Recurring concern
Unreliable ambulance-service computer systems for safety-critical information
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Request correctionFirst reported 30 Oct 2013•Latest report 27 Jan 2020
What this concern includes
Includes failures of ambulance-service computer programmes and integrated call-handling systems that fail to account for, synchronise, update, display or otherwise make safety-critical clinical or operational information available for emergency response decisions.
Not included
- Excludes failures of ambulance dispatch capacity, call triage or clinical judgement where no computer-system deficiency is identified.
- Excludes generic electronic patient-record or hospital information-system failures not specifically tied to ambulance-service computer systems.
- Excludes failures limited to transferring information between ambulance services or between ambulance crews and other organisations when the ambulance computer system itself is not deficient.
- Excludes generic IT access, staffing, training or communication deficiencies unless they directly impair the safety-critical operation of an ambulance-service computer system.
- Reports
- 6
- Individual concerns
- 6
- Date range
- 2013–2020
- Stated actions
- 8
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
Failure of the Adastra system to update location information across screens in real time
This report raised 20 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
Deploy a software update warning users when a second user opens the same case and address details may be out of date.
Stated by Advanced -
Action
Save consultation address changes immediately so they are contemporaneously available to other users on other screens.
Stated by Advanced
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
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Stated by NHS England
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Concerns raised1
Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
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
Consult other ambulance trusts to share best practices and solutions for recording and transmitting patient disposition information.
Stated by East of England Ambulance Service NHS Trust -
Action
Draft and issue dispatch instructions specifying pertinent information, including NHS 111 disposition descriptions, for transmission to attending resources.
Stated by East of England Ambulance Service NHS 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
The organisation is not constituted to mandate or instruct individual ambulance services on local information-sharing processes.
Stated by Association of Ambulance Chief Executives
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Concerns raised1
Lack of a system for using linked repeat-call information to provide patient safety-netting
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
Existing CAT access to prior attendances, summary care records and local GP records enables informed onward-referral or safe-at-home decisions.
Stated by East Midlands Ambulance Service NHS Trust
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Concerns raised1
Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
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
Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.
Stated by NHS England -
Action
Trial a new ambulance coding system.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.
Stated by North West Ambulance Service NHS Trust
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Position
The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.
Stated by Department of Health and Social Care -
Position
Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.
Stated by Department of Health and Social Care -
Position
The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.
Stated by NHS England
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Concerns raised1
Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons
This report raised 5 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
Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.
Stated by London Ambulance Service NHS Trust -
Action
Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.
Stated by London Ambulance Service NHS Trust
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Concerns raised1
Failure of the ambulance service computer programme to take account of critical clinical information
This report raised 1 other concern. 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.
Data last updated 7 September 2026