First reported 31 Jul 2014•Latest report 18 Feb 2025
Definition
What this concern includes
Includes failures in ambulance call assessment, communication, callback arrangements, support planning, monitoring or escalation that are specifically dedicated to safely managing callers who are alone, including operation of the MPDS or equivalent ambulance call pathway.
Not included
Excludes generic ambulance delays or dispatch failures that are not specifically linked to a caller being alone.
Excludes communication failures involving patients, families or clinicians outside the ambulance call-handling pathway.
Excludes generic training, staffing, documentation or policy deficiencies unless the source explicitly ties them to the safety of ambulance calls involving callers who are alone.
Reports
5
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
3
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 Pathways2
Department of Health and Social Care1
London Ambulance Service NHS Trust1
Senedd Cymru1
South East Coast Ambulance Service NHS Foundation Trust1
Welsh Government1
NHS trust2
Sub-organisation2
Devolved government1
Devolved legislature1
Ministerial department1
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.
Gwent
Concerns raised1
Inability of a patient who is alone to inform the ambulance service of deterioration
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.
Manchester South
Concerns raised1
Failure to automatically escalate disconnected ambulance calls from callers who are alone
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Failure of emergency caller scripts to positively persuade lone callers to contact someone when paramedic attendance is delayed
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
Amend closing instructions to advise callers to contact someone immediately if needed, then keep the telephone line free for ambulance-service callbacks.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS Pathways cannot mandate advice for delayed ambulance attendance because it lacks delay information held by 999 providers.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Each 111 and 999 provider manages demand and delayed-attendance procedures through its own operational systems and local procedures.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Brighton and Hove
Concerns raised3
Failure of the callback process to remain safe for lone callers who become unresponsive
Failure to manage support arrangements safely for callers who are alone
Failure to establish whether an emergency caller is alone and whether another person can be spoken to
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.2
Action
Review worsening care advice, including instructions for first-party callers to call 999 if they become unresponsive.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019.
Action
Review the closing instruction for callers alone, consider adding advice to call someone else, and work with 999 services on its development.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The service cannot add contradictory instructions to its own script because it must follow NHS Pathways and this could confuse callers.
Stated by South East Coast Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Advice to call the ambulance service if the patient becomes unresponsive is outside the service’s control because it is prescribed by NHS Pathways.
Stated by South East Coast Ambulance Service NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The instruction not to contact others after ambulance dispatch remains necessary because ambulance services may need to call patients back.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NHS Pathways is responsible for amending the script to ask whether patients are alone and provide corresponding instructions.
Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The decision to require call handlers to ask whether another person is present is an operational matter for South East Coast Ambulance Service.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure of MPDS to ask whether an overdose patient is alone
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures in ambulance call assessment, communication, callback arrangements, support planning, monitoring or escalation that are specifically dedicated to safely managing callers who are alone, including operation of the MPDS or equivalent ambulance call pathway.
