staff knowledge or training, with available resources not allocated and escalation not undertaken when timescales were breached.

    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 adhere to ambulance dispatch and resource-review protocols

    Wider context from the report

    “(1) Protocols for ambulance dispatch and review of resources were not adhered to and there appeared to be an absence of any system to “safety net” should an individual operative not manually refresh and look at the system. ”

    Source location

    Barry Stuart Hodges · 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

    Lack of knowledge, training and understanding of ambulance dispatch and resource-review protocols

    Wider context from the report

    “(2) A lack of knowledge/training/understanding of the protocols that 4 resources were available at different times but none were utilised. ”

    Source location

    Barry Stuart Hodges · 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

    Reduce the amber-call resourcing target from 10 minutes to 5 minutes and communicate the revised target to EOC staff.

    Verbatim wording from the response

    “Also the timeframes for resourcing of incidents for amber category calls has been reduced to 5 minutes from the original 10 minutes, this new time target has been communicated to all staff in the EOC. Further awareness on the importance of reviewing available resources will be emphasized to all staff at the EOC training away days throughout June and July 2017.”

    Source location

    2017-0133-Response-by-South-Yorkshire-Ambulance-Service
    Page 2 · response
    Published 5 June 2017

    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

    Deliver EOC training away days covering role responsibilities, incident review, revision, allocation and timely prioritisation of high-priority calls.

    Verbatim wording from the response

    “The Trust has intense training away days for all EOC staff set up to take place throughout the summer months. Part of these training away days will include reiterating to all EOC staff the core elements of their role, especially around the fundamental aspects of review, revise and allocate with emphasis on not delaying allocation to high priority calls.”

    Source location

    2017-0133-Response-by-South-Yorkshire-Ambulance-Service
    Page 3 · response
    Published 5 June 2017

    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

    Use monthly one-to-one performance information to monitor dispatchers’ resourcing performance against targets.

    Verbatim wording from the response

    “EOC staff members have monthly 1:1’s at which the Trust are now able to produce personal performance information, this enables the manager to review whether the dispatcher is meeting appropriate targets, this includes information regarding resourcing of incidents. If it is found there are areas which require improvement the Trust allocates a team champion to sit with the staff member to supervise their work until it is felt that the staff member is performing satisfactorily.”

    Source location

    2017-0133-Response-by-South-Yorkshire-Ambulance-Service
    Page 3 · response
    Published 5 June 2017

    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 Dispatcher Standard Operating Procedure supporting consistent standards and live-environment incident auditing.

    Verbatim wording from the response

    “We are also in the process of introducing a Standard Operating Procedure (SOP) to ensure that Emergency Operations Centre Dispatchers are delivering consistently good standards of care to the patients of Yorkshire, this is attached (Appendix 2). This process will facilitate a fair and appropriate audit of incidents in the live environment to ensure that Dispatchers are supported in their role and areas of concern are addressed immediately where possible.”

    Source location

    2017-0133-Response-by-South-Yorkshire-Ambulance-Service
    Page 3 · response
    Published 5 June 2017

    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

    Reduce the allocation target for amber, soon-to-be-red, calls from two minutes to 30 seconds and disseminate the process through staff training and dispatch guidance.

    Verbatim wording from the response

    “We are also reducing the expected time to allocation for amber details (soon to be Red) from 2 minutes to 30 seconds once coding is confirmed or the detail is available for dispatch from the waiting stack. This change will assist in responding to these patients sooner and reduce any delays at the beginning of the dispatch process. The new process will be discussed, shared and educated on the EOC training away days with all staff and will also be visible on all dispatch bays in the updated Dispatch Quick Reference Guide.”

    Source location

    2017-0133-Response-by-South-Yorkshire-Ambulance-Service
    Page 2 · response
    Published 5 June 2017

    Open published response

  2. South Yorkshire (Eastern)

    AI-generated summary

    Jack Owen Sheldon · 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

    Jack Owen Sheldon died in a shed fire after petrol vapours from paint stripping reached a candle flame on 27 October 2016. Concerns included the handling and prioritisation of multiple emergency calls, staff communication and training, appliance mobilisation protocols, and systems for checking appliance availability and location.

    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 effective protocols for mobilisation of appropriate appliances

    Wider context from the report

    “(3) Lack of effective protocols for mobilisation of appropriate appliances and associated training of staff ”

    Source location

    Jack Owen Sheldon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    Mia Gibson · 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

    Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.

    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 issue open-mic reports to mobilise available ambulance crews

    Wider context from the report

    “2. No ‘open mic’ report was put out to see if other crews could make themselves available to attend this emergency. ”

    Source location

    Mia Gibson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Central Lincolnshire

    AI-generated summary

    Stuart Knight · 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

    Stuart Knight was found unconscious in a road in Wainfleet after apparently falling backwards and hitting his head. There were delays in the arrival of ambulance services, including 1 hour and 24 minutes between the first call and the arrival of the double-crewed ambulance; the report identified these delays as significant and unacceptable. Mr Knight was taken to hospital and died later that day, following a head injury with haemorrhage and skull fracture, with alcohol excess also recorded as a medical cause.

    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 dispatching ambulances to patients

    Wider context from the report

    “(I) Significant and unacceptable delays occurred in dispatching an ambulance to a patient who was unconscious and had clearly suffered a serious head injury. Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS. ”

    Source location

    Stuart Knight · 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

    Increase frontline and emergency operations centre staffing, including flexible relief capacity for predicted demand.

    Verbatim wording from the response

    “East Midlands Ambulance Service has made significant investment in both staff and vehicle resources since 2014 in both “frontline” staff who attend 999 calls but also in staffing within the emergency operations centre.”

