Inappropriate Emergency Call Transfers
Non-clinical staff inappropriately transferring emergency calls without clear inter-service criteria, leading to delays or misdirection.
Source spread
Where this theme appears
This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.
91 PFD reports
2 HSSIB recs
1 CQC action
12 PPO recs
10 IOPC recs
2 Scottish FAIs
40 PHSO decisions
1 LGO/SPSO decision
1 CJINI report
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(91)— showing 50 strongest matches
David Selman
Concerns: The coroner raises concerns about miscommunication between the control room and ambulance staff regarding instructions to 'stand down' versus 'stand back', and the lack of continual assessment of a patient's symptoms to ensure appropriate ambulance deployment.
Overdue
Millie Elizabeth Thompson
Concerns: 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.
Response (Edward Timpson MP): • The government published plans in July 2013 to improve childcare quality and availability. • A public consultation, 'The Regulation of Childcare,' was launched from July to September 2013, which … (AI summary)
Response (North West Ambulance Service NHS Trust): • The Trust maintains a robust and competitive recruitment process for Emergency Medical Dispatchers (EMDs) and continually reviews this process. • All EMDs complete a six-week training course that includes … (AI summary)
Response (Department of Health): • The Department reported that North West Ambulance Service emergency response vehicles are equipped with a range of paediatric emergency equipment. • The Department will share the Regulation 28 report … (AI summary)
Responded
Clive Gould
Concerns: 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.
Response (South Central Ambulance Service): • SCAS stated it was transitioning to the NHS Pathways system for call priority allocation, with completion expected by the end of autumn 2014. • Rapid Response Vehicle cover was … (AI summary)
Responded
Gianna Khan
Concerns: 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.
Response (Luton NHS Clinical Commissioning Group): • Children with head injuries, children conveyed by ambulance, and babies 6 months and under were immediately excluded from the streaming protocol. • These patient groups are now assessed and … (AI summary)
Responded
Gary Million
Concerns: 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.
Overdue
Toni Skillington
Concerns: 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.
Overdue
Sonielia Holmes
Concerns: The coroner raised concerns regarding the inability to contact the Haematology Department and a lack of response from haematologists to messages seeking advice or patient review, identifying this as a risk to patient lives.
Overdue
Mark Hudson
Concerns: The coroner raised concerns that urgent requests for specialist care within the CICU department may be delayed or unanswered. This is due to procedures for CICU staff requesting assistance via the Hospital Switchboard being insufficiently robust.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): • The Resuscitation Team undertook training with senior members of the Cardiac Intensive Care Unit team on iGel tube placement. • The Trust adopted a policy of using end tidal … (AI summary)
Responded
Samia Shara
Concerns: 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.
Overdue
Adil Habib
Response (HM Prison and Probation Service): • A DVD and accompanying training material on the safe use of force and medical complications of restraint have been completed. • The DVD includes medical advice on safe restraint … (AI summary)
Response (London Ambulance Service NHS Trust): • The London Ambulance Service (LAS) added the Roman Way gate address for HMP Pentonville to its Gazetteer with GPS information. • The LAS obtained a list of postal addresses … (AI summary)
Responded
Stuart Knight
Concerns: Significant delays occurred in despatching an ambulance to an unconscious patient who had clearly suffered a serious head injury.
Response (East Midlands Ambulance Service): • The service has invested in staff and vehicle resources, including recruitment, training, and fleet expansion since 2014. • It introduced the Paramedic Pathfinder tool, with 94% of staff trained … (AI summary)
Responded
Mrs Withers
Concerns: 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.
Overdue
Christopher Smith
Concerns: 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.
Overdue
Thomas Collins
Concerns: The coroner noted that the attending paramedic lacked the confidence required to make a clinical decision.
Response (North West Ambulance Service NHS Trust): • NWAS Paramedics perform a clinical assessment of patients and apply a clinical algorithm called 'Paramedic Pathfinder'. • NWAS has agreements with thirty Commissioning Groups (CCGs) to refer patients identified … (AI summary)
Response (Haughton Thornley Medical Centres): • The practice will ensure findings are clearly recorded and more information is obtained regarding the circumstances of a fall, particularly whether it was witnessed or unwitnessed. • The practice … (AI summary)
Responded
Ronald Volante
Concerns: 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.
Response (Magenta Living): • Magenta Living revised its procedures to ensure call handlers proactively share medical details with emergency services unless service users specifically advise otherwise. • Call handlers were briefed on a … (AI summary)
Responded
Lisa Day
Concerns: 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.
