Inappropriate Emergency Call Transfers
Non-clinical staff inappropriately transferring emergency calls without clear inter-service criteria, leading to delays or misdirection.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
William Nute
The coroner noted concerns regarding delays in Mr Nute's ambulance attendance and transfer, inappropriate 999 call triage, and insufficient communication to police about a road traffic accident, leading to poor scene management.
Matched on
terms: call, inappropriate, transfer
HSSIB recommendation
82match
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service reviews and implements changes to current communication methods between staff at the scene of an incident and the ambulance service call centre. This is to ensure that situational information about the patient is passed directly from the scene to the call handlers, meaning faster and more accurate triage and categorisation...
Matched on
terms: call, emergency
PFD report
81match
Millie Elizabeth Thompson
The coroner raised concerns about insufficient paediatric first aid training among nursery staff and expired certifications. Issues were also identified with an ambulance call-taker's misinterpretation leading to incorrect triage, and a lack of suitable paediatric life-saving equipment in emergency ambulances.
Matched on
terms: call, emergency
PFD report
81match
Luke Ayres
The coroner noted that ward staff did not directly call 999, risking call disconnections during transfers, and that staff providing information to ambulance services might lack up-to-date patient status. Additionally, there was no one immediately available to escort paramedics upon their arrival at reception, causing delay.
Matched on
terms: call, transfer
PFD report
81match
William Moody
The current 999 call system in Hampshire creates delays and confusion for those seeking help during a mental health crisis at home, due to unclear emergency service roles and a lack of effective triage and information sharing between agencies.
Matched on
terms: call, emergency
PFD report
77match
Joshua Smith
The coroner identified deficiencies in the emergency response, including a delay in immediately alerting police, difficulties in identifying the caller's location, and a lack of clear command, control, and coordination, noting that JESIP was not followed.
Matched on
terms: call, emergency
IOPC learning recommendation
77match
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review measures to be taken by control room staff in instances where emergency calls to third parties such as West Midlands Ambulance Service (WMAS) are placed on hold for a significant amount of time. These measures may include a second call being made to 999 by control room staff,...
Matched on
terms: call, emergency
PFD report
73match
Ronald Volante
The coroner raised concerns regarding the induction training for call handlers at Magenta Living Support Link, specifically on using a client's medical history and communicating changes in their presentation to emergency services. The report indicates a need to revisit the training manual and methods for call handlers.
Matched on
terms: call, emergency
PFD report
73match
Patricia Mercieca
The coroner highlighted gaps in call handler training concerning contacting resident managers after medical emergencies and the process for sharing information with other agencies. Protocols for escalating non-responses from emergency call system users also require attention.
Matched on
terms: call, emergency
PFD report
73match
David Lee
The coroner noted concerns regarding the inappropriate termination of a call, which prevented the escalation of urgent medical assistance. There was a lack of adherence to existing call termination guidance and no subsequent staff training has been provided.
Matched on
terms: call, inappropriate
PFD report
73match
Mark Banks
The coroner identified failures in contacting the ambulance service, recording the request, and correctly grading an emergency call. There were also insufficient efforts to search for and check on Mr. Banks' wellbeing at the scene.
Matched on
terms: call, emergency
PFD report
73match
Matthew Lewis
The coroner noted confusion among emergency responders regarding call handler instructions, which appeared inconsistent with the primary duty to preserve life. Clearer guidance and training for call handlers are needed to ensure effective responses in hanging incidents.
Matched on
terms: call, emergency
PFD report
73match
Robert Cobbina
The coroner noted that emergency call handlers did not prompt callers reporting a person in the river to request coastguard assistance or provide location references from signage, potentially delaying the arrival of appropriate assets.
Matched on
terms: call, emergency
IOPC learning recommendation
73match
Recommendations - Metropolitan Police Service, January 2026
The IOPC recommends that the Metropolitan Police Service (MPS) creates Memorandums of Understanding (MOU) with neighbouring forces to support effective management of cross border incidents and misrouted calls. This recommendation has arisen as a result of a review of the MPS's handling of a complaint. Three MPS call handlers followed force policy when refusing to transfer the complainant's...
Matched on
terms: call, transfer
CJINI report
70match
Answering the Call – An inspection of the Police Service of Northern Ireland Contact Management Arrangements
Matched on
terms: call
PFD report
69match
Gary Million
The coroner identified inadequate training and procedures for 111 and ambulance dispatch staff when locating callers with incomplete address details, leading to significant delays. The North East Ambulance Trust's investigation and new protocols were deemed insufficient, with no robust policy or specific training implemented eight months after the death.
