Recurring concern
Unreliable emergency access to hospital care
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Request correctionFirst reported 25 Feb 2014•Latest report 5 Jun 2026
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
- Individual concerns
- 60
- Date range
- 2014–2026
- Stated actions
- 99
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
Delays in calling paramedics for deteriorating patients
This report raised 7 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.4
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Action
Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Deliver comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Action
Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
Stated by Nottinghamshire Healthcare 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
A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Lack of practical guidance for police conveyance of patients to hospital when ambulances are unavailable
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.2
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Action
Use developed Authorised Professional Practice to guide officers’ dynamic risk assessments and decisions when transporting patients without an ambulance.
Stated by College of Policing -
Action
Escalate the issue to the NPCC First Aid Forum for consideration of practical advice that can be offered to forces.
Stated by College of Policing
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Transportation of casualties to hospital falls outside the First Aid Learning Programme’s scope and first-aider responsibilities.
Stated by College of Policing
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Position
The College does not issue specific transport guidance because police conveyance carries inherent risks, liabilities and risks of normalising the practice.
Stated by College of Policing -
Position
Existing Authorised Professional Practice and dynamic risk assessment already provide appropriate guidance when officers transport casualties without an ambulance.
Stated by College of Policing
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Concerns raised1
Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared
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 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.1
-
Position
Records indicate the hospital-transfer authorisation was generated immediately after the emergency code was called, rather than being delayed.
Stated by HM Prison and Probation Service
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Concerns raised1
Delays in contacting emergency ambulance services after a fall
This report raised 9 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
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
Stated by Castlehill Specialist Care Centre -
Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality Commission
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
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality Commission
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Concerns raised1
National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis
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.
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
The choice of clinical triage tool remains the responsibility of individual ambulance services rather than being mandated nationally.
Stated by Department of Health and Social Care
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Position
No Pathfinder changes are considered necessary because the tool remains a safe and effective assessment and triage tool.
Stated by Department of Health and Social Care
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Concerns raised1
Delays in transferring patients into hospital care, preventing emergency ambulance release
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 raised2
Lack of guidance on whether and when to call an ambulance during mobilisation of the medical emergency team
Delays in calling an ambulance for transfer in a medical emergency
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
Review and refresh the deteriorating-patient policy to clarify actions when physical health deteriorates and medical intervention is required.
Stated by St Andrew's Healthcare -
Action
Automatically call an ambulance whenever a medical emergency is called, rather than leaving the decision to the nursing team.
Stated by St Andrew's Healthcare -
Action
Monitor medical emergencies and ambulance attendances through the physical healthcare governance meeting, escalating identified problems or challenges.
Stated by St Andrew's Healthcare
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
Earlier arrival at the General Hospital would not have altered the outcome in this case.
Stated by St Andrew's Healthcare
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Concerns raised1
Failure to inform medical professionals of ambulance delays of 39 minutes or less
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.
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
Call takers cannot provide accurate expected arrival times because emergency responses are fluid and may be diverted to more urgent incidents.
Stated by Association of Ambulance Chief Executives
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Concerns raised1
Failure to assess painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Potential medical emergencies outside Code Red and Code Blue requiring hospital transfer within less than an hour
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 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.
Data last updated 7 September 2026