    Source location

    2015-0385-Response-by-East-Midlands-Ambulance-Service
    Page 2 · response
    Published 22 September 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

    Increase the available vehicle fleet to deploy more ambulance resources concurrently.

    Verbatim wording from the response

    “In addition we have invested in our fleet provision to increase the number of vehicles we have available allowing the trust to deploy more resources at any one time.”

    Source location

    2015-0385-Response-by-East-Midlands-Ambulance-Service
    Page 2 · response
    Published 22 September 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 Paramedic Pathfinder and train frontline staff to use it for pre-hospital assessment and appropriate referral.

    Verbatim wording from the response

    “We have supported our frontline staff with the introduction of Paramedic Pathfinder (PP). PP is a pre hospital assessment guide based around the widely used NEWS (National early warning system) designed to assist crews to identify patients that are suitable for onward referral as opposed to transport to the emergency department. Typically when a patient is not conveyed from their home address (See and Treat), the job cycle time (total time the ambulance is dealing with that particular call and is therefore unavailable) is reduced. Starting in April 2014, by October 2015 94% of staff have completed the training.”

    Source location

    2015-0385-Response-by-East-Midlands-Ambulance-Service
    Page 2 · response
    Published 22 September 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

    Develop specialist pathfinder tools and referral services for specific conditions through CQUIN-funded project work.

    Verbatim wording from the response

    “For the longer term this translates into a project based on Commissioning for Quality and Innovation (CQUIN) money to develop specialist pathfinder tools for specific conditions ultimately to identify and”

    Source location

    2015-0385-Response-by-East-Midlands-Ambulance-Service
    Page 2 · response
    Published 22 September 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

    Expand the Clinical Assessment Team to provide continuous clinician-led telephone assessment and hear-and-treat support.

    Verbatim wording from the response

    “We have invested significantly in the scope of our Clinical Assessment Team (CAT) based in the emergency operations centre. The CAT team are a group of clinicians, qualified Paramedics and Nurses, who work within the EOC on a 24 hour a day 7 day per week rota. They work providing support and telephone assessment to 999 calls received by the trust. The result of the telephone assessment can, in some serious cases, ensure that a call is dealt with as a higher priority due to clinical need or, in other cases, result in the call being dealt with to a conclusion by the CAT clinician. This is termed as “hear and treat”. In dealing with calls in this manner this ensures that frontline resources are not sent if not required therefore making them available to mobilise to patients with more serious clinical need that require immediate treatment or transport.”

    Source location

    2015-0385-Response-by-East-Midlands-Ambulance-Service
    Page 3 · response
    Published 22 September 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

    Operate a dynamically deployable single Ambulance Technician vehicle in Skegness and Boston for suitable calls, supported by Clinical Assessment Team referrals or discharge.

    Verbatim wording from the response

    “As a local initiative between the Trust and the commissioning group in east Lincolnshire, a single Ambulance Technician vehicle is available to be deployed dynamically to calls where a traditional double crewed ambulance may not be required, for example a non-injury fall requiring assistance. Supported by the CAT team this resource can suitable respond to a call and through CAT refer or discharge at scene, again negating the need for an ambulance to be deployed. The scheme covers both the Skegness and Boston areas and has run from April 2015 with the following attendances. On average this initiative allows around 40 calls per month to be appropriately and safely assisted, referred and discharged without the need for the attendance of an emergency ambulance.”

    Source location

    2015-0385-Response-by-East-Midlands-Ambulance-Service
    Page 3 · response
    Published 22 September 2015

    Open published response

  5. Northumberland (North)

    AI-generated summary

    Barbara Patterson · 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

    Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.

    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 by ambulance dispatchers to dispatch the closest available ambulance

    Wider context from the report

    “3. The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased’s location ”

    Source location

    Barbara Patterson · 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

    Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.

    Verbatim wording from the response

    “The CQC intend to carry out a planned comprehensive inspection of North East Ambulance Service (NEAS) as part of its ongoing inspection process. During this inspection we will investigate to what extent and degree call handlers are supported by systems and procedures already in place. We will also require NEAS to furnish oral and written evidence to demonstrate that they understand their role and responsibilities in relation to call handlers and that they provide regular monitoring to ensure that the system is functioning at an appropriate level.”

    Source location

    2015-0198-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 21 May 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

    Meet with NEAS in September 2015 to discuss management of ambulance dispatch processes.

    Verbatim wording from the response

    “This issue will be included as part of our planned comprehensive inspection and investigated to ascertain whether procedures presently in place by NEAS relating to the dispatch of ambulances is appropriate and what, if any, improvements can be made to the current system. Additionally, we will be meeting with NEAS in September 2015 to discuss how they are managing the process of dispatching ambulances.”

    Source location

    2015-0198-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 21 May 2015

    Open published response

  6. County Durham and Darlington

    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

  7. North London

    AI-generated summary

    Graham James Sutton · 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

    On 10 July 2013, Graham James Sutton fell five feet from a ladder while cutting a hedge, struck his head on concrete, and later died after being taken to hospital and transferred to a Trauma Centre. The concern was that the London Ambulance Service did not automatically link the fall, his age over 50, and his use of the anti-clotting medication Clopidogrel to a response within eight minutes.

    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 automatically link fall height, age and anti-clotting medication use to an eight-minute ambulance response

    Wider context from the report

    “The fact that Mr Sutton had fallen as little as 5 feet, that he was over 50 years old and that he was taking anti-clotting medications, (Clopidogrel), were not linked automatically by the London Ambulance Service to result in a response within 8 minutes. ”

    Source location

    Graham James Sutton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026