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.
Manchester South
Concerns raised1
Failure to distinguish calls from residential facilities where contact cannot be established from calls where contact is lost during the call
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The AACE cannot mandate or instruct ambulance services, limiting its authority to require implementation of responsive safety changes.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Bedfordshire and Luton
Concerns raised2
Failure to code uncertain self-harm ingestion calls as Category 2
Failure to code uncertain self-harm ingestion calls as Category 2
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.1
Action
Encourage ambulance trusts to implement early clinical review of calls involving patients threatening suicide.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 8 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mandating or instructing ambulance services is outside the organisation’s constitution and authority.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
ECPAG, an NHS England-led group, is responsible for approving changes to clinical code sets and response categories.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised2
Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Failure of the 999 service to safety-net inappropriate 111 categorisation
This report raised 19 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
Change NHS Pathways ambulance categorisation so symptoms suggesting life-threatening anaphylaxis receive a category 1 response, and deploy the changes nationally.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Continue participating in ambulance user groups to share data, discuss cases, exchange learning, and support triage-system improvements through feedback mechanisms.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Work with NHS England and other partners, and request resolution of inconsistent anaphylaxis coding between AMPDS and NHS Pathways.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.8
Position
Ambulance categorisation and alignment of NHS Pathways with MPDS are not NHS Digital’s responsibility or oversight function.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS England oversees both systems and must address ambulance categorisation or inconsistencies between MPDS and NHS Pathways.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Established NHS Pathways governance systems capture, review and resolve clinical coding issues, including those raised through Prevention of Future Deaths reports.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
ECPAG, acting for NHS England, controls ambulance categorisation and can identify inconsistencies between NHS Pathways and MPDS.
Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Changes to MPDS and NHS Pathways operation are matters for IAED and NHS Digital respectively.
Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
ECPAG has limited ability to align NHS Pathways and MPDS because the systems use different methodologies.
Stated by London Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
No remaining anaphylaxis categorisation inconsistency exists between NHS 111 and ambulance services because 111 incidents pass directly into ambulance dispatch.
Stated by Association of Ambulance Chief ExecutivesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
An independent body, rather than NHS Digital, should conduct the review of clinical triage systems because NHS Digital provides the NHS 111 Pathways system.
Stated by AdvancedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Wales Central
Concerns raised2
Failure to ask callers how long the patient has been fitting
Failure to consistently categorise non-maintenance of airways as a continuous red code
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing MPDS triage, clinical support and escalation arrangements are considered sufficient to prioritise healthcare professional calls appropriately.
Stated by Welsh Ambulance Services NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The existing pan-Wales CPAS governance framework and international MPDS system are considered sufficient for best-practice call categorisation without a separate hospital pathway.
Stated by Welsh Ambulance Services NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Buckinghamshire
Concerns raised1
Failure of overdose call categorisation to ensure timely ambulance 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 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
Deploy Release 18, including the Dx0124 disposition code, to identify higher-risk suicide cases for early clinical review.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2019.
Action
Develop a disposition code for symptomatic accidental-overdose patients, subject to National Clinical Governance Group review, to enable urgent clinical risk assessment.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Ambulance response standards and category mappings are set by NHS England, not by NHS Pathways.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS Pathways cannot automatically identify higher-risk overdoses from drugs taken because closed questions cannot safely capture the relevant variables.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure of priority dispatch systems to take patient age into account when determining response speed and acuity
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.
Nottinghamshire
Concerns raised2
Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event
Insufficient resources for triage of all non-category 1 emergency calls
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.
Carmarthenshire and Pembrokeshire
Concerns raised1
Failure to categorise conscious, breathing patients with chest pains and related conditions as Category Red
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The response model appropriately assigns red priority only to chest-pain calls involving unconsciousness and absent breathing.
Stated by Welsh Ambulance Services NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised2
Lack of call-handling provision for identifying unrecognised ED/ABD presentations
Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
This report raised 15 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.
Northamptonshire
Concerns raised2
Lower priority allocation by the ‘111’ Pathway triaging system than by the ‘999’ AMPDS system
Failure of ‘111’ and EMAS call handling systems to treat neurological signs as urgent
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 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
Share concerns about NHS Pathways’ ability to identify possible sepsis with the software developers.
Stated by DHU 111 (East Midlands) CICStated completedThe respondent said that this action was complete when they made their response on 11 April 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The triage systems would not have warranted a Category 2 ambulance without both severe illness and new marks being present.
Stated by DHU 111 (East Midlands) CICDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
