Recurring concern
Unreliable ambulance call triage and re-triage
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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.
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Concerns raised1
Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions
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.
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
Apply overdose safeguards including timely clinical review, automatic escalation when delayed, TOXBASE consultation, and assessment of ongoing suicidal ideation.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Develop an ambulance-service workstream exploring artificial intelligence to identify rare or uniquely risky 999 calls and support earlier clinical attention.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Publish a national operational procedure requiring clinical oversight and timely escalation for Category 3 overdose and suicidal-ideation calls.
Stated by NHS England
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Action
Update overdose guidance to include Category 5 dispositions and require urgent remote clinical assessment pending appropriate ambulance response.
Stated by NHS England
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
Existing overdose procedures provide additional clinical review, TOXBASE assessment and automatic escalation, supporting Category 3 ambulance dispositions.
Stated by South East Coast Ambulance Service NHS Foundation Trust
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Concerns raised1
Lack of clinician awareness of the ability to challenge ambulance call categorisation and request clinical review
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
Publish and maintain a national framework enabling healthcare professionals to challenge ambulance call categorisation and request clinical review.
Stated by NHS England
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 framework advises healthcare professionals that they may challenge the assigned ambulance category or response time based on clinical concern.
Stated by NHS England
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Concerns raised1
Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code
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
Write to ambulance trusts requesting confirmation of compliance with guidance on 999 overdose and suicidal-ideation calls.
Stated by NHS England -
Action
Request AMPDS trusts to amend specified 25-C medication or substance calls to Category 2 until the software update is implemented.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing clinical oversight safeguards for overdose and suicidal ideation calls are considered sufficient beyond initial ambulance response-category mapping.
Stated by NHS England
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Position
NHS England owns 999 call categorisation matters and administers the process for considering proposed changes.
Stated by Association of Ambulance Chief Executives and National Ambulance Service Medical Directors
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Concerns raised1
Failure to complete timely clinical validation or re-triage of Category 3 and 4 calls
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
Implement a portal enabling Urgent Community Response teams to pull suitable Category 3 and 4 patients awaiting clinical validation.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Roll out Urgent Care Navigation Hubs and geographically zoned clinical assessment for Category 3 and 4 patients awaiting validation.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Recruit substantive staff, paramedics and experienced agency nurses for control-room clinical validation of 999 calls.
Stated by South East Coast Ambulance Service NHS Foundation Trust
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Action
Operate a harm review process for patients experiencing the longest daily waits for Category 3 and 4 validation, using findings to improve operational processes.
Stated by South East Coast Ambulance Service NHS Foundation Trust
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Concerns raised1
Failure to account for actual category 3 ambulance response times when accepting call categorisation
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
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Position
The Category 3 ambulance categorisation was audited and considered safe and appropriate based on the patient’s presentation.
Stated by NHS England
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Concerns raised1
Failure to maintain regular welfare calls and reassess delayed ambulance responses
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.2
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Action
Establish a dispatch support role whose day-to-day responsibilities include undertaking welfare calls for patients waiting prolonged periods for ambulance responses.
Stated by Welsh Ambulance Services NHS Trust -
Action
Explore technology-enabled methods for providing welfare calls to patients waiting in the community, informed by processes used by other UK ambulance trusts.
Stated by Welsh Ambulance Services NHS 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
High demand and limited capacity prevent regular welfare calls while emergency calls are prioritised.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Failure to detect worsening conditions in Category 2 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.
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
Finalise the EOC clinician procedure for managing deteriorating patients.
Stated by North East Ambulance Service NHS Foundation Trust -
Action
Operate the Dispatch Clinical Risk Assessment procedure to prioritise Category 2 responses by clinical risk.
Stated by North East 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
The call handler followed NHS Pathways correctly, and the patient's conscious, breathing condition did not warrant a Category 1 response.
Stated by North East Ambulance Service NHS Foundation Trust
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Concerns raised1
Delays in triaging emergency calls involving threats of overdose
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.
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
Deploy mental health professionals in 999 call centres and clinical assessment services to direct people in crisis to appropriate care.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to risk-stratify high-risk overdoses for immediate clinical response
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
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Action
Publish a national operational procedure requiring further overdose-call clinical intervention within 30 minutes and escalation to Category 2 if it does not occur within 40 minutes.
Stated by NHS England -
Action
Complete a national review of the overdose and suicidal-ideation call procedure to ensure it remains fit for purpose.
Stated by NHS England -
Action
Re-share the overdose and suicidal-ideation initial assessment principles document with the ambulance service concerned.
Stated by NHS England
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
Changes to overdose ambulance categorisation are determined by the Clinical Coding Review Group and Emergency Call Prioritisation Advisory Group.
Stated by NHS England
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Concerns raised1
Failure of the control-room computer system to allow clinician assessment and upgrading of calls during ongoing live calls
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
Change records to open in read-only mode, requiring users to request a lock.
Stated by Cleric Computer Services Limited -
Action
Streamline requests to release a record lock from one user to another.
Stated by Cleric Computer Services Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The system did not wholly preclude clinician access or call upgrading because several built-in mechanisms could overcome a locked record.
Stated by Cleric Computer Services Limited
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Position
Record locks will remain because they are fundamental, while existing operational procedures handle circumstances involving locked calls.
Stated by Cleric Computer Services Limited
Data last updated 7 September 2026