First reported 6 Dec 2013•Latest report 11 May 2026
Definition
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
Distinct published reports
Individual concerns
61
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
72
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.
NHS England17
Department of Health and Social Care12
Association of Ambulance Chief Executives8
Welsh Ambulance Services NHS Trust7
London Ambulance Service NHS Trust5
NHS Pathways5
National Ambulance Service Medical Directors4
South East Coast Ambulance Service NHS Foundation Trust4
Emergency Call Prioritisation Advisory Group3
North West Ambulance Service NHS Trust3
College of Paramedics2
East Midlands Ambulance Service NHS Trust2
East of England Ambulance Service NHS Trust2
National Institute for Health and Care Excellence2
NHS West and North London Integrated Care Board2
NHS trust28
Executive non-departmental public body17
Ministerial department12
Health-sector membership body8
Health professional body6
Sub-organisation5
Police force4
Type not available4
Integrated care board3
Other public body3
Devolved government2
Private limited company2
Clinical commissioning group1
Community interest company1
Company1
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.
Staffordshire South
Concerns raised1
Failure of ambulance categorisation pathways to allow movement away from rigid categories
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 concerns
Each 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
Operate a clinical validation process that triages category 3 and 4 incidents, routes patients to appropriate outcomes, and increases ambulance response categories where clinically indicated.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Have senior clinical navigators risk-assess patients awaiting clinical assessment, arrange ambulance dispatch for unsuitable patients, and upgrade incidents when indicated.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing clinical validation, prioritisation, risk assessment and escalation arrangements are considered sufficient to manage category 3 and 4 delays safely.
Stated by West Midlands Ambulance Service University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Call-handler pathway failing to consider adrenal crisis risk after trauma
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.5
Action
Liaise with JRCALC to align ambulance protocols and clarify additional oral or intramuscular hydrocortisone for trauma or injury.
Stated by Society For EndocrinologyStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
Action
Work with ambulance, 999 and 111 services through NHSE to include steroid emergency information in call-handler triage and support category 2 ambulance dispatch.
Stated by Society For EndocrinologyStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
Action
Raise the NHS Pathways concern about adrenal-insufficiency risks following trauma on the clinical concern log.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
Action
Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Action
Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Ambulance hydrocortisone availability and authorised personnel should not prevent administration during trauma or injury.
Stated by Society For EndocrinologyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
WMAS cannot change the nationally required NHS Pathways triage system used to assess 999 calls.
Stated by West Midlands Ambulance Service University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing NHS Pathways design is considered sufficient because extra adrenal-insufficiency questioning could delay care or create confusion.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
AACE has no responsibility for changing the NHS Pathways system used to assess 999 calls in the West Midlands.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Milton Keynes
Concerns raised1
Failure to upgrade emergency incident categorisation when clinical deterioration warranted a higher priority
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gwent
Concerns raised1
Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
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 concerns
Each 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
Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
Stated by Eluned MorganRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gwent
Concerns raised1
Failure to account for the clinical ramifications of prolonged lying in elderly patients during ambulance categorisation
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 concerns
Each 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.6
Action
Review long-waiting patients through Clinical Support Desk clinical assessment and increase response priority when acuity warrants it.
Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2022.
Action
Continually review and update dispatch guidance for falls and frailty responders.
Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2022.
Action
Refer categorisation of elderly patients affected by prolonged immobility after falls to the Clinical Priority Software Advisory Group.
Stated by Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Action
Provide enhanced Clinical Desk capacity for targeted telephone advice to patients awaiting responses, including pressure-ulcer prevention and reduced immobility.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Review post-fall patient guidance and immobility risks through the Older Persons Improvement Group, then suggest improvements.
Stated by Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Action
Monitor the three new falls MPDS code suffixes and review data to consider recommendations on differentiated priorities.
Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current demand pressures mean the Trust is unlikely to send responses or act differently within the newly assigned MPDS time targets.
Stated by Welsh Ambulance Services NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised2
Failure to categorise ambulance calls accurately for appropriate ambulance dispatch
Failure of the ambulance call algorithm to direct exploration of concerning symptom responses
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised2
Early termination of 999 call triage before completion
Failure to recognise drowsiness as a new symptom requiring re-triage
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Existing NHS Pathways early-exit options and clinical validation arrangements adequately manage complex or incompletely triaged calls.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Wales Central
Concerns raised1
Inconsistent response coding and categorisation leading to unreliable vehicle dispatch decisions
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 concerns
Each 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
Use Clinical Support Desk flags to identify overdose incidents and enable faster or out-of-order vehicle allocation.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Drug-specific overdose responses cannot be incorporated because drugs vary widely and prioritisation is based on current condition, not potential future deterioration.
Stated by Welsh Ambulance Services NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Birmingham and Solihull
Concerns raised1
Failure to allow a category 1 ambulance response for severe ABD involving restraint
Responses linked to these concerns
Each 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
Propose that NHS England and AACE consider an evidence-based review of Acute Behavioural Disturbance response categorisation.
Stated by College of ParamedicsStated plannedThe respondent said that this action was planned when they made their response on 31 January 2022.
Action
Write to ambulance services reminding them to provide senior-clinician oversight for ABD calls and upgrade to Category 1 when deterioration or restraint occurs.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2022.
Action
Conduct a joint police and ambulance review of suspected ABD presentations to assess deterioration risk and appropriate response categories.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Action
Consider whether restraint alone should trigger an automatic Category 1 response for suspected ABD.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.8
Position
NHS Pathways recognises ABD and restraint risks and complies with the nationally mandated Category 2 response standard.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Any change to ambulance response categorisation must be considered by NHS England and AACE groups and approved by ECPAG.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for determining NHS ambulance response categories lies with NHS England, supported by AACE evidence and guidance.
Stated by College of ParamedicsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Severe and mild ABD cannot be reliably distinguished during pre-hospital or telephone triage, so severity cannot determine the response category.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Suspected ABD appropriately receives a Category 2 response, with senior clinical oversight and escalation to Category 1 when the patient’s condition warrants it.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
AACE cannot decide or mandate emergency response categories and therefore cannot undertake that decision-making work.
Stated by Association of Ambulance Chief ExecutivesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NHS England, through ECPAG, is responsible for deciding appropriate ambulance response categories.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing evidence-based arrangements consider Category 2 appropriate for suspected ABD unless immediately life-threatening signs warrant Category 1; restraint alone does not require Category 1.
Stated by Association of Ambulance Chief ExecutivesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Automatic categorisation of abandoned calls as category 3
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 concerns
Each 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
Review the process for abandoned calls, including calls involving potential mental health concerns.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 November 2020.
Action
Introduce and revise the mental health abandoned-call procedure to guide Category 2 responses for patients actively at risk.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 November 2020.
Action
Develop, approve and release an abandoned-call procedure covering Category 2 escalation and mandatory Duty Manager checks, including call-recording review.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 November 2020.
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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.
