First reported 24 Mar 2014•Latest report 12 Aug 2024
Definition
What this concern includes
Includes failures to make required telephone contact with patients or their families for patient follow-up, requested contact, or assessment of a requested service.
Not included
Excludes failures to telephone treating healthcare professionals about abnormal results, unless the concern is specifically patient or family telephone follow-up or assessment.
Excludes general failures of referral escalation, investigation tracking, or safety-netting that do not specifically involve required telephone contact.
Excludes isolated communication failures unrelated to a required patient or family telephone contact.
Reports
18
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
23
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.
Department of Health and Social Care3
Welsh Ambulance Services NHS Trust3
South East Coast Ambulance Service NHS Foundation Trust2
Welsh Government2
Aneurin Bevan University LHB1
Cardiff & Vale University LHB1
Central and North West London NHS Foundation Trust1
Daughter of the deceased1
Frimley Health NHS Foundation Trust1
Healthcare Inspectorate Wales1
Hereford Medical Group1
Kent and Medway Mental Health NHS Trust1
King's College Hospital1
London Ambulance Service NHS Trust1
NHS England1
NHS trust14
Healthcare site4
Ministerial department3
Devolved government2
Local health board2
Clinical commissioning group1
Coronial office1
Executive non-departmental public body1
Health and care inspectorate1
Health professional body1
Independent healthcare provider1
Integrated care board1
Type not available1
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 North
Concerns raised1
Failure to make a 48-hour post-discharge follow-up call
This report raised 13 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
A 48-hour follow-up call is not required where a confirmed NHS community appointment exists within 72 hours of discharge.
Stated by Priory GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner West London
Concerns raised1
Failure to provide follow-up contact or assessment after an interrupted treatment call
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 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
Review guidance on follow-up after treatment sessions are interrupted and calls are disconnected.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2024.
Action
Clarify for staff the actions required after treatment sessions are interrupted and calls are disconnected.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responding to the Coroner’s specific concerns falls outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust is responsible for responding to the Coroner’s specific concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Sefton, St Helens and Knowsley
Concerns raised1
Failure to follow up whether a patient has obtained urgent medical assistance
This report raised 6 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.
Herefordshire
Concerns raised1
Failure to telephone patients as requested or advised
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 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
Update reception protocols so receptionists telephone patients first to explain the GP’s triage decision.
Stated by Hereford Medical GroupStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
Inner West London
Concerns raised1
Failure to contact the patient after discharge
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
Remind nursing and medical colleagues to telephone patients 48 hours after discharge, unless qualifying community or crisis-team follow-up is confirmed within 72 hours.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
Action
Continue monthly audits of post-discharge telephone calls until three successive months achieve 100% compliance.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023.
Mid Kent and Medway
Concerns raised1
Failure to conduct an adequate location-finding follow-up call
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
Implement a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2021.
Gwent
Concerns raised1
Failure to make contact with callers or their families
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
Review policies and procedures for establishing contact with patients or callers at scene.
Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2018.
Surrey
Concerns raised1
Failure to maintain scheduled telephone contact with discharged patients or their families
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Delays in making and chasing-up welfare calls
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
Remind clinical contact centre leads to handle Protocol 23 overdose cases promptly.
Stated by Cardiff & Vale University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Demand-related capacity constraints make it challenging to undertake a robust welfare-call procedure consistently.
Stated by Cardiff & Vale University LHB and Welsh Ambulance Services NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Failure to return calls within pre-set time guidelines to obtain further medical details
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.8
Action
Deliver refresher training for Control Services staff on call handling and MPDS application, including an anonymised learning-from-experience case study.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Action
Reassess minimum Clinical Hub staffing levels in light of the new national response standard and increased demand.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Action
Secure funding for additional recruitment to address Clinical Hub and operational staffing pressures.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Action
Introduce three additional Clinical Hubs in Kenton, Barking and Croydon to increase flexible Clinical Hub staffing capacity.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Action
Introduce a further Clinical Hub in New Malden to expand local Clinical Hub coverage.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.
Action
Run a specific Clinical Hub recruitment programme to increase the pool of staff trained in Manchester Triage System and Clinical Hub procedures.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Action
Continue the operational staff recruitment drive to increase available staffing capacity.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Action
Submit LAS data to the national review of ambulance response priorities, call-backs and safe systems to support improvement and learning.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The national review of ambulance response times and safe call-back systems is led by the Association of Ambulance Chief Executives.
Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures to make required telephone contact with patients or their families for patient follow-up, requested contact, or assessment of a requested service.
