First reported 1 Apr 2014•Latest report 23 Mar 2026
Definition
What this concern includes
Includes failures of controls dedicated to grading emergency incidents, defining or communicating response-time requirements, and coordinating police and ambulance dispatch functions where inconsistent understanding can delay or misdirect emergency attendance.
Not included
Excludes general emergency-service staffing, resource or attendance delays where no failure in incident grading, response-time requirements or dispatch coordination is identified.
Excludes failures confined to ambulance call triage or police incident allocation when the response-time coordination or cross-service understanding issue is not material.
Excludes generic training, communication or policy deficiencies that are not directly tied to emergency-service incident grading or response-time coordination.
Reports
8
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
18
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.
NHS England2
Association of Ambulance Chief Executives1
Department of Health and Social Care1
East Midlands Ambulance Service NHS Trust1
East of England Ambulance Service NHS Trust1
Essex Police1
HM Prison and Probation Service1
Independent Office for Police Conduct1
Isle of Wight NHS Trust1
Lancashire Constabulary1
Ministry of Justice1
Northumbria Police1
Nottinghamshire Healthcare NHS Foundation Trust1
Ofcom1
Recipient name withheld1
NHS trust5
Police force4
Executive non-departmental public body2
Ministerial department2
Economic regulator1
Executive agency1
Health-sector membership body1
Police oversight body1
Type not available1
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.
Teesside and Hartlepool
Concerns raised1
Lack of an immediate-response category for patients who require urgent ambulance attendance but do not meet Category 1 criteria
Responses linked to these concerns
Each 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
Action
Implement national ambulance response standards to prioritise the sickest patients and provide appropriate responses.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing Category 1 and 2 ambulance categorisations are sufficient for effective triage and timely intervention for life-threatening and emergency conditions.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Development of 999 triage question sets and instructions is assigned to the approved triage system provider.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Whether call handlers stay on the line with deteriorating patients is an operational decision for each ambulance service.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Implement a standalone procedure for suspected or confirmed Acute Behavioural Disturbance, removing “excited delirium” terminology and requiring Category 1 escalation with clinical review for possible downgrade.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 February 2026.
Action
Update, approve and disseminate the detained-patient procedure and Emergency Operations Centre escalation guidance to reflect the Acute Behavioural Disturbance procedure.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
National ambulance response categories are determined by NHS England’s ECPAG, not by AACE.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Hampshire, Portsmouth and Southampton
Concerns raised1
Insufficient understanding of Category 1 response criteria for hanging incidents
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 concerns
Each 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
Action
Request national review of whether Category 1 disposition is appropriate for patients threatening to hang themselves.
Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Deliver mandatory refresher training and updated materials on suicidal-patient call management, escalation, response categories, information gathering, and risk assessment.
Stated by Isle of Wight NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Action
Continue working with national bodies to strengthen guidance and NHS Pathways for risks involving suicidal patients and potential hanging.
Stated by Isle of Wight NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
National NHS Pathways bodies are responsible for deciding whether Category 1 responses are appropriate for potential hanging incidents.
Stated by Isle of Wight NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Issue overdose and suicidal-intent guidance requiring further clinical intervention or automatic response upgrades and TOXBASE review for overdose incidents.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Update overdose guidance to include callers receiving a Category 5 disposition.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Develop specific training and a protocol for first-party callers in crisis.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Ingestion of a potentially fatal substance does not, by itself, justify assigning a Category 1 ambulance response.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing overdose protocols, intentional-overdose coding and clinical oversight enable appropriate prioritisation regardless of the substance ingested.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The relevant ambulance Emergency Operation Centre, including EMAS in this case, determines and applies the local response category.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Listing every potentially fatal substance for dispatcher-led response assignment is impractical and risks dangerous over-triage because caller information may be unreliable.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing intentional-overdose coding and clinician review are considered sufficient; listing every potentially fatal agent would cause over-triage and delays.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Insufficient understanding between police and ambulance dispatch functions of each other’s triaging, dispatching processes and response times
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 concerns
Each 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.7
Action
Add NHS Pathways and response-time input from SECambs Clinical Operations to the online Mental Health training package.
Stated by Surrey PoliceStated plannedThe respondent said that this action was planned when they made their response on 16 April 2020.
Action
Train Contact Centre and Force Control Room staff on NHS Pathways, ambulance response categories, response times and surge arrangements.
Stated by Surrey PoliceStated completedThe respondent said that this action was complete when they made their response on 16 April 2020.
Action
Conduct staff exchanges between Surrey Police and SECambs contact and dispatch functions.
Stated by Surrey PoliceStated completedThe respondent said that this action was complete when they made their response on 16 April 2020.
Action
Prepare and distribute partner-organisation guidance on ambulance call categorisations and response targets.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2020.
Action
Create and disseminate guidance explaining the Surge Management Plan, call prioritisation, response targets, triggers and resulting actions.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2020.
Action
Notify police force control rooms by email when Surge Management Plan thresholds indicate substantial risk of missing target response times.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2020.
Action
Review the Surge Management Plan with the three local police forces to discuss joint actions and opportunities for closer control-room collaboration.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The first matter of concern concerns Surrey Police alone and is outside the respondent’s remit.
Stated by South East Coast Ambulance Service NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing EOC procedures and clinical oversight make staff knowledge of police dispatching processes sufficient for safe, appropriate functions.
Stated by South East Coast Ambulance Service NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Each police force is responsible for internally cascading the respondent’s ambulance processes and response information to relevant personnel.
Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Lancashire and Blackburn with Darwen
Concerns raised1
Deficiencies in initial grading of calls to identify initial responses
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Lincolnshire
Concerns raised2
Failure to include time from the initial call to regrading in response-time measurement
Failure to meet response times
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 concerns
Each 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
Action
Agree contract terms securing additional investment for clinical staff, ambulances and other response resources.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
Action
Invest additional funding in clinical staff, ambulances and other resources to improve ambulance response times and consistency.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The response clock for re-categorised calls starts at regrading because this timing was decided from a national perspective.
Stated by East Midlands Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gateshead and South Tyneside
Concerns raised1
Lack of clear training and understanding of graded-incident response times
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls dedicated to grading emergency incidents, defining or communicating response-time requirements, and coordinating police and ambulance dispatch functions where inconsistent understanding can delay or misdirect emergency attendance.
