Includes failures of dedicated audit, quality-assurance or review controls for emergency call handling, including audits of emergency service calls or Clinical Advisor calls, where required audit volumes, frequency, coverage, follow-up or use for identifying safety risks are not achieved.
What is not included
Excludes generic care, clinical-record or organisational auditing deficiencies that are not specifically tied to emergency call handling.
Excludes failures in the substantive triage, advice, welfare-call or escalation process when no deficiency in auditing or assurance is identified.
Excludes generic staffing, training or governance deficiencies unless they directly impair the dedicated auditing of emergency call handling.
Excludes auditing of unrelated processes, including home leave, medication education, equipment checks or non-emergency communications.
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.
NHS England3
Association of Ambulance Chief Executives2
NHS West and North London Integrated Care Board2
South East Coast Ambulance Service NHS Foundation Trust2
Advanced Health And Care Limited1
Appello Careline Limited1
Bausch & Lomb U.K. Limited1
Care Quality Commission1
Department of Health and Social Care1
London Ambulance Service NHS Trust1
London Central & West Unscheduled Care Collaborative Limited1
Medicines and Healthcare products Regulatory Agency1
National Institute for Health and Care Excellence1
NHS Enfield Clinical Commissioning Group1
Sister of Kala Skinner1
NHS trust4
Executive non-departmental public body3
Health-sector membership body2
Integrated care board2
Private limited company2
Clinical commissioning group1
Health and social care service regulator1
Healthcare site1
Independent healthcare provider1
Medicines and medical devices regulator1
Ministerial department1
Professional membership body1
Type not available1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
West Sussex, Brighton and Hove
Concerns raised1
Inadequate quality of the call auditing system
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Appello Careline Limited
Association of Ambulance Chief Executives
NHS England
South East Coast Ambulance Service NHS Foundation Trust
TSA
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
South East Coast Ambulance Service NHS Foundation Trust
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
South East Coast Ambulance Service NHS Foundation Trust
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
Appello Careline Limited
Reinforce information capture and communication through continuing operator training, call audits, supervision and operational reviews.
TSA
Strengthen QSF criteria for certified TEC monitoring organisations to improve call monitoring and emergency response quality.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
South East Coast Ambulance Service NHS Foundation Trust
NHS Pathways owns the national audit framework, so reviewing documentation weighting is its responsibility.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Association of Ambulance Chief Executives
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
TSA
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure of 111 call audits to identify all significant call-handling failings
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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.1
NHS England
Develop and apply an audit framework for NHS Pathways providers, including audit standards, frequencies, qualifications and training requirements.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
Providers are responsible for operating the audit system and managing failed call audits within NHS Digital’s framework.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex
Concerns raised1
Failure to audit the required number of calls
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
South East Coast Ambulance Service 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
South East Coast Ambulance Service NHS Foundation Trust
Provide dedicated, time-protected staffing for NHS Pathways audits.
South East Coast Ambulance Service NHS Foundation Trust
Introduce reporting and recording systems to monitor NHS Pathways audit performance.
South East Coast Ambulance Service NHS Foundation Trust
Introduce technology-based solutions to streamline the NHS Pathways audit process.
South East Coast Ambulance Service NHS Foundation Trust
Provide additional staff training to support the NHS Pathways audit function.
Avon
Concerns raised1
Failure to audit at least 3% of Clinical Advisor calls every month
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner West London
Concerns raised1
Lack of auditability of long and complex 999 and 111 calls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.