Recurring concern
Unreliable Medical Priority Dispatch System emergency assessment and advice pathways
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Request correctionFirst reported 31 Jul 2014•Latest report 10 Oct 2025
What this concern includes
Includes failures of the named MPDS system and its dedicated operational controls, including incomplete or unsuitable protocols, omitted clinical choices, unclear questioning requirements, failure to follow the appropriate pathway and inadequate assurance that MPDS-based assessment or advice remains fit for purpose.
Not included
- Excludes general ambulance resource shortages, dispatch delays or hospital handover failures when the MPDS assessment or advice system is not itself deficient.
- Excludes generic call-handler training or human-error concerns that are not specifically tied to operating or following an MPDS pathway.
- Excludes downstream clinical treatment or ambulance response failures after MPDS assessment and advice have been completed.
- Excludes non-MPDS telephone triage, referral and call-handling processes unless the report explicitly identifies the same MPDS system.
- Reports
- 8
- Individual concerns
- 10
- Date range
- 2014–2025
- 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 emergency dispatch questioning to establish availability of tracheostomy suction equipment and a capable person
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.
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Concerns raised1
Failure of the MPDS system to remain fit for purpose for response prioritisation
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
Embed new clinical roles in control rooms to triage 999 calls earlier and support better care decisions.
Stated by Welsh Ambulance Services NHS Trust -
Action
Use the deployed Emergency Communication Nurse System and Call Priority Streaming System to support the Trust’s clinical and call-prioritisation strategy.
Stated by Welsh Ambulance Services NHS Trust
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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Position
Developing an alternative call-prioritisation system would require significant in-house work beyond the Trust’s capacity and capability.
Stated by Welsh Ambulance Services NHS Trust
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Position
MPDS remains the best available call-prioritisation product for the Trust, supported by linked ECNS and CPSS systems.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Failure of handlers to follow the appropriate MPDS pathway for providing clinically beneficial advice
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.4
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Action
Complete a focused audit of protocol 21 calls and Post-Dispatch Instructions.
Stated by Welsh Ambulance Services NHS Trust -
Action
Issue all call handlers a reminder about correctly using Post-Dispatch Instructions.
Stated by Welsh Ambulance Services NHS Trust -
Action
Undertake a further targeted audit of protocol 21 calls to verify correct delivery of Post-Dispatch Instructions.
Stated by Welsh Ambulance Services NHS Trust
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Action
Undertake improvement actions identified through the further targeted audit.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Lack of MPDS support for clearing the mouth and nose during alcohol intoxication
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.
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Concerns raised2
Failure of the asthma triage script to require direct questioning about ineffective breathing
Failure of the MPDS algorithm to account for the cumulative effect of multiple symptoms
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.
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
Review progress on ineffective-breathing improvement actions through monthly commissioner-led clinical quality assurance meetings.
Stated by NHS Lancashire and South Cumbria Integrated Care Board -
Action
Hold a learning event for ambulance services and triage-system providers to share best practice on safely identifying ineffective breathing.
Stated by NHS England
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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Position
NWAS, not commissioners, decides which clinical decision-support tool operates in the 999 environment; response categories are nationally determined.
Stated by NHS Lancashire and South Cumbria Integrated Care Board
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Position
As of January 2021, NWAS was not a national outlier in recognising ineffective breathing and performed similarly to other ambulance services.
Stated by NHS Lancashire and South Cumbria Integrated Care Board -
Position
When used correctly, the MPDS algorithm identifies life-threatening asthma and results in a Category 1 response.
Stated by NHS England
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Concerns raised1
Omission of chest-pain questions from the breathing-difficulties dispatch card
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.2
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Position
AMPDS users must ask Priority Dispatch directly to review and change the system’s call-handling questions.
Stated by Department of Health and Social Care
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Position
The Department cannot provide further help implementing the proposed AMPDS call-handling changes.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to use a clear method for establishing whether a patient is conscious or unconscious
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure of MPDS to ask whether an overdose patient is alone
Failure to include methadone among MPDS drug choices following an overdose
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026