Matched on
terms: call
PFD report
69match
Christopher Smith
A 12-minute delay occurred in police contacting the ambulance service due to a communication breakdown between Greater Manchester Police and Motorway Control. The coroner identified a need for a clear procedure to immediately establish who is responsible for calling an ambulance.
Matched on
terms: call
PFD report
69match
Diane Greenslade
The coroner identified issues with the initial emergency call categorisation, the lack of escalation or welfare check when contact failed, and a nearby rapid response vehicle being unavailable due to it being ring-fenced.
Matched on
terms: call, emergency
PFD report
69match
Graham Smith
The emergency call handling system lacks the capacity to link repeat calls for the same patient at the same address, meaning there is no senior review or 'red flag' warning to alert attending crews to heightened concern.
Matched on
terms: call, emergency
PFD report
69match
Paul Mclean
The coroner raised concerns about seizure call scripting, specifically regarding how fitting duration is determined for call upgrades and the immediate prioritisation for patients not maintaining airways. Insufficient pathways for updating prison healthcare on call changes and for dialogue between hospital emergency departments and WAST on call categorisation were also noted.
Matched on
terms: call, emergency
IOPC learning recommendation
69match
Recommendation - Cheshire Constabulary, December 2022
The IOPC recommends that Cheshire Constabulary should ensure that the procedures for call handlers to escalate incidents are set out clearly in force policy. This follows an IOPC review of a Serious Injury investigation, where a man took an overdose following several calls to the police expressing concern for his welfare, over a number of hours. A local...
Matched on
terms: call
PPO recommendation
68match
The Governor
The Governor should ensure that when staff call a medical emergency code, they promptly provide information about a prisoner’s condition to the control room so that they can pass this information to the Ambulance Service.
Matched on
terms: call, emergency
PHSO casework decision
68match
P-003271 - London Ambulance Service NHS Trust
Miss T complained the Trust incorrectly categorised her son's emergency calls, causing ambulance delays. She believed earlier arrival could have prevented cardiac arrest and saved his life.
Matched on
terms: call, emergency
PFD report
65match
Clive Gould
The coroner raised concerns regarding the ambulance service's call priority allocation, which led to diversions, and insufficient system resilience, particularly in rural areas. Additionally, communication with callers about estimated arrival times and potential delays was identified as needing review.
Matched on
terms: call
PFD report
65match
Mrs Withers
The coroner raised concerns about ambulance service policies on obtaining and saving patient medical history, call-back procedures for unresponsive patients, and staff abstraction levels. Further issues were noted regarding time loss during ambulance handovers to hospital A&E.
Matched on
terms: call
PFD report
65match
Richard Barrett
The coroner noted an underestimation of ambulance demand and insufficient ambulances, exacerbated by unrealistic A&E turnaround times leading to significant delays. Concerns were also raised about the unreliable system for welfare calls and the lack of engagement with police for welfare checks.
Matched on
terms: call
PFD report
65match
Gladys Furnival
The coroner noted a lack of provision for the ambulance service to utilise other emergency services for assistance or updates during significant delays when no personnel were on scene.
Matched on
terms: emergency
PFD report
65match
Christina Lawal
The coroner noted the absence of a cordless phone at Duncan Court, delaying a 999 call. Concerns were also raised regarding the London Ambulance Service's triage system, which relies on the caller being with the patient to provide accurate, real-time information.
Matched on
terms: call
PPO recommendation
64match
The Governor of HMP Belmarsh
The Governor should write to the Ombudsman, setting out what improvements have been made to ensure that: • control room staff call an ambulance immediately and provide all possible information required, remaining on the line until an ambulance is dispatched; and; • there are no delays in escorting ambulance and paramedics in an emergency.
Matched on
terms: call, emergency
PHSO casework decision
64match
P-002601 - South Central Ambulance Service NHS Foundation Trust
Mrs T complained the Ambulance Service delayed and mishandled her father's emergency call, causing a slow ambulance arrival and resulting in him dying alone.
Matched on
terms: call, emergency
IOPC learning recommendation
63match
Recommendations - Essex Police, September 2019
The IOPC investigated a complaint relating to the information given by call handlers in the force control room (FCR) to callers. Essex Police procedure on responding to incidents states that, for emergency graded incidents, callers should be given an estimated time of arrival (ETA). However, this complaint related to a call which was graded as ‘significant’. The policy...
Matched on
terms: call, emergency
PHSO casework decision
63match
P-001290 - West Midlands Ambulance Service University NHS Foundation Trust
Mrs C complained about the poor handling of 999 calls for her son, Mr B, alleging incorrect categorization, insufficient information, and inappropriate staff comments, delaying paramedics.