Response (Lisa Day Response2): • The London Ambulance Service (LAS) and NHS 111 agreed a process for 111 clinicians to alert LAS Emergency Operations Control about calls with clinical concerns. • An electronic flagging … (AI summary)
Response (Lisa Day): • London 111 providers agreed to amend the memorandum of understanding with London Ambulance Service to require clinicians to discuss self-conveyance options and risks with patients and callers during periods … (AI summary)
Responded
Luke Ayres
Concerns: 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.
Response (Birmingham and Solihull NHS Trust): • The Trust approved funding to replace the aged telephony system at Reaside Clinic, with work anticipated to commence in Quarter 3 of 2016. • The Trust decided to extend … (AI summary)
Responded
Mia Gibson
Concerns: The coroner identified an over-reliance on maternal observations in obstetric emergencies, potentially overlooking fetal distress, and noted significant ambulance resource delays due to meal break management and lack of 'open mic' reports.
Overdue
Christopher Fields
Concerns: 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.
Response (North West Ambulance Service NHS Trust): • The Trust has secured funding for 400 additional frontline staff and 60 new vehicles. • The Trust is exploring methods to minimise lengthy waits during periods of high demand. (AI summary)
Response (Department of Health): • The Department of Health stated that the algorithms used for coding emergency calls are not considered inaccurate or unfit for purpose. • It was noted that the initial emergency … (AI summary)
Response (Greater Manchester Police): • An officer received management action for issues with documentation in their pocket notebook. • Errors in recording inaccurate information were addressed through witness evidence at the inquest. • Greater … (AI summary)
Response (NHS England): • NHS England is leading a review of ambulance coding systems and trialling a new system. • The review will consider outcomes of previous 999 calls and concerns raised by … (AI summary)
Responded
Ratidzai Sangare
Concerns: Healthcare staff did not recognise Mrs Sangare's need for immediate cardiopulmonary resuscitation, and did not respond immediately to an activated alarm, assuming it was a behavioural issue. There was also limited telephone access for agency staff.
Overdue
William Nute
Concerns: 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.
Response (South Western Ambulance Service NHS Trust): • The Trust acknowledged that police should have been notified once a road traffic collision was confirmed, in accordance with its Standard Operating Procedure. • An investigation and audit of … (AI summary)
Overdue
Luisa Mendes
Concerns: Concerns were raised regarding the categorisation of violent incidents by call handlers, the lack of formalised handover procedures and training for controllers, and the absence of an alert feature in the STORM computer system for unauthorised deferrals.
Response (Warwickshire Police): • Warwickshire Police refreshed training for all Operations and Communications Centre staff on incident categorisation models and commenced workshops on vulnerability. • Changes were made to the initial training programme … (AI summary)
Responded
Patricia Mercieca
Concerns: 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.
Response (London Ambulance Service): • The London Ambulance Service stated that its existing call records indicated the caller was a third party not with the patient. • The service advised that, under existing protocols, … (AI summary)
Responded
Joshua Smith
Concerns: 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.
Response (Maritime Coastguard Agency): • The agency reviewed its systems, issued updated guidance, and modified training packages. • All Coastguard tactical commanders attend JESIP courses, and strategic level commanders attend Multi-Agency 'Gold' courses. • … (AI summary)
Response (Northumberland Fire and Rescue Service): • Northumberland Fire and Rescue Service (NFRS) confirmed and reaffirmed internal procedures for 999 call handling, including dual monitoring and immediate review for missing persons calls. • NFRS reviewed its … (AI summary)
Response (Northumbria Police): • A multi-agency meeting and formal debrief were conducted to discuss the concerns identified in the report. • A specific THRIVE training program for North East Ambulance Service (NEAS) call … (AI summary)
Overdue
David Lee
Concerns: 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.
Overdue
Colin Sluman
Concerns: 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.
Response (NHS England): • SWAST raised concerns with NHS Pathways regarding the prioritisation of incidents for patients who are alone and the inclusion of dizziness symptoms in the major haemorrhage triage pathway. • … (AI summary)
Response (South Western Ambulance Service NHS Foundation Trust): • The Trust secured funding to recruit an additional ten clinicians to increase clinical support within the hubs. • 'Major blood loss' (without other symptoms) and other major blood loss … (AI summary)
Responded
Reginald Dixon
Concerns: The coroner noted incorrect triaging of a call where evidence of vomiting and drowsiness should have led to a faster response, and insufficient resources resulted in average response times of 29 minutes.
Response (West Midlands Ambulance Service): • West Midlands Ambulance Service included further education and refresher training on head injuries in the NHS Pathways update scheduled for October. • The Director of Clinical Commissioning and Service … (AI summary)
Responded
Mark Banks
Concerns: 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.
