First reported 25 Feb 2014•Latest report 5 Jun 2026
Definition
What this concern includes
Includes failures of controls dedicated to emergency hospital access, including recognition of need, escalation, approval for release or transfer, ambulance activation and coordination where these affect timely access to hospital care.
Not included
Excludes generic training, staffing, communication or protocol deficiencies not explicitly tied to emergency access to hospital care.
Excludes routine or non-emergency referrals and transfers.
Excludes unrelated emergency procedures or transport arrangements that do not concern access to hospital care.
Reports
50
Distinct published reports
Individual concerns
60
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
99
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 England10
Department of Health and Social Care6
Care Quality Commission5
London Ambulance Service NHS Trust4
East of England Ambulance Service NHS Trust3
HM Prison and Probation Service3
College of Policing2
Recipient name withheld2
South East Coast Ambulance Service NHS Foundation Trust2
University Hospitals Sussex NHS Foundation Trust2
Welsh Ambulance Services NHS Trust2
Aneurin Bevan University LHB1
Association of Ambulance Chief Executives1
Asthma + Lung UK1
Beech Cliffe Grange1
NHS trust25
Executive non-departmental public body11
Ministerial department7
Healthcare site6
Health and social care service regulator5
Private limited company5
Prison or young offender institution4
Executive agency3
Health professional body2
Integrated care board2
Local health board2
Multi-service care provider2
National policing body2
Residential care home2
Sub-organisation2
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.
North London
Concerns raised1
Failure to convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital
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.3
Action
Deliver further ECG-focused training and updated myocardial infarction guidance through the 2026–2027 Core Skills Refresher cycle.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Action
Reinforce guidance and training on intermittent symptoms and presentations suggestive of acute coronary syndrome.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Action
Commence a trial transmitting ECGs to Heart Attack Centre clinicians for early interpretation and specialist referral.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing paramedic training, national guidance and holistic clinical assessment are considered sufficient for recognising and managing suspected acute coronary syndrome.
Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Local ambulance services are responsible for the operational concerns and are best placed to respond to them.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Coventry
Concerns raised1
Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
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.3
Action
Fund urgent and emergency care capacity expansions, connected ambulance care records, and replacement ambulances.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Implement the Release to Rescue approach across trusts, beginning handover at 30 minutes and completing it by 45 minutes.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.
Action
Implement the Release to Rescue programme and work with regional partners to reduce ambulance handover delays to a 45-minute maximum.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England will address the report’s other concerns in a separate response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinicians, not non-clinical call handlers, are responsible for deciding whether higher-category patients may travel to hospital independently.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to call an ambulance promptly for a medical emergency
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
Review and strengthen welfare escalation procedures for prompt emergency-service contact when guests present serious symptoms.
Stated by FOLDStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Require immediate ambulance calls when a guest’s vital signs and temperature are high, regardless of hallucinations or antidepressant history.
Stated by FOLDStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Contract and deploy Frontline Medical Response medical staff and life-support equipment at all nighttime events to support welfare assessment and escalation.
Stated by FOLDStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
North London
Concerns raised1
Failure to arrange prompt hospital transfer after two unsuccessful replacement catheter insertion attempts
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
Create and implement a full clinical protocol for catheterisation emergencies and escalation.
Stated by High MeadowsStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Distribute a quick-reference catheterisation emergency poster to all nursing stations.
Stated by High MeadowsStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Review clinical documentation and escalation procedures to improve clarity and accountability.
Stated by High MeadowsStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Create and implement an escalation protocol.
Stated by High MeadowsStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Distribute a quick-reference escalation flowchart to team leads.
Stated by High MeadowsStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Provide face-to-face refresher training in catheterisation for all nurses and team leads.
Stated by High MeadowsStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Limit replacement-catheter insertion to two attempts, stop sooner for resistance, pain, or bleeding, and call 999 after two failures or earlier if sepsis is suspected.
