Recurring concern
Unreliable emergency-department triage
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Request correctionFirst reported 9 May 2014•Latest report 10 Oct 2025
What this concern includes
Includes failures of the emergency-department triage process, including adoption and application of the triage system, triage procedures, recognition of clinically significant symptoms or relevant history, prioritisation and escalation, where the deficiency directly affects safe emergency-department triage.
Not included
- Excludes failures of the specifically named Manchester Triage System, which is tracked as a separate concern.
- Excludes ambulance call triage, GP appointment triage and other non-emergency-department triage processes.
- Excludes generic emergency-department crowding, staffing or capacity deficiencies unless they directly result in an unsafe emergency-department triage failure.
- Excludes downstream assessment, treatment or communication failures after triage where triage itself was not deficient.
- Reports
- 16
- Individual concerns
- 17
- Date range
- 2014–2025
- Stated actions
- 17
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
Lack of standard operating practice and training to ensure recent surgery is considered in Emergency Department triage
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to prioritise and place seriously ill pre-alerted patients in Resus on arrival
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 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
Operate the new Urgent and Emergency Care Centre with four resuscitation rooms and an expanded five-bay First Assessment area.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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
Treatment in the First Assessment area was a reasonable alternative because airway management was not required on arrival.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to provide timely medical triage of Majors patients at risk of clinical decline
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 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
Improve initial self-presenting patient assessment through a quality improvement project, assessment pathways and nursing education.
Stated by Barts Health NHS Trust -
Action
Use electronic vital-sign frequency and red-heart alerts to prompt repeat observations and urgent attention.
Stated by Barts Health NHS Trust -
Action
Use customised acuity flags to prioritise patients with specified clinical, infectious, vulnerability or mental-health risks.
Stated by Barts Health NHS Trust
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Concerns raised1
Delays in emergency department triage
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 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.5
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Action
Provide triage support during periods of high demand.
Stated by UHSx -
Action
Implement direct handover of police-conveyed patients to Trust staff.
Stated by UHSx -
Action
Revise and implement the Trust-wide Missing Persons policy, including risk assessment, detention, communication, escalation and post-departure procedures.
Stated by UHSx
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Action
Review and update emergency-department triage, mental-health liaison, observation and communication documentation with partner clinicians.
Stated by UHSx -
Action
Introduce daytime emergency-department front-door streaming by placing a nurse in reception for immediate assessment and patient redirection.
Stated by UHSx
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Concerns raised1
Delays in triage of ill babies in Paediatric ED
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 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
Review and circulate the Children and Young People escalation tool, including triage-time triggers and required escalation actions.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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Concerns raised2
Failure to record triage of ambulance arrivals at the Emergency Department
Ineffective triage of ambulance arrivals at the Emergency Department
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.1
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Action
Use the Manchester Triage Tool and electronic Symphony records for ambulance handovers and triage decisions.
Stated by Betsi Cadwaladr University LHB
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
Existing Manchester Triage, continuous nursing cover, senior ambulance triage and electronic recording address emergency department triage concerns.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Inability of emergency departments to triage patients during OPEL 4 pressures
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 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
Increase the number of Emergency Department senior decision makers to enable timely patient assessment and treatment.
Stated by NHS Lancashire and South Cumbria Integrated Care Board -
Action
Increase the Emergency Department nursing workforce to ensure safe staffing levels.
Stated by NHS Lancashire and South Cumbria Integrated Care Board
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
Specific local actions addressing the concerns are the responsibility of Lancashire and South Cumbria Integrated Care Board.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to accurately transcribe communications received at emergency department triage
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to consistently adopt an appropriate triage system in Accident and Emergency
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.2
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Action
Review the Emergency Department triage and escalation policy.
Stated by Wye Valley NHS Trust -
Action
Submit the reviewed triage and escalation policy.
Stated by Wye Valley NHS Trust
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
Existing clinical streaming, Manchester Triage, electronic tracking and Band 6 oversight are relied on as safeguards for Emergency Department triage.
Stated by Wye Valley NHS Trust
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Concerns raised1
Lack of DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival
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 concernsEach 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
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Position
NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.
Stated by Department of Health and Social Care
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Position
Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.
Stated by NHS England
Data last updated 7 September 2026