Response (Devon Cornwall Police): • The police's grading and deployment policy (DO51) was reviewed and updated, integrating the THRIVE risk assessment tool to guide call handlers in incident grading. • Specific staff members were … (AI summary)
Responded
Derek Dudley
Concerns: 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.
Overdue
Andrew Crane
Concerns: The coroner noted a lack of clarity for prison officers on when to initiate a Code Blue for chest pain. Additionally, critical updates on the patient's deteriorating condition were not relayed to the ambulance service, affecting response priority.
Overdue
Olive Nutt
Concerns: 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.
Response (London Ambulance Service NHS Trust): • The Emergency Medical Dispatcher involved received prompt feedback regarding the application of the Medical Priority Dispatch System protocol. • Refresher training on call handling and MPDS protocol, incorporating a … (AI summary)
Responded
Richard Barrett
Concerns: 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.
Response: • The Welsh Ambulance Services NHS Trust is implementing Optima Predict software to enhance demand analysis and resource planning. • The Welsh Ambulance Services NHS Trust has recruited 90 additional … (AI summary)
Response (Welsh Government): • The Cabinet Secretary for Health and Social Services commissioned a clinically-led review of the ‘Amber’ category of ambulance calls. • The Welsh Ambulance Services NHS Trust is considering options … (AI summary)
Responded
Diane Greenslade
Concerns: 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.
Response: • The Health Board has identified escalation protocols to guide staff in the Emergency Department for receiving and offloading ambulances, including triggers for patient transfers to create capacity. • The … (AI summary)
Response (Welsh Ambulance Services): • The Trust implemented a Falls Framework and Falls Assistant role across five health boards in partnership with St John Ambulance Cymru Wales. • The Trust reviewed its Resource Escalation … (AI summary)
Responded
Susan Longden
Concerns: 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.
Response (NHS England): • NHS Pathways is reviewing its abdominal pain algorithms, including the severe pain section, to consider the inclusion of a question about recent surgical procedures. • This review is scheduled … (AI summary)
Responded
Mark Harris
Concerns: Insufficient information sharing between ambulance and police services included a misspelled name that hindered police intelligence and unclear communication regarding the purpose of police attendance. There is no agreed protocol for such welfare checks.
Overdue
Matthew Lewis
Concerns: 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.
Response (South Wales Police): • South Wales Police confirmed it has a procedure for new and inexperienced call handlers, involving monitoring by a trainer or experienced operator. • South Wales Police developed a new … (AI summary)
Response (College of Policing): • The College of Policing stated it would amend learning standards for contact management staff to reflect that the preservation of life is paramount and that suitable instructions should be … (AI summary)
Responded
Olive Johnson
Concerns: 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.
Response (East Midlands Ambulance Service NHS Trust): • A demand and capacity review identified a gap between available resources and national performance standards. • New contract terms were agreed with Hardwick Clinical Commissioning Group, providing up to … (AI summary)
Responded
Jack Hubbard
Concerns: The coroner raised concerns regarding Egg Nightclub's protocol which stipulates that a duty manager must be called and a second set of observations taken before an ambulance can be requested.
Overdue
John Scott
Concerns: No specific concerns text was provided for summarization.
Response (NHS England): • NHS Pathways Release 17, deployed from May 2019, provides call handlers with a script to advise callers of an ambulance's estimated arrival time. • NHS Pathways will review the … (AI summary)
Response (South East Coast Ambulance Service NHS Trust): • South East Coast Ambulance Service NHS Trust (SECAmb) has discussed potential script amendments with NHS Pathways during monthly meetings. • SECAmb uses a 'surge script' for calls that may … (AI summary)
Responded
Aidan Ridley
Concerns: 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.
Response (Wiltshire Police): • Wiltshire Police sought national guidance, which confirmed that police call handlers should not provide first aid advice. • This guidance has been communicated to all call handling staff, and … (AI summary)
Responded
Graham Smith
Concerns: 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.
Response (East Midlands Ambulance Service NHS Trust): • East Midlands Ambulance Service NHS Trust stated it has a process to alert Emergency Operations Centre staff to previous calls from the same address within nine hours. • The … (AI summary)
Response (Associaion of Ambulance Chief Executives): • The Association of Ambulance Chief Executives (AACE) will request JRCALC to review UK ambulance service clinical practice guidelines related to the management of patients who have misused alcohol, including … (AI summary)
Responded
Robert Cobbina
Concerns: 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.
