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
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.
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
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
Stated by Essex Partnership University NHS Foundation Trust
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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.
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
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.
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
Include formal neonatal-resuscitation competency assessment in induction training.
Stated by RBFT -
Action
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.
Stated by RBFT
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
Current community intrapartum training is sound and effective, with no training-topic gaps identified, although recommendations will clarify and consolidate it.
Stated by RBFT
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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.
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.4
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Action
Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Deliver comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Action
Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
Stated by Nottinghamshire Healthcare 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
A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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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.
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
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
Stated by Castlehill Specialist Care Centre -
Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality Commission
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
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality Commission
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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.
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
Establish an on-call rota identifying a manager responsible for out-of-hours periods.
Stated by Wakefield City Council
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
Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.
Stated by Wakefield City Council
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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
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 refresh the deteriorating-patient policy to clarify actions when physical health deteriorates and medical intervention is required.
Stated by St Andrew's Healthcare -
Action
Automatically call an ambulance whenever a medical emergency is called, rather than leaving the decision to the nursing team.
Stated by St Andrew's Healthcare -
Action
Monitor medical emergencies and ambulance attendances through the physical healthcare governance meeting, escalating identified problems or challenges.
Stated by St Andrew's Healthcare
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
Earlier arrival at the General Hospital would not have altered the outcome in this case.
Stated by St Andrew's Healthcare
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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
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
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.
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
Delay in summoning an ambulance for cases to be stepped up to hospital
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