Matched on
terms: call, inappropriate
PFD report
61match
Toni Skillington
The Medical Priority Dispatch System does not include methadone as an overdose drug choice or ask if a patient is alone. There were also concerns about a three-hour delay in paramedic response to an overdose call and a lack of appropriate follow-up after failed welfare checks.
Matched on
terms: call
PFD report
61match
Adil Habib
Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.
Matched on
terms: call
PFD report
61match
Christopher Fields
The coroner identified issues with police decision-making in leaving a vulnerable person before an ambulance arrived. Concerns also included a significant ambulance response delay and the inadequacy of call coding algorithms to assign a Red response for critical injuries.
Matched on
terms: call
PFD report
61match
Colin Sluman
The coroner identified that the NHS Pathways protocol for ambulance call handlers does not include "dizziness" and "patient on their own" as rapid response triggers for catastrophic haemorrhage. There are also insufficient clinically trained call handlers and a lack of clinical supervisors available for advice and oversight.
Matched on
terms: call
PFD report
61match
Derek Dudley
The Telecare service lacked a protocol for informing emergency contacts, allowed unsupervised trainee operators, and provided insufficient structured information to assess service users after alarm activation.
Matched on
terms: emergency
PFD report
61match
Olive Nutt
The LAS failed to properly record the deceased's symptoms, resulting in an incorrect priority decision and delayed attendance. Additionally, the LAS did not adhere to its own guidelines for returning a call to gather further medical details.
Matched on
terms: call
PFD report
61match
Susan Longden
The NHS Pathways algorithm lacks a question regarding recent surgical procedures for patients reporting severe abdominal pain. There is also insufficient emphasis on speaking directly with the patient when a non-patient makes the NHS 111 call.
Matched on
terms: call
PFD report
61match
Olive Johnson
The coroner identified concerns regarding the non-deployment of first responders and EMAS exceeding response targets. The report also notes issues with how call regrading affects response time calculations and the adequacy of conveying resources.
Matched on
terms: call
PFD report
61match
Aidan Ridley
The coroner identified concerns regarding a police call handler's advice not to turn a person over and their inadequate guidance to seek ambulance service advice. The report also notes insufficient training and supervision for call handlers.
Matched on
terms: call
PHSO casework decision
61match
P-001421 - North West Ambulance Service NHS Trust
Mrs O complained the 999 call for her father was incorrectly triaged, an ambulance was not sent, and inaccurate information about arrival times was given, potentially delaying treatment and contributing to his death.
Matched on
terms: call
PHSO casework decision
61match
P-003783 - South East Coast Ambulance Service NHS Foundation Trust
Mrs V complained the Ambulance Trust completed a welfare call instead of arranging an ambulance for her mother, delaying treatment and contributing to her death.
Matched on
terms: call
IOPC learning recommendation
60match
Recommendation - Avon and Somerset Constabulary, June 2025
The IOPC recommends that Avon and Somerset Constabulary should put in place a process to ensure the control room telephone number is displayed to callers during a threat-to-life incident or a voice message is left enabling them to call back if their initial call is missed. This recommendation follows a review where Avon and Somerset Constabulary received a...
Matched on
terms: call, emergency
PPO recommendation
60match
The Director at Parc
The Director at Parc should ensure that control room staff call an ambulance immediately they receive a medical emergency code.
Matched on
terms: call, emergency
PPO recommendation
60match
The Director and Head of Healthcare
control room staff call for an ambulance immediately when a medical emergency code is called
Matched on
terms: call, emergency
PHSO casework decision
59match
P-004067 - East of England Ambulance Service NHS Trust
Mr L complained that his friend's 999 call was triaged incorrectly and an ambulance delay occurred, and that the ambulance crew refused to take his wheelchair during a hospital transfer.
Matched on
terms: call, transfer
PFD report
57match
Gianna Khan
A patient presenting with a head injury was streamed to a GP clinic instead of the Emergency Department, contrary to medical advice that all suspected head injuries should be referred to the A&E Team.
Matched on
terms: emergency
PFD report
57match
Samia Shara
The coroner identified that long, complex 999 and 111 calls were not available for audit by the CCG to improve outcomes. Concerns were also raised about call takers being able to downgrade calls to a lower acuity pathway.
Matched on
terms: call
PFD report
57match
Lisa Day
Alternative hospital transport options were not discussed with the friend who called 111, and the potentially grave consequences of a vomiting illness in a person with diabetes were not explained to him.
Matched on
terms: call