First reported 1 Oct 2013•Latest report 26 May 2026
Definition
What this concern includes
Includes deficiencies in communication, information transfer, handover, communication strategy or role clarity that are directly dedicated to coordinating or escalating a medical emergency response, including communication between healthcare staff and prison, control-room, ambulance or other responding personnel.
Not included
Excludes communication deficiencies unrelated to a medical emergency response.
Excludes standalone training, staffing, equipment, documentation or clinical-assessment deficiencies unless the report directly identifies their effect on medical-emergency communication.
Excludes failures confined to a specific clinical guideline or treatment decision where emergency communication is not the shared unsafe condition.
Excludes generic information-sharing problems that are not tied to coordinating or escalating a medical emergency.
Reports
42
Distinct published reports
Individual concerns
49
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
61
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.
Department of Health and Social Care11
HM Prison and Probation Service5
Association of Ambulance Chief Executives3
Ministry of Justice3
NHS England3
Home Office2
London Ambulance Service NHS Trust2
National Institute for Health and Care Excellence2
South Central Ambulance Service NHS Foundation Trust2
Boldmere Court Care Home1
Bourne Leisure Limited1
Capita Business Services Ltd1
Capita PLC1
Cardiff Prison1
Care Quality Commission1
NHS trust17
Ministerial department14
Prison or young offender institution9
Police force6
Private limited company6
Executive agency5
Executive non-departmental public body5
Health professional body3
Health-sector membership body3
Healthcare site2
Company1
Company limited by guarantee1
Fire and rescue service1
Health and social care service regulator1
Limited liability partnership1
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.
South Wales Central
Concerns raised1
Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support
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 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
Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
Stated by Cardiff PrisonStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.
Action
Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
Stated by Cardiff PrisonStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Milton Keynes
Concerns raised1
Inhibitory hierarchical structure preventing staff from speaking up during emergencies
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
Develop multidisciplinary training resources and short scenarios on unrecognised oesophageal intubation.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Action
Work with stakeholders to highlight the need for sufficient theatre-team time for essential emergency-drill training.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Action
Promote and embed the Human Factors guidance for Anaesthesia recommendations in practice.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Individual NHS trusts are responsible for delivering emergency simulation and team-based training, subject to available resources and clinical trainer time.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Worcestershire
Concerns raised2
Failure to provide WMAS with critical patient-condition information promptly during emergencies
Failure of prison and healthcare staff to recognize the need to update WMAS with critical patient-condition information
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.9
Action
Review and update local emergency-incident policies and protocols, republish them, and issue Governor’s notices reinforcing information-sharing expectations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Create an Emergency Control Room checklist specifying vital ambulance-service information and follow-up questions for ongoing incident updates.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Instruct custodial managers to communicate concise, accurate prisoner-condition reports at the earliest opportunity and issue notices describing required information.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Amend Prison Service Instruction 03/2013 to clarify requirements for providing emergency-condition information to control rooms.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Issue the revised emergency-response instruction, pocket cards, and control-room posters reminding staff of ambulance-service information requirements.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Jointly review ambulance-call information requirements with WMAS.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Write a new ambulance-calling process based on patient-specific information requirements.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Provide prison staff with guidance on communicating relevant patient information to ambulance dispatch teams.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Disseminate a Purple Alert across healthcare sites requiring escalation systems for deteriorating patients, particularly those requiring CPR.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Plymouth, Torbay and South Devon
Concerns raised1
Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical 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.1
Action
Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
Stated by Hart Care LimitedStated completedThe respondent said that this action was complete when they made their response on 30 March 2021.
Dorset
Concerns raised1
Failure of Emergency Services to use mutually understood control-room terminology
This report raised 8 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
Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
Stated by College of Policing and National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2019.
Action
Continue national work with emergency-service partners to improve consistency in ABD recognition and prioritisation.
Stated by College of Policing and National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
There are seldom misunderstandings about response urgency because call handlers seek details and ambulance triage is based on clinical presentation.
Stated by College of Policing and National Police Chiefs’ CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.
Stated by College of Policing and National Police Chiefs’ CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Lack of common terminology or use of “on the hurry up” is not considered the cause of the ambulance response problem.
Stated by Association of Ambulance Chief ExecutivesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised2
Failure to communicate the nature of an emergency when summoning first aiders
Failure to provide a competent handover to ambulance services
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.
Cheshire
Concerns raised1
Lack of provision to provide updates to other emergency services during significant ambulance delays
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 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.
Suffolk
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 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
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 ExecutivesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Absence of immediate poolside telephone access for summoning medical 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.
Inner North London
Concerns raised1
Inaccessibility of information about recent contacts with other services during emergency call-outs
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
Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
Stated by London Borough of CamdenStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
Action
Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
Stated by London Borough of CamdenStated plannedThe respondent said that this action was planned when they made their response on 25 September 2018.
Action
Develop information-sharing arrangements with London Ambulance Service.
Stated by London Borough of CamdenStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.
Stated by London Borough of CamdenExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.
Stated by London Borough of CamdenDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes deficiencies in communication, information transfer, handover, communication strategy or role clarity that are directly dedicated to coordinating or escalating a medical emergency response, including communication between healthcare staff and prison, control-room, ambulance or other responding personnel.