Stated by High MeadowsStated plannedThe respondent said that this action was planned when they made their response on 5 November 2025.
Action
Record each 999 call reference number and assign a staffed phone to respond promptly to emergency-service return calls.
Stated by High MeadowsStated plannedThe respondent said that this action was planned when they made their response on 5 November 2025.
Cornwall and Isles of Scilly
Concerns raised1
Failure to assess need for hospital conveyance during nurse clinician review
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.
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
Share CFT’s MIU ambulance-receiving procedure with LML and reinforce ambulance-based assessment, handover, family involvement and suitability decisions through staff communications and learning forums.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Disseminate inquest learning on ambulance patient assessment, family and carer involvement, handover and safe escalation through CFT meetings, forums, staff communications and governance groups.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Kent and Medway
Concerns raised1
Unclear prison officer roles in conveying prisoners lacking capacity to hospital
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.
Cornwall and Isles of Scilly
Concerns raised1
Failure of the ambulance triage system to distinguish abdominal complaints and assign timely hospital-conveyance dispositions
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
Discuss the abdominal pain case within the AMPDS clinical coding subgroup with PDC to identify opportunities to improve assessment and differentiation of surgical emergencies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Telephone triage cannot make differential diagnoses requiring visual, historical and diagnostic information unavailable during the call.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Priority Dispatch Corp manages AMPDS protocols and questions, including responsibility for making changes to the commercial international system.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Individual ambulance services are responsible for processes and timescales enabling timely clinical navigation and validation of calls requiring further assessment.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Sussex
Concerns raised1
Failure to classify transfers for aortic dissection requiring emergency surgery as category 1
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
Inter-facility transfers requiring immediate treatment at a receiving facility are categorised by clinical condition and urgency, rather than diagnosis, as Category 2.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised2
Failure of nursing staff to call ambulances without prior senior clinician approval
Delays in calling emergency ambulances
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.
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
Complete refresher Intermediate Life Support training for the nurse involved.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2024.
Action
Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Nursing staff do not require senior permission to call emergency services; this is not agreed Trust practice.
Stated by East London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Suffolk
Concerns raised2
Failure of ambulance transfer triage to prioritise urgent clinician-requested transfers
Unavailability of ambulances for timely urgent transfers and emergency call attendances
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.18
Action
Maintain and update the national framework for inter-facility ambulance transfers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Review the National Framework for Inter-Facility Transfers with NHS England in light of the death.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Publish the Delivery Plan for Recovering Urgent and Emergency Care Services.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Provide £200 million of additional ambulance funding to expand capacity and improve response times.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Deliver new ambulances and specialist mental health vehicles.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Provide £1.6 billion over two years to support timely and effective hospital discharge.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Increase the NHS ambulance and support workforce.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Boost the number of paramedics by up to 15,600 through the NHS Long Term Workforce Plan.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Improve ambulance performance and response times across England.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Increase ambulance capacity by growing the workforce.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Speed up hospital discharges to support ambulance availability and urgent care flow.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Recruit additional frontline clinicians to increase ambulance staffing, targeting more than 300 clinicians in place by March 2024.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Recruit additional control-room clinicians to expand clinical triage and enable safer transfers to alternative services.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Establish and operate the Suffolk Unscheduled Care Coordination Hub with healthcare partners to increase appropriate referrals and provide remote crew support.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Work with local acute trusts to reduce hospital delays affecting ambulance availability.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Implement the Call before you convey programme with healthcare partners to support appropriate conveyance and pathway decisions.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Implement a same-day emergency care team at West Suffolk Hospital to direct patients to appropriate facilities and reduce emergency-department handover delays.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS England and the ambulance trust are responsible for responding to the report’s specific concerns within their respective remits.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of controls dedicated to emergency hospital access, including recognition of need, escalation, approval for release or transfer, ambulance activation and coordination where these affect timely access to hospital care.
