Recurring concern
Unreliable ambulance call triage and re-triage
- Reports that mention this concern
- 50
- Times this concern has been raised
- 61
- Stated actions linked to this concern
- 72
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.
What is 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.
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 50 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Insufficient clinician capacity for timely secondary triage of 999 calls
This report raised 3 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
Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- NHS England
- North West Ambulance Service NHS 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.2
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NHS England
Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.
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NHS England
Trial a new ambulance coding system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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North West Ambulance Service NHS Trust
The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.
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Department of Health and Social Care
The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.
-
Department of Health and Social Care
Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.
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NHS England
The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.
-
Concerns raised1
Lack of a triage tool to recognise agonal or inadequate breathing
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to proactively ask and record the type of fit during triage calls
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to assign red prioritisation to calls regarding unconscious patients
This report raised 1 other concern. 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
Omission of chest-pain questions from the breathing-difficulties dispatch card
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Department of Health and Social Care
AMPDS users must ask Priority Dispatch directly to review and change the system’s call-handling questions.
-
Department of Health and Social Care
The Department cannot provide further help implementing the proposed AMPDS call-handling changes.
-
Concerns raised2
Failure to implement or consider automated call recategorisation
Failure to implement or consider clinical re-triaging
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- London Ambulance Service NHS 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
-
London Ambulance Service NHS Trust
Assess the clinical appropriateness and feasibility of automated call re-categorisation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
London Ambulance Service NHS Trust
Automated call recategorisation could increase risk by causing inappropriate ambulance dispatches and reducing protection for patients requiring eight-minute responses.
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London Ambulance Service NHS Trust
Existing clinical hub staffing, standard operating procedures and surge-management processes are considered sufficient, removing the need for automated call-handling processes.
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Concerns raised1
Failure to prevent call takers from downgrading calls to lower-acuity pathways
This report raised 1 other concern. 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
Failure to allocate appropriate priorities to ambulance calls
This report raised 2 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.1
-
South Central Ambulance Service NHS Foundation Trust
Transition from AMPDS to the clinically focused NHS Pathways assessment system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
South Central Ambulance Service NHS Foundation Trust
National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.
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Concerns raised1
Failure of ambulance call-takers to correctly assess breathing and triage calls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- North West Ambulance Service NHS 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.2
-
North West Ambulance Service NHS Trust
Provide all Emergency Medical Dispatchers with a six-week training course covering procedures, call taking, first aid, paediatric resuscitation and AMPDS.
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North West Ambulance Service NHS Trust
Require Emergency Medical Dispatchers to provide continuing-education and audit-review evidence to maintain certification.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Responsibility for selecting and training ambulance call-taking staff rests with the North West Ambulance Service Trust.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026