Includes failures in the dedicated hospital pre-alert process, including deciding when a pre-alert is required, assigning responsibility for making it, conveying relevant clinical information to the hospital and auditing or assuring the system's effectiveness.
What is not included
Excludes general ambulance, referral or clinical communication failures where no hospital pre-alert process is identified.
Excludes failures in hospital assessment, treatment or handover after the pre-alert has been reliably made and received.
Excludes generic audit, training or accountability deficiencies unless they directly impair the hospital pre-alert process.
Excludes routine notifications that do not function as a pre-alert for a seriously unwell patient.
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.
Ambulnz Community Partners Ltd.1
Department of Health and Social Care1
Dinnington Group Practice1
Kent Central Ambulance Service Ltd1
London Ambulance Service NHS Trust1
Northern Care Alliance NHS Foundation Trust1
North West Ambulance Service NHS Trust1
Welsh Ambulance Services NHS Trust1
Whittington Health NHS Trust1
Yorkshire Ambulance Service NHS Trust1
NHS trust4
Independent healthcare provider2
Healthcare site1
Ministerial department1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
North East Kent
Concerns raised1
Lack of clarity about responsibility for making pre-alert calls to hospital
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Kent Central Ambulance Service Ltd
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
Kent Central Ambulance Service Ltd
Mandate internal clinical escalation through the Clinical Support Line and empower crews to pre-alert hospitals independently when concerned or uncertain.
Kent Central Ambulance Service Ltd
Deliver refresher training for all crews on hospital pre-alert criteria and documentation.
Kent Central Ambulance Service Ltd
Create and distribute a Medical Operational Plan for every event, covering staffing, response structure, communications and escalation pathways.
Kent Central Ambulance Service Ltd
Distribute an event-readiness checklist covering equipment, clinical signs, contacts, escalation, hospital pre-alerts and documentation.
North Wales (East and Central)
Concerns raised1
Failure to require pre-alerts for suspected sepsis in life-threatening time-critical situations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Welsh Ambulance Services NHS 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
Welsh Ambulance Services NHS Trust
Implement pre-alert guidance for suspected sepsis, developed with Welsh Health Board clinical directors and the Royal College of Emergency Medicine Wales.
Welsh Ambulance Services NHS Trust
Deliver mandatory training and a national education session to help emergency medical services staff recognise sepsis red flags and use pre-alerts.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Welsh Ambulance Services NHS Trust
An exhaustive mandatory pre-alert policy is not feasible because clinical circumstances are too complex for an all-encompassing list.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to include pregnancy information in pre-hospital alerts
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
London Ambulance Service NHS Trust
Whittington Health NHS 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.6
London Ambulance Service NHS Trust
Complete an EOC observation session for the crew to support learning from the incident.
London Ambulance Service NHS Trust
Review the crew’s learning from the EOC observation and confirm use of a structured information-sharing and handover approach.
London Ambulance Service NHS Trust
Update pre-alert guidance to require the EOC to ask for other specific and critical information during information read-back.
London Ambulance Service NHS Trust
Make operational staff aware of the updated pre-alert guidance.
London Ambulance Service NHS Trust
Update joint maternity training to include EOC staff alongside operational, midwifery and maternity support staff.
Whittington Health NHS Trust
Replace the Emergency Department priority-call information sheet with a version prompting staff to ask whether a relevant patient is pregnant.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
London Ambulance Service NHS Trust
The failure to communicate pregnancy information involved both the crew and emergency operations centre, not the emergency operations centre alone.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised2
Absence of systems to audit the effectiveness and reliability of the pre-alert system
Lack of staff knowledge and training for reliable actioning of pre-alert requests
This report raised 6 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.
Manchester South
Concerns raised1
Lack of clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
North West Ambulance Service NHS 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.1
Department of Health and Social Care
Write to the Health and Safety Executive to bring the case to its attention regarding independent ambulance-service access to receiving emergency departments.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Department of Health and Social Care
Local meetings among the ambulance provider, receiving Trust and ambulance service are considered sufficient to prevent a similar incident.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
Licensing and medical-cover arrangements at public events are the responsibility of local authorities.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Amending the Purple Guide to specify independent ambulance access arrangements is ultimately for the HSE to decide.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North West Ambulance Service NHS Trust
NWAS should not and cannot act as gatekeeper for NHS hospital standby numbers.
Outside remitThe respondent said that this matter was outside its role or authority.
North West Ambulance Service NHS Trust
Hospitals and private ambulance providers must determine whether hospital standby numbers are shared.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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.