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.
Somerset
Concerns raised1
Insufficient English proficiency among direct care staff to communicate urgent medical needs and summon emergency help
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
Tighten Health and Care visa sponsorship requirements so only CQC-regulated providers can sponsor care worker and senior care worker applications from Spring 2024.
Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 1 December 2023.
Action
Keep immigration requirements, including English-language requirements, under review as part of the Health and Care visa changes.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Different English language requirements for different sectors would be difficult to assess and manage.
Stated by Home OfficeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Imposing English requirements on routes without them could defeat those routes' intended purposes.
Stated by Home OfficeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Raising Skilled Worker English requirements is considered inappropriate, impractical, and unlikely to address all concerns.
Stated by Home OfficeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Employers are primarily responsible for ensuring overseas care staff can fulfil their roles and may require higher English standards.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Delays in calling duty doctors during emergencies
This report raised 14 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
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023.
Action
Remind medical staff to respond to ERT alarms and alert the duty doctor promptly.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to promptly inform and coordinate with the site co-ordinator during emergencies
This report raised 15 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
Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Inner South London
Concerns raised1
Inadequate handover during resuscitation emergencies
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire Eastern
Concerns raised1
Failure of prison officers to initiate or coordinate CPR in an emergency
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.2
Action
Update the emergency-response training video and distribute it to training centres and prisons for staff training.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022.
Action
Review first-aid policy and collaborate on updated guidance covering CPR commencement and signposting safer-custody guidance.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022.
Birmingham and Solihull
Concerns raised1
Lack of a mechanism to broadcast a medical emergency by tannoy at the base
This report raised 18 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.
West Sussex
Concerns raised1
Unavailability of an external phone line for emergencies
This report raised 13 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 South London
Concerns raised1
Failure to communicate detainee medical distress with appropriate urgency
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The officer’s comments had no bearing on the circumstances of the incident.
Stated by Metropolitan Police ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The conduct did not meet the threshold for disciplinary proceedings, so no disciplinary action was pursued.
Stated by Metropolitan Police ServiceNo action considered necessaryThe respondent said that no further action was needed.
Position
The officer’s behaviour did not meet the statutory threshold for disciplinary proceedings and therefore did not require treatment as a conduct matter.
Stated by Independent Office for Police ConductNo action considered necessaryThe respondent said that no further action was needed.
Position
A further investigation was unnecessary because existing body-worn video and inquest evidence established the officer’s behaviour, while reflective practice provided appropriate intervention.
Stated by Independent Office for Police ConductExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Lancashire and Blackburn with Darwen
Concerns raised1
Lack of effective communication between healthcare personnel at medical emergencies and prison or ambulance control
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
Implement the revised emergency response process, including a second healthcare responder, scene SBAR completion and direct ambulance communication.
Stated by Spectrum CICStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.
Action
Provide supporting training on the new emergency response process to relevant staff and incorporate it into responses to all emergencies.
Stated by Spectrum CICStated completedThe respondent said that this action was complete when they made their response on 25 January 2022.
Action
Develop and deliver clinician training on ambulance categorisation and challenging incorrect categorisation.
Stated by Spectrum CICStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Access to mobile phones or alternative communication methods is the responsibility of HMPPS partners.
Stated by Spectrum CICRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Spectrum Healthcare has no influence to change the Code Blue and Code Red communication arrangements.
Stated by Spectrum CICUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Lancashire and Blackburn with Darwen
Concerns raised2
Inadequate communication between healthcare personnel at medical emergency scenes and prison or ambulance control
Failure of healthcare to liaise with the ambulance service over medical emergencies
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.6
Action
Liaise with NWAS to define clinician training needs and incorporate ambulance-control communication guidance into the HMP Lancaster Farms emergency-response procedure.
Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Conduct joint prison-healthcare debriefs after incidents to identify communication lessons involving healthcare, the communications department and NWAS.
Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Implement a dedicated radio net enabling clinicians and the prison communications room to communicate directly and relay information securely during medical emergencies.
Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Monitor the new emergency-communication system through staff feedback, healthcare incident reviews and safety-huddle and organisational learning.
Stated by SpectrumStated plannedThe respondent said that this action was planned when they made their response on 16 December 2021.
Action
Use a dedicated radio channel to connect clinicians directly with ambulance services through the communications room during medical emergencies.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Restrict access to the emergency radio network to the communications room, healthcare staff and first responders on scene.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 16 December 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Using the wing phone could delay emergency communication and leave the patient without a nurse while the clinician makes the call.
Stated by SpectrumUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A mobile phone was not a reliable communication solution because phone signal at HMP Lancaster Farms was unreliable.
Stated by SpectrumUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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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.