Response: • The London Ambulance Service NHS Trust (LAS) committed to reviewing its procedure for informing the Maritime Coastguard Agency (MCA) and reminding staff of the correct process. • The LAS … (AI summary)
Overdue
Alf Rewin
Concerns: The coroner identified matters giving rise to concern during the inquest, noting a risk that future deaths could occur unless action is taken.
Response (NHS England): • Release 18 of NHS Pathways, deployed from October 2019, included a new disposition code (Dx0124) to facilitate early clinical review of higher-risk suicidal patients. • NHS England issued letters … (AI summary)
Responded
Gladys Furnival
Concerns: 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.
Overdue
Ffion Jones
Concerns: The improvement plan presented did not address specific service shortcomings, and there is no dedicated channel for external healthcare professionals to urgently discuss patient clinical needs with ambulance staff to inform response urgency.
Overdue
William Moody
Concerns: 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.
Overdue
Anna Hedman
Concerns: The coroner identified that training for part-time police call handlers was too short and rushed, especially for call coding, and did not adequately emphasize preservation of life. Post-training coaching and mentoring were also deemed insufficient.
Overdue
Ian Bean
Concerns: An ambulance was incorrectly dispatched to the wrong address, sending it to Mr Bean's father in Nottingham instead of Mr Bean in Cornwall.
Overdue
Paul Mclean
Concerns: 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.
Response (Welsh Ambulance Service NHS Trust): • The Trust changed guidance for prolonged fitting, instructing call takers to remain on the line and escalate calls to Red. • The Trust increased clinicians on the Clinical Support … (AI summary)
Responded
Christina Lawal
Concerns: 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.
Overdue
HSSIB safety recommendations(2)
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 …
Safety Recommendation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Association of Ambulance Chief Executives, reviews and amends the design of the medical emergency response card, to better support staff in identifying emergency situations and providing the situational …
Safety Recommendation
PPO death in custody recommendations(12)
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.
The Director at Parc
The Director at Parc should ensure that control room staff call an ambulance immediately they receive a medical emergency code.
The Governor of HMP Lincoln
The Governor should review Lincoln’s local guidance on medical emergency response codes to remind control room staff that, in the event of a medical emergency code, they should not wait for authorisation to request an ambulance.
The Governor of HMP The Mount
The Governor should ensure that all prison staff understand their responsibilities during medical emergencies, including that they: • use the appropriate emergency code when they discover a medical emergency; and • enter cells as quickly as possible when it is …
The Governor
ensure that staff understand the importance of calling the appropriate medical emergency code promptly.
The Director and Head of Healthcare
control room staff call for an ambulance immediately when a medical emergency code is called
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; …
The Governor
The Governor should ensure that control room staff call an ambulance as soon as they receive a medical emergency code.
The Effective Practice and Service Improvement Group
The Effective Practice and Service Improvement Group should liaise with SSCL to ensure that any calls raising credible concerns about a prisoner should be transferred to Humber’s Safer Custody hotline.
The Governor
The Governor should ensure that when staff call a medical emergency code, they provide relevant information about the prisoner’s condition to control room staff so that they can inform the Ambulance Service.
The Governor of HMP Liverpool
The Governor will wish to assure himself that such calls are directed appropriately once received at the prison.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should investigate the concerns raised by London Ambulance Service paramedics, identify any learning and develop an action plan for improvement for individual staff as required.
IOPC learning recommendations(10)
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 …
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 …
Recommendations - Metropolitan Police Service, January 2026
The IOPC recommends that the Metropolitan Police Service (MPS) reviews and updates its call handling policy to ensure its policy complies with the National Standards for Incident Recording (NSIR). This recommendation has arisen as a result of a review of …
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 …
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 …
Recommendations - Essex Police, September 2019
It was identified during the IOPC investigation, that control room staff in Essex Police do not receive any notification when calls go past their target response time. Essex Police should introduce a measure for control room staff to be notified …
Police response to a domestic incident - Essex Police, September 2020
The IOPC recommends that Essex Police consider formalising its process for dealing with abandoned 999 calls, with any new or amended policy or procedure dealing with abandoned 999 calls to include: a) clear direction about who has responsibility for updating …
Recommendation - Derbyshire Constabulary, November 2020
The IOPC recommends that Derbyshire Police considers mandating the responsibilty of calling an ambulance to a specific role within the Force Control Room. This learning has been identified following a DSI review, where it was established that an ambulance was …
Investigations into the actions surrounding a missing persons enquiry - Metropolitan Police …
The IOPC recommends that the Metropolitan Police Service (MPS) consider allocating a Force Control Supervisor each shift to monitor messages sent between the MPS incident recording system (known as CAD) and the call handling system (CHS). The investigation identified that …
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 …
Scottish Fatal Accident Inquiries(2)
Andrew Logan
(b) that there is a need to take steps to ensure that all staff at the Ambulance Control Centre of Scottish Ambulance Centre are familiar with, and understand the importance of complying with, the protocol in force in respect of procedure when an urgent call will not be dealt with within the required timescale; It seems to me, therefore, that …
Sep 2015
David McClenaghan
That the Scottish Ambulance Service investigate whether a telephony technology solution could be introduced that would assist emergency call handling staff in distinguishing between a silent call and a disconnected call. If such a solution can be identified, it is recommended that it is implemented as soon as possible.
