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.
East Sussex
Concerns raised1
Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment
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 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
Actively review the emergency-escort policy.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
Teesside and Hartlepool
Concerns raised1
Failure to consider alternative transport to hospital
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
Implement the Emergency Ambulance Response Validation procedure, including welfare-call prioritisation and documented assessment of suitable alternative transport.
Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A taxi was not appropriate because suicidal intent and other red flags made non-clinical transport unsafe.
Stated by North East Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
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.8
Action
Maintain additional ambulance capacity funded to expand capacity and improve response times.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
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 15 September 2023.
Action
Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Complete and register a group-wide risk assessment addressing ambulance transfer delays.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
Stated by Spire Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
Stated by Spire Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.
Stated by Spire Healthcare LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Delays in ambulance transfer to hospital for elderly frail patients with hip fractures
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.3
Action
Improve ambulance response times through the urgent and emergency care recovery plan.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
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 21 July 2023.
Action
Achieve the Ambulance Response Programme standards in the region.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Manchester South
Concerns raised1
Delays in ambulance access and transfer to Emergency Departments
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.4
Action
Fund additional ambulance capacity and maintain the resulting capacity uplift through 2024/25.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift through 2024/25.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Provide two-year funding to support timely and effective hospital discharge.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Continue working with NHS England to reduce ambulance response times and A&E waiting 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 21 July 2023.
North West Wales
Concerns raised1
Failure of the vascular emergency transfer pathway to provide direct hospital admission
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.4
Action
Map the emergency ischaemic limb patient journey across North Wales hospitals, identify delays and bottlenecks, and take steps to reduce them.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2022.
Action
Commence the vascular emergency bypass pathway for direct admission of suitable stable patients to the vascular ward and monitor its implementation until embedded.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2022.
Action
Finalise and implement the vascular emergency bypass pathway with BCU Health Board, including direct hospital admission arrangements and operational contact and destination details.
Stated by Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2022.
Action
Operate the implemented vascular bypass protocol across the South East Wales Vascular network for conditions including abdominal aortic aneurysm and ischaemic limb.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The vascular pathway cannot be released for immediate use until the Health Board provides a contact number and destination.
Stated by Welsh Ambulance Services NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Worcestershire
Concerns raised1
Delays in calling an ambulance when a resident’s condition requires emergency assistance
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 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
Delays in ambulance attendance and transport for patients requiring hospital care
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.4
Action
Invest an additional £3.3 billion in each of 2023–24 and 2024–25 to improve urgent and emergency care performance.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
Action
Allocate £150 million in additional system funding to support ambulance-service pressures, including call-handler recruitment and retention.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Provide £20 million to upgrade the ambulance fleet.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Invest significantly in the ambulance workforce 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 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The NHS will set out detailed recovery plans to improve urgent and emergency care performance.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Berkshire
Concerns raised1
Failure to prioritise calling an ambulance during a home birth emergency
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
Include formal neonatal-resuscitation competency assessment in induction training.
Stated by RBFTStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Provide new midwives with maternity-unit shifts as part of induction and require annual completion of homebirth competency and confidence documents by maternity support workers.
Stated by RBFTStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current community intrapartum training is sound and effective, with no training-topic gaps identified, although recommendations will clarify and consolidate it.
Stated by RBFTExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South London
Concerns raised1
Failure to use emergency transport for a medical emergency
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The care did not reflect a lack of urgency, and arrest did not influence the timeliness or appropriateness of assessment, management or care.
Stated by London Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
