Recurring concern
Unreliable emergency access to hospital care
- Reports that mention this concern
- 50
- Times this concern has been raised
- 60
- Stated actions linked to this concern
- 99
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 50 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Nottinghamshire Healthcare NHS Foundation Trust
Stated actions 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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Nottinghamshire Healthcare NHS Foundation Trust
Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
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Nottinghamshire Healthcare NHS Foundation Trust
Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
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Nottinghamshire Healthcare NHS Foundation Trust
Deliver comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
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Nottinghamshire Healthcare NHS Foundation Trust
Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
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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Nottinghamshire Healthcare NHS Foundation Trust
A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
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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.
Linked response
- College of Policing
Stated actions 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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College of Policing
Use developed Authorised Professional Practice to guide officers’ dynamic risk assessments and decisions when transporting patients without an ambulance.
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College of Policing
Escalate the issue to the NPCC First Aid Forum for consideration of practical advice that can be offered to forces.
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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College of Policing
Transportation of casualties to hospital falls outside the First Aid Learning Programme’s scope and first-aider responsibilities.
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College of Policing
The College does not issue specific transport guidance because police conveyance carries inherent risks, liabilities and risks of normalising the practice.
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College of Policing
Existing Authorised Professional Practice and dynamic risk assessment already provide appropriate guidance when officers transport casualties without an ambulance.
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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.
Linked response
- HM Prison and Probation Service
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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HM Prison and Probation Service
Records indicate the hospital-transfer authorisation was generated immediately after the emergency code was called, rather than being delayed.
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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.
Linked responses
- Care Quality Commission
- Castlehill Specialist Care Centre
Stated actions 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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Castlehill Specialist Care Centre
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
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Care Quality Commission
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
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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Care Quality Commission
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
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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.
Linked response
- Department of Health and Social Care
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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Department of Health and Social Care
The choice of clinical triage tool remains the responsibility of individual ambulance services rather than being mandated nationally.
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Department of Health and Social Care
No Pathfinder changes are considered necessary because the tool remains a safe and effective assessment and triage tool.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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
Linked response
- St Andrew's Healthcare
Stated actions 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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St Andrew's Healthcare
Review and refresh the deteriorating-patient policy to clarify actions when physical health deteriorates and medical intervention is required.
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St Andrew's Healthcare
Automatically call an ambulance whenever a medical emergency is called, rather than leaving the decision to the nursing team.
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St Andrew's Healthcare
Monitor medical emergencies and ambulance attendances through the physical healthcare governance meeting, escalating identified problems or challenges.
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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St Andrew's Healthcare
Earlier arrival at the General Hospital would not have altered the outcome in this case.
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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.
Linked response
- Association of Ambulance Chief Executives
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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Association of Ambulance Chief Executives
Call takers cannot provide accurate expected arrival times because emergency responses are fluid and may be diverted to more urgent incidents.
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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.
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026