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 an ambulance
This report raised 9 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.
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 former operator no longer controls future hospital safety steps, which fall to the successor operator.
Stated by Cambian Group plc
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Concerns raised1
Delays in arranging emergency hospital assessment and transport after suspected significant injury
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
Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.
Stated by Borough Care Ltd
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Concerns raised1
Failure to recognise when immediate cardiopulmonary resuscitation, alarm activation and ambulance summoning are required
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.
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 after an incident
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.2
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Action
Complete a full review and compile a controlled Emergency Procedures document addressing the reported safety concerns.
Stated by W.E.Rawson Limited -
Action
Issue the new Emergency Procedures document to all personnel as a refresher, including instructions to call emergency services promptly and station lookouts at site access points.
Stated by W.E.Rawson Limited
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 first aider correctly prioritised the emergency-services call before contacting the company Health and Safety manager.
Stated by W.E.Rawson Limited
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Concerns raised1
Delays and uncertainty in calling an emergency ambulance and using the code blue call
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.
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
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Action
Verify current staff understanding of the Emergency Code Protocol and obtain signed confirmation.
Stated by Durham Prison -
Action
Issue pocket-sized Emergency Code Protocol cards to staff.
Stated by Durham Prison -
Action
Display Emergency Code Protocol posters prominently in all residential areas.
Stated by Durham Prison
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Action
Embed Emergency Code Protocol instruction, understanding checks, signed confirmation and card issuance in new-staff induction.
Stated by Durham Prison -
Action
Reinforce the Emergency Code Protocol through staff meetings, management briefings, notices, email, intranet publication and line-manager cascades.
Stated by Durham Prison
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Concerns raised1
Failure to immediately establish responsibility for calling an ambulance
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
Lack of written guidance on when to summon an ambulance
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.
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 of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Unavailability of an emergency code protocol for calling an ambulance
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.
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
Responsibility for establishing the prison’s emergency medical response code protocol rests with the Prison Service, specifically HMP Dartmoor’s Governor.
Stated by Dorset Healthcare University NHS Foundation Trust
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Concerns raised1
Delays in summoning ambulances after emergency medical codes are broadcast
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.1
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Action
Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.
Stated by Frankland Prison
Data last updated 7 September 2026