Recurring concern
Failure to call an ambulance promptly when emergency assistance is required
- Reports that mention this concern
- 37
- Times this concern has been raised
- 42
- Stated actions linked to this concern
- 46
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.
What is 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.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 37 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Delays in calling emergency services and relaying basic emergency information
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions 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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Essex Partnership University NHS Foundation Trust
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
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Essex Partnership University NHS Foundation Trust
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
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Essex Partnership University NHS Foundation Trust
Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
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Concerns raised1
Delays in calling an ambulance when a resident’s condition requires emergency assistance
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to prioritise calling an ambulance during a home birth emergency
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- RBFT
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
RBFT
Include formal neonatal-resuscitation competency assessment in induction training.
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RBFT
Provide new midwives with maternity-unit shifts as part of induction and require annual completion of homebirth competency and confidence documents by maternity support workers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
RBFT
Current community intrapartum training is sound and effective, with no training-topic gaps identified, although recommendations will clarify and consolidate it.
-
Concerns raised1
Delays in calling paramedics for deteriorating patients
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Nottinghamshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Nottinghamshire Healthcare NHS Foundation Trust
Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
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Nottinghamshire Healthcare NHS Foundation Trust
Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
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Nottinghamshire Healthcare NHS Foundation Trust
Deliver comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
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Nottinghamshire Healthcare NHS Foundation Trust
Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
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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Nottinghamshire Healthcare NHS Foundation Trust
A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
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Concerns raised2
Failure to follow the policy requiring 999 calls after falls involving head injury
Delays in contacting emergency ambulance services after a fall
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Castlehill Specialist Care Centre
Stated actions 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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Castlehill Specialist Care Centre
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
-
Care Quality Commission
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Care Quality Commission
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
-
Concerns raised1
Lack of an ambulance escalation safety net when Adult Social Care cannot respond promptly
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Wakefield City Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Wakefield City Council
Establish an on-call rota identifying a manager responsible for out-of-hours periods.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Wakefield City Council
Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.
-
Concerns raised2
Lack of guidance on whether and when to call an ambulance during mobilisation of the medical emergency team
Delays in calling an ambulance for transfer in a medical emergency
Linked response
- St Andrew's Healthcare
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
St Andrew's Healthcare
Review and refresh the deteriorating-patient policy to clarify actions when physical health deteriorates and medical intervention is required.
-
St Andrew's Healthcare
Automatically call an ambulance whenever a medical emergency is called, rather than leaving the decision to the nursing team.
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St Andrew's Healthcare
Monitor medical emergencies and ambulance attendances through the physical healthcare governance meeting, escalating identified problems or challenges.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
St Andrew's Healthcare
Earlier arrival at the General Hospital would not have altered the outcome in this case.
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Concerns raised2
Delays in calling an ambulance pending contact with the duty manager
Delays in calling an ambulance pending repeat observations regardless of initial results
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to consider and communicate ambulance involvement when clinically indicated
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Delay in summoning an ambulance for cases to be stepped up to hospital
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026