Recurring concern
Failure to call an ambulance promptly when emergency assistance is required
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Request correctionFirst reported 1 Aug 2013•Latest report 27 Jan 2026
What this concern includes
Includes failures of the dedicated process for recognising the need for emergency ambulance assistance and initiating the call without avoidable delay, including delays caused by repeat observations, seeking managerial approval, uncertainty about the threshold for calling, or prioritising other tasks.
Not included
- Excludes delays in ambulance attendance, dispatch, travel or hospital handover after the ambulance has been called.
- Excludes emergency call-handling, triage or ambulance-resource failures where the issue is not the prompt initiation of the ambulance call.
- Excludes generic emergency-response delays or failures that do not specifically concern calling an ambulance.
- Excludes failures to provide advice or care while awaiting an ambulance when the ambulance call itself was made promptly.
- Reports
- 37
- Individual concerns
- 42
- Date range
- 2013–2026
- Stated actions
- 46
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to call an ambulance promptly for a medical emergency
Responses linked to these concernsEach 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
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Action
Review and strengthen welfare escalation procedures for prompt emergency-service contact when guests present serious symptoms.
Stated by FOLD -
Action
Require immediate ambulance calls when a guest’s vital signs and temperature are high, regardless of hallucinations or antidepressant history.
Stated by FOLD -
Action
Contract and deploy Frontline Medical Response medical staff and life-support equipment at all nighttime events to support welfare assessment and escalation.
Stated by FOLD
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Concerns raised1
Delays in calling an emergency ambulance for very unwell residents
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 concernsEach 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
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Action
Present learning from the matter to home managers, including escalation expectations and immediate 999 calls for newly unresponsive residents.
Stated by Barchester Healthcare Limited -
Action
Complete themed supervisions covering RESTORE2 clinical judgement and managing resident deterioration.
Stated by Barchester Healthcare Limited -
Action
Provide staff with Clinical Shots guidance for assessing residents and responding to deterioration.
Stated by Barchester Healthcare Limited
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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Position
The reported 09:30 incident time is unsupported; staff identified no concerns about the resident’s health or wellbeing then.
Stated by Barchester Healthcare Limited
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Position
Staff did not consider a 49-minute escalation period appropriate for an unresponsive resident and recalled no significant delay in this case.
Stated by Barchester Healthcare Limited
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Concerns raised1
Failure to call an ambulance promptly following a concern for welfare call
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Train officers requiring additional medical support to telephone 999 from the scene so operators can liaise directly and allocate resources.
Stated by Devon & Cornwall Police -
Action
Require officers using the police control room to explain why they cannot call 999 directly, and train police and ambulance personnel to record relevant information when liaising.
Stated by Devon & Cornwall Police
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Concerns raised1
Delays in escalating and responding to an apparent emergency
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 concernsEach 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
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Action
Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.
Stated by Unite Students -
Action
Review training, policies and procedures so staff promptly contact emergency services alongside requesting assistance for room entry during safety concerns or emergencies.
Stated by Unite Students -
Action
Review Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.
Stated by Unite Students
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Concerns raised1
Delays in calling emergency ambulances
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Complete refresher Intermediate Life Support training for the nurse involved.
Stated by East London NHS Foundation Trust -
Action
Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.
Stated by East London NHS Foundation Trust
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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Position
Nursing staff do not require senior permission to call emergency services; this is not agreed Trust practice.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to make an immediate ambulance call when a code blue or red is raised
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Circulate and mandate Code Red/Blue NTS and follow PSI contingency responses.
Stated by Guys Marsh Prison
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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Position
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social Care
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Position
Mandatory code red and blue procedures and PSI contingency arrangements are considered sufficient and are being followed.
Stated by Guys Marsh Prison
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Concerns raised1
Uncertainty about when medical professionals should call the ambulance service
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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 the medical-emergency escalation process and reinforce it through resuscitation training.
Stated by Gloucestershire Health and Care NHS Foundation Trust
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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Position
The existing medical-emergency escalation process remains fit for purpose and is reinforced through training and induction.
Stated by Gloucestershire Health and Care NHS Foundation Trust
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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 concernsEach 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
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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 Trust
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Concerns raised2
Failure to summon emergency medical assistance when required
Failure to apply the emergency-calling procedure consistently across practice staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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
Delays in calling an ambulance for patients with concerns for their breathing
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026