Recurring concern

Unreliable ambulance response-time standards and prioritisation

First to latest report 16 Dec 2013 — 2 Feb 2026

Reports that mention this concern: 13
Times this concern has been raised: 13
Stated actions linked to this concern: 17

What this concern includes

Includes failures in ambulance-service arrangements for defining, communicating, applying or reviewing response-time standards and prioritisation criteria for urgent calls, including Amber-category calls, where unclear targets or grading can delay appropriate emergency attendance.

What is not included

Excludes actual ambulance attendance delays where no deficiency in response-time standards or prioritisation is identified.
Excludes ambulance dispatch communication, hospital handover and downstream treatment failures unless they directly concern the response-time-standard or prioritisation process.
Excludes condition-specific clinical triage systems where the assertion does not identify an ambulance response-time or prioritisation control.
Excludes generic staffing or resource shortages unless they are directly linked to failure to establish or meet a defined response-time standard.

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

Reports about this concern sent to each recipient.

NHS England3

Association of Ambulance Chief Executives2

Department of Health and Social Care2

NHS Pathways2

Welsh Ambulance Services NHS Trust2

Advanced Medical Priority Dispatch System (AMPDS)1

Aneurin Bevan University LHB1

College of Paramedics1

East Midlands Ambulance Service NHS Trust1

East of England Ambulance Service NHS Trust1

Essex Police1

London Ambulance Service NHS Trust1

NHS Greater Manchester Integrated Care Board1

Nottinghamshire Healthcare NHS Foundation Trust1

Ofcom1

Reports and published responses 13 reports

See individual reports that have raised this concern, and the actions taken in response

14 Mar2017
South Yorkshire (Eastern)
Concerns raised1
1. Lack of effective prioritisation of appliances
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jack Owen Sheldon · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jack Owen Sheldon died in a shed fire after petrol vapours from paint stripping reached a candle flame on 27 October 2016. Concerns included the handling and prioritisation of multiple emergency calls, staff communication and training, appliance mobilisation protocols, and systems for checking appliance availability and location.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of effective prioritisation of appliances
Wider context from the report
“(1) Lack of an effective system for management of multiple calls being received regarding the same incident and prioritisation of appliances. ”
Source location
Jack Owen Sheldon · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Aug2015
Inner North London
Concerns raised1
1. Failure to assign red prioritisation to calls regarding unconscious patients
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Anthony SWEENEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David Anthony Sweeney was found unconscious and vomiting after a public call to the London Ambulance Service on 18 April 2015. The call was incorrectly categorised, an ambulance arrived 1 hour 40 minutes later, and Mr Sweeney suffered a cardiac arrest shortly before its arrival; he died a week later from hypoxic brain injury and acute alcohol toxicity. The principal concern was that the call did not receive red prioritisation and that a recurring theme might be emerging in the handling of calls about unconscious patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assign red prioritisation to calls regarding unconscious patients
Wider context from the report
“A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation. You will remember that I wrote to you on 27 May 2015, regarding the assumption made by an LAS EMD that a child was asleep but rousable, when in fact the little boy was likely to have been unconscious. I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients. ”
Source location
David Anthony SWEENEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Dec2013
Oxfordshire
Concerns raised1
1. Failure to allocate appropriate priorities to ambulance calls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

South Central Ambulance Service NHS Foundation Trust
Stated actions 1
1. South Central Ambulance Service NHS Foundation Trust
  Transition from AMPDS to the clinically focused NHS Pathways assessment system.
Respondent positions 1
1. South Central Ambulance Service NHS Foundation Trust
  National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.
  Redirects responsibility
AI-generated summary

Clive GOULD · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to allocate appropriate priorities to ambulance calls
Wider context from the report
“(1) The original call made by ████████ was allocated a priority green status which meant that should a higher priority call be received (a red status call) then an ambulance would be diverted, which is what happened on two occasions. An internal audit of that call suggests that a different priority could have been given to the original call and the presenting concerns of Mr Gould's status. ”
Source location
Clive GOULD · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Transition from AMPDS to the clinically focused NHS Pathways assessment system.

Verbatim wording from the response
“SCAS have recognised that AMPDS is a dispatch tool as opposed to a clinical decision software support tool. SCAS are currently transitioning, with full support from our Commissioners, from the AMPDS system to a more clinically focused assessment system called NHS Pathways which is also fully licensed by the Department of Health. The benefits of this change will be to quickly identify patients in a life threatening situation and dispatch accordingly for those patients who are more time critical and then to allocate remaining resources only if clinically required to do so. This transition will be completed by the end of autumn 2014.”

Source location
2013-0357-Response-by-South-Central-Ambulance-Service
Page 1 · response
Published 16 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
National-level arrangements determine ambulance response allocation through the licensed AMPDS triage system.

Verbatim wording from the response
“SCAS response Currently SCAS operates the Department of Health licensed 999 triage software system called AMPDS. As this is a licensed tool all ambulance responses are determined at a national level. As a Trust we are required to maintain our AMPDS licence and ensure that call audits are carried out on a pre-determined percentage of inbound call volumes. The AMPDS product has been developed by Priority Dispatch Corporation with a comprehensive training programme that is prescriptive in nature and in order to be compliant all our Emergency Call Takers are required to meet the training standards and are audited on a monthly basis. As we currently use AMPDS our Call Takers are required to ask a pre-determined set of verbatim questions.”

Source location
2013-0357-Response-by-South-Central-Ambulance-Service
Page 1 · response
Published 16 December 2013
Open published response