Recurring concern
Failure to use the appropriate emergency contact route
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Request correctionFirst reported 20 Aug 2015•Latest report 6 Feb 2026
What this concern includes
Includes failures to select or initiate the required emergency contact route or number for a safety-critical report, including use of 101 instead of 999 and use of 111 instead of 999 when emergency assistance is required.
Not included
- Excludes delays or failures in call handling, dispatch, ambulance attendance, police attendance or hospital handover after the appropriate emergency contact has been initiated.
- Excludes general uncertainty about whether emergency assistance is clinically required where the unsafe condition is the decision threshold rather than use of the wrong contact route.
- Excludes ordinary non-emergency use of 101, 111 or other services where no safety-critical emergency report should have been made.
- Excludes generic staff training, communication or escalation deficiencies unless they directly cause selection of the wrong emergency contact route.
- Reports
- 4
- Individual concerns
- 5
- Date range
- 2015–2026
- Stated actions
- 7
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 use the required emergency 999 number for the report
This report raised 10 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.3
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Action
Refine the Trust AWOL policy to clarify when emergency 999 police escalation is required.
Stated by The Trust -
Action
Deliver refresher training to ward staff on applying the Trust and Pan-London AWOL policies together in practice.
Stated by The Trust -
Action
Develop and implement mandatory AWOL policy training for all clinical staff, including competency assessment against both applicable AWOL policies.
Stated by The Trust
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Concerns raised1
Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators
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.1
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Action
Share updated ambulance-service SOPs, including electricity-network maps and distribution-network-operator contact details, across NHS ambulance services.
Stated by Association of Ambulance Chief Executives
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The membership organisation can provide guidance and collaboration but cannot mandate NHS ambulance services to implement safety action.
Stated by Association of Ambulance Chief Executives
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Position
Preparing or overseeing local or national standard operating procedures and nationally overseeing 111 or 999 operations fall outside NHS Pathways’ remit.
Stated by NHS England -
Position
Distribution and transmission network operators have suitable and effective arrangements with local emergency services for incidents involving electricity-network equipment.
Stated by Health and Safety Executive
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Concerns raised2
Failure to follow the policy requiring 999 calls after falls involving head injury
Failure to follow the policy requiring 999 calls after falls involving head injury
This report raised 8 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
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
Stated by Castlehill Specialist Care Centre -
Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality Commission
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
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality Commission
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Concerns raised1
Lack of staff training in appropriate use of 999 or 111
This report raised 11 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
Provide refresher training on the appropriate use of 999 and 111.
Stated by MERIDIAN HEALTHCARE LIMITED
Data last updated 7 September 2026