Recurring concern
Failure to ensure care staff can initiate appropriate emergency calls
- Reports that mention this concern
- 9
- Times this concern has been raised
- 9
- Stated actions linked to this concern
- 13
What this concern includes
Includes failures of training, competence, guidance or access arrangements that directly prevent care staff from recognising which emergency number to use or promptly initiating an appropriate 999 or 111 call.
What is not included
- Excludes ambulance or police dispatch, call-handler triage, response-time and hospital-handover failures after the emergency call has been initiated.
- Excludes CPR, choking treatment, clinical assessment or other first-aid competence failures unless they also directly impair the initiation of the emergency call.
- Excludes generic staff-training deficiencies without a direct connection to care staff initiating an appropriate emergency call.
- Excludes emergency calls made by patients, relatives or members of the public where care-staff capability is not the deficient control.
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 9 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
Failure to train staff to call emergency services immediately
This report raised 3 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.
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Concerns raised1
Lack of ward staff awareness of telephone restrictions affecting 111 calls
This report raised 13 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.
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Concerns raised1
Failure of staff to call emergency services for serious incidents
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Beech Cliffe Limited
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
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Beech Cliffe Limited
Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.
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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Beech Cliffe Limited
Staff were trained and authorised to contact doctors or emergency services directly, rather than being required to route medical issues through managers.
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Beech Cliffe Limited
The evidence did not establish that staff encountered or recognised a faecal-vomit emergency requiring an immediate ambulance call.
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Concerns raised1
Failure to train care staff in basic emergency call processes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Avery Healthcare Group
- Care Quality Commission
- NHS England
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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Avery Healthcare Group
Implement an additional action plan and timetable responding to the inquest findings.
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Avery Healthcare Group
Continue embedding all organisational policies and procedures at Aran Court.
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Care Quality Commission
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Avery Healthcare Group
The orientation checklist is considered sufficient to ensure staff understand telephone, nurse-call and emergency procedures.
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Care Quality Commission
Existing emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.
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NHS England
Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.
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Concerns raised1
Lack of staff knowledge about obtaining an outside telephone line to emergency services
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Independence Homes
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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Independence Homes
Remove the requirement to dial 9 for an outside telephone line.
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Independence Homes
Communicate the changed outside-line procedure to staff verbally, by email and in the communications book.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Independence Homes
Clear guidance on obtaining an outside telephone line was already provided at the time of the death.
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Concerns raised1
Failure of ward staff to call 999 directly
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Birmingham and Solihull Mental Health 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.2
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Birmingham and Solihull Mental Health NHS Foundation Trust
Replace Reaside Clinic’s telephony system with the Trust’s standard system.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Extend ward medical-emergency simulations to test ambulance-call connection and availability of patient information and observations.
-
Concerns raised1
Lack of staff training in appropriate use of 999 or 111
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- MERIDIAN HEALTHCARE LIMITED
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
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MERIDIAN HEALTHCARE LIMITED
Provide refresher training on the appropriate use of 999 and 111.
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Concerns raised1
Failure to ensure staff know to call an ambulance directly when required
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sunrise Senior Living UK
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
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Sunrise Senior Living UK
Communicate that the person discovering an incident must call emergency services when warranted, and embed this instruction in General Managers’ training for team members.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026