First reported 10 Nov 2017•Latest report 5 Jan 2026
Definition
What this concern includes
Includes failures to obtain, record, check or transfer clinical findings, referral dispositions, admission arrangements and other patient-specific information needed by ambulance crews, control rooms or specialist ambulance functions.
Not included
Generic ambulance communication not carrying patient-specific safety information
Hospital handover failures after the ambulance-service transfer has operated reliably
Address-only or administrative information with no material bearing on patient response, conveyance or care
Failure of a named information system where the system itself is the supported unsafe control
Reports
6
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2017–2026
First to latest report issue date
Stated actions
21
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.
East Midlands Ambulance Service NHS Trust2
NHS England2
Department of Health and Social Care1
East of England Ambulance Service NHS Trust1
London Ambulance Service NHS Trust1
London's Air Ambulance1
NEMS Community Benefit Services Limited1
NHS Nottingham and Nottinghamshire Integrated Care Board1
North East Ambulance Service NHS Foundation Trust1
South Central Ambulance Service NHS Foundation Trust1
University Hospitals of Northamptonshire NHS Group1
Yorkshire Ambulance Service NHS Trust1
NHS trust6
Executive non-departmental public body2
Company limited by guarantee1
Integrated care board1
Ministerial department1
NHS provider group1
Registered charity1
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.
Nottinghamshire
Concerns raised1
Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service
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 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
Review transferred EMAS cases, monitor monthly UCCH themes, escalate risks and participate in joint governance and After Action Reviews.
Stated by NEMS Community Benefit ServicesStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2026.
Action
Improve CAD-to-Adastra transfer formatting, structure, legibility and visibility of prior NHS 111 clinical validation with system partners.
Stated by NEMS Community Benefit ServicesStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2026.
Action
Implement BaRS in Adastra and migrate CAS and Out of Hours profiles from legacy ITK with required system configuration.
Stated by NEMS Community Benefit ServicesStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2026.
Action
Review whether internal NEMS risk flags are needed when duplicated or poorly formatted information obscures clinical clarity.
Stated by NEMS Community Benefit ServicesStated plannedThe respondent said that this action was planned when they made their response on 8 January 2026.
Action
Develop a technological solution with partner organisations to transfer complete patient information across urgent care services.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Upgrade the CAD system to automatically transmit 999-call information to receiving systems and support comprehensive referral information.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Require clinicians to review available information and make all Category 3 transfers through the clinical push model.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Many technical solutions for reliable information transfer are outside NEMS’s direct control, limiting its ability to implement them independently.
Stated by NEMS Community Benefit ServicesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Concerns about the urgent care pathway, CAD information, Category 3 call handling and transfer criteria should be addressed by EMAS, NEMS and the ICB.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Northamptonshire
Concerns raised1
Failure to adequately record and accurately and completely convey symptom information
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
Use Siren to review ambulance pre-arrival patient information and reduce registration delays.
Stated by University Hospitals of Northamptonshire NHS GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Action
Introduce a NerveCentre pre-arrival screen using ambulance clinical histories to prepare handovers before arrival.
Stated by University Hospitals of Northamptonshire NHS GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The second call was upgraded because the patient’s condition deteriorated and accurate triage information became available.
Stated by South Central Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised2
Failure to convey accurate and relevant clinical information from scene paramedics to the HEMS desk
Failure of HEMS desk paramedics to request full clinical parameters
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.5
Action
Expand use of SBAR handovers when clinicians provide reports requesting additional specialist clinical support.
Stated by London Ambulance Service NHS Trust and London's Air AmbulanceStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Action
Prepare and issue a joint Medical Director’s bulletin explaining SBAR handover requirements, information content and practical application.
Stated by London Ambulance Service NHS Trust and London's Air AmbulanceStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
Action
Circulate the SBAR bulletin to LAS clinical staff, LAA paramedics and operations-centre clinical staff through email, intranet, devices and management communications.
Stated by London Ambulance Service NHS Trust and London's Air AmbulanceStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Action
Incorporate SBAR handover content into LAS Core Skills Refresher training and scenario-based education.
Stated by London Ambulance Service NHS Trust and London's Air AmbulanceStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Action
Update training for operations-centre clinicians receiving clinical information to prompt an SBAR handover when needed.
Stated by London Ambulance Service NHS Trust and London's Air AmbulanceStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
South Yorkshire (Western)
Concerns raised1
Failure to accurately transfer EPR information to patient information leaflets
This report raised 4 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.1
Action
Embed Patient Information Leaflet contents fully within the EPR.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust will not undertake patient-leaflet photo audits because of practical difficulties and concerns that advance notice would skew results.
Stated by Yorkshire Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Norfolk
Concerns raised1
Failure to communicate arranged admission-bed information to ambulance crews
This report raised 4 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
Work with the CAD supplier to alter call duplication so pertinent destination information transfers into the active call.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Action
Require dispatch staff to transfer pertinent information manually into new calls until the technological solution is available.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Share CAD information-recording and transmission best practice and solutions with other ambulance services.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Sunderland
Concerns raised1
Failure of dynamic risk assessments to facilitate ambulance crews requesting further information or clarification
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
Disseminate Joint Operating Procedure and dynamic-risk-assessment guidance through staff briefings, memoranda, meetings, face-to-face sessions, induction and operational assurance activities.
Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 February 2018.
Action
Produce and install vehicle dashboard stickers prompting dynamic risk assessment before requesting police support.
Stated by North East Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 February 2018.
Action
Provide operational staff with statutory and mandatory dynamic-risk-assessment, conflict-resolution and breakaway training.
Stated by North East Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 February 2018.
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Includes failures to obtain, record, check or transfer clinical findings, referral dispositions, admission arrangements and other patient-specific information needed by ambulance crews, control rooms or specialist ambulance functions.
