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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to coordinate cardiac-arrest responses
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
Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
Stated by SPFTStated completedThe respondent said that this action was complete when they made their response on 22 June 2026.
Action
Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
Stated by SPFTStated completedThe respondent said that this action was complete when they made their response on 22 June 2026.
Action
Develop a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.
Stated by SPFTStated in progressThe respondent said that this action was in progress when they made their response on 22 June 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
Stated by SPFTExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Suffolk
Concerns raised1
Failure of GPs to promptly communicate with the Medical Assessment Unit or Accident and Emergency department
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.1
Action
Restrict the Medical Assessment Unit bleep to external calls, increasing capacity for timely responses and reducing call queues.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing electronic messaging, bleep arrangements and ambulance pre-alert processes are considered an adequate response to communication concerns.
Stated by East Suffolk and North Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Primary care providers are expected to request ambulance attendance for patients with suspected sepsis or life-threatening conditions requiring hospital conveyance.
Stated by East Suffolk and North Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Failure to establish ambulance staff role and assessment status
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
Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Kent and Medway
Concerns raised1
Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
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.5
Action
Direct HMP Elmley staff to follow local medical-emergency procedures consistently, including responsibilities for resuscitation, restraints and ligature removal.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Jointly draft a memorandum of understanding defining agencies’ responsibilities and coordinating joint working during major incidents.
Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Prepare and return SECAmb comments on the memorandum of understanding defining roles and responsibilities for prison incidents.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Add a command-and-control framework for incidents in HM Prison establishments to the SECAmb Incident Response Plan.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Arrange a meeting with prison healthcare leads to clarify primacy of care while developing the memorandum of understanding.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Healthcare professionals or paramedics, rather than prison staff, are responsible for leading medical interventions beyond first aid or CPR.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing arrangements establish Oxleas’ responsibility and leadership for acute medical emergencies, with paramedics supporting Oxleas staff when required.
Stated by Oxleas NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Primacy of care in prisons rests with commissioned prison healthcare services, while ambulance staff assume responsibility after handover and departure.
Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Kent and Medway
Concerns raised2
Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings
Failure to establish a communication strategy during critical medical emergencies in custodial settings
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.2
Position
HM Prison and Probation Service is responsible for leadership, command and control of prison emergencies, including medical emergencies.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Ambulance Service is expected to provide further detail about paramedics’ role in medical emergencies within prisons.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised3
Failure to coordinate detention and medical staff roles during a medical emergency
Failure of communication between detention and medical staff to facilitate prompt CPR commencement
Lack of protocols defining detention and medical staff roles during a medical emergency in a cell
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.5
Action
Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.
Stated by West Yorkshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
Stated by Leeds Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.
Stated by Leeds Community Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Include coordination of response in investigations of life-threatening incidents and deaths in custody.
Stated by Leeds Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.
Stated by Leeds Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
Stated by West Yorkshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Cancellation of ambulance responses without discussion with callers
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.2
Position
Ambulance validation and cancellation fall outside NHS Pathways’ remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Greater Manchester Clinical Assessment Service is responsible for investigating the ambulance validation and cancellation.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Lack of national standards and guidance requiring confirmation that basic observations are received by Accident and Emergency personnel
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 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
Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Unclear responsibility for calling a medical 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.1
Action
Review and reinforce the emergency medical-call process, requiring staff to call an ambulance when immediate physical-health concerns arise.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
East Sussex
Concerns raised1
Breakdown in healthcare-prison communication about emergency hospital transfer
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.1
Action
Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
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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.
