Recurring concern
Unreliable ambulance call triage and re-triage
Pin
Get email alerts
Request correctionFirst reported 6 Dec 2013•Latest report 11 May 2026
What this concern includes
Includes failures of the ambulance call triage and re-triage process, including initial clinical validation, categorisation, evidence-based category changes, recognition of new or worsening symptoms, timely re-triage and escalation to a more urgent response.
Not included
- Excludes generic ambulance response delays or resource shortages where the triage or re-triage decision is not deficient.
- Excludes failures in communicating dispatch status or expected response times after a triage decision has been made.
- Excludes downstream ambulance attendance, hospital handover or clinical treatment failures that do not concern ambulance call triage or re-triage.
- Excludes non-ambulance triage processes unless the report explicitly identifies the same ambulance call triage concern.
- Reports
- 50
- Individual concerns
- 61
- Date range
- 2013–2026
- Stated actions
- 72
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.
-
Concerns raised1
Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
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 concernsEach 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
A separate sepsis algorithm pathway is unnecessary because sepsis screening is embedded across multiple symptom-based NHS Pathways.
Stated by NHS England
-
Concerns raised1
Failure to re-triage and re-classify cases when subsequent relevant information is received
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
-
Action
Publish a Patient Safety and Experience Newsletter article reminding staff to re-triage calls when presentations change.
Stated by East of England Ambulance Service NHS Trust -
Action
Discuss re-triage learning and potential themes at the Learning Group.
Stated by East of England Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Re-triage at the second call was unlikely to produce a higher categorisation because pain is excluded from AMPDS triage questions.
Stated by East of England Ambulance Service NHS Trust
-
Concerns raised1
Failure to update ambulance response categorization when a patient's condition deteriorates during a delayed response
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.3
-
Action
Have senior clinicians regularly review and reprioritise waiting ambulance calls according to potential deterioration and clinical need.
Stated by North West Ambulance Service NHS Trust -
Action
Provide interim care and worsening-condition advice before closing ambulance calls, enabling callers to seek reassessment when circumstances change.
Stated by North West Ambulance Service NHS Trust -
Action
Increase clinician telephone triage and referrals to alternative care pathways to support ambulance availability for Category 1 and 2 patients.
Stated by North West Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
NWAS considers accurate estimates, worsening advice, clinical oversight and reprioritisation the most effective response to prolonged ambulance waits.
Stated by North West Ambulance Service NHS Trust
-
Concerns raised3
Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials
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 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
-
Action
Implement a standalone procedure for suspected or confirmed Acute Behavioural Disturbance, removing “excited delirium” terminology and requiring Category 1 escalation with clinical review for possible downgrade.
Stated by East of England Ambulance Service NHS Trust -
Action
Update, approve and disseminate the detained-patient procedure and Emergency Operations Centre escalation guidance to reflect the Acute Behavioural Disturbance procedure.
Stated by East of England Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
National ambulance response categories are determined by NHS England’s ECPAG, not by AACE.
Stated by Association of Ambulance Chief Executives
-
Concerns raised1
Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
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.4
-
Action
Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Stated by NHS England -
Action
Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Stated by NHS England -
Action
Continue refining and aligning the MPDS and NHS Pathways triage systems.
Stated by NHS England
-
Action
Continue monitoring triage categorisation and strengthening clinical oversight.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Stated by NHS England
-
Position
The two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Stated by NHS England -
Position
No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Stated by NHS England
-
Concerns raised1
Failure to base triage category changes on evidence of clinical change or deterioration
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 concernsEach 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
The second call was upgraded because the patient’s condition deteriorated and accurate triage information became available.
Stated by South Central Ambulance Service NHS Foundation Trust
-
Concerns raised1
Failure of MPDS chest-pain triage to identify reported heart attacks for a Category 1 response
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of the ambulance triage system to distinguish abdominal complaints and assign timely hospital-conveyance dispositions
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
-
Action
Discuss the abdominal pain case within the AMPDS clinical coding subgroup with PDC to identify opportunities to improve assessment and differentiation of surgical emergencies.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
Telephone triage cannot make differential diagnoses requiring visual, historical and diagnostic information unavailable during the call.
Stated by NHS England
-
Position
Priority Dispatch Corp manages AMPDS protocols and questions, including responsibility for making changes to the commercial international system.
Stated by NHS England -
Position
Individual ambulance services are responsible for processes and timescales enabling timely clinical navigation and validation of calls requiring further assessment.
Stated by NHS England
-
Concerns raised1
Failure to verify police supervision status when determining ambulance disposition
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
-
Action
Train control-room personnel to notify the ambulance service when officers attending an urgent incident are redeployed.
Stated by Devon & Cornwall Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
SWAST should account for possible police redeployment when conducting its triage and risk assessment for patients needing medical attention.
Stated by Devon & Cornwall Police
-
Concerns raised1
Failure to revise ambulance priority when a patient is deteriorating and in extremis
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.3
-
Action
Establish a national group of clinical and operational leads to review measures for incidents outside the purple and red categories.
Stated by Welsh Government -
Action
Undertake a review of whether measures are required for incidents outside the purple and red categories, including relevant amber conditions.
Stated by Welsh Government -
Action
Seek assurance at the next integrated quality planning and delivery meeting on call categorisation and provision of clinically appropriate responses.
Stated by Welsh Government
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Welsh Ministers do not deliver health services or make WAST’s operational decisions on emergency ambulance call categorisation.
Stated by Welsh Government
-
Position
WAST is responsible for operational emergency ambulance call categorisation and is best placed to respond to required action.
Stated by Welsh Government
Data last updated 7 September 2026