Jan 2026
Other
1 rec
PHSO casework decisions(40)
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.
NHS in England
Upheld
Jun 2022
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.
NHS in England
Aug 2025
P-001508 — North West Ambulance Service NHS Trust
Mr B complained the ambulance service failed to send an ambulance for his partner, Miss L, or properly assess her, which he believes led to her death.
NHS in England
Aug 2022
P-002269 — Humber and North Yorkshire Integrated Care Board
Mrs A complained a GP failed to arrange a home visit and poorly communicated her husband's end-of-life status. She also alleged carers moved her husband incorrectly after a fall.
NHS in England
Oct 2023
P-002774 — North West Ambulance Service NHS Trust
The Trust's 111 service allegedly mishandled her son's call, which Mrs S believes contributed to his death.
NHS in England
Jul 2024
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.
NHS in England
Not Upheld
Jan 2025
P-004129 — West Midlands Ambulance Service University NHS Foundation Trust
Mrs A complained the ambulance crew did not take her husband, Mr A, to hospital, advising a GP visit instead, leading to his death a few days later.
NHS in England
Oct 2025
P-004266 — London Ambulance Service NHS Trust
Mrs O complained London Ambulance Service NHS Trust incorrectly triaged her sister on three occasions (999, 111, GP call), failing to send an ambulance, which she believes led to her sister dying alone.
NHS in England
Nov 2025
P-004665 — An independent provider in the City of Derby …
The K's complained 111 and WMAS incorrectly categorised their mother's symptoms, delayed ambulance arrival, and provided incorrect complaint responses, causing distress.
NHS in England
Jan 2026
P-001051 — North West Ambulance Service NHS Trust
Miss A complained the ambulance service incorrectly categorised her father's 999 call, delayed adrenaline treatment, and failed to use a defibrillator promptly, leading to his death.
NHS in England
Upheld
Apr 2021
P-001217 — Yorkshire Ambulance Service NHS Trust
Mrs A complained a Clinical Advisor failed to prioritise an ambulance for her mother, leading to a critical delay in response before her mother stopped breathing.
NHS in England
Nov 2021
P-001627 — South Central Ambulance Service NHS Foundation Trust
Mrs A complained that NHS 111 staff asked Mrs T unnecessary questions, incorrectly escalating her callback timeframe, and failed to arrange an ambulance despite her symptoms.
NHS in England
Partly Upheld
Nov 2022
P-002372 — East of England Ambulance Service NHS Trust
Mrs A complained the Trust incorrectly categorised her father's 999 call, causing a ten-hour ambulance delay and his avoidable death.
NHS in England
Dec 2023
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.
NHS in England
May 2024
P-002766 — South Central Ambulance Service NHS Foundation Trust
Miss M complained the Trust incorrectly categorised her father's 111 call, delaying ambulance attendance and potentially affecting his survival from a GI haemorrhage.
NHS in England
Upheld
Jul 2024
P-003664 — A practice in the Forest of Dean area
Mrs N complained a receptionist failed to review her husband's medical history or seek clinical advice for foot pain, advising him to call NHS 111, which delayed his cellulitis diagnosis.
NHS in England
Jul 2025
P-004019 — Yorkshire Ambulance Service NHS Trust
Miss A complained about delays in an ambulance reaching her father during a heart attack, leading to his death. She also complained about the Trust's delayed and mishandled complaint response.
NHS in England
Not Upheld
Sep 2025
P-004372 — South East Coast Ambulance Service NHS Foundation Trust
Miss E complained her father's 999 call for a heart attack was incorrectly categorised, leading to an ambulance delay and his death.
NHS in England
Nov 2025
P-004391 — A practice in the Dorset area
Ms R complained the Practice's inadequate triage and assessment of her mother's breathing difficulties delayed hospital admission and contributed to her death.
NHS in England
Dec 2025
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.
NHS in England
Partly Upheld
Feb 2022
P-001699 — A practice in the Lancashire area
Miss B complained her uncle's GP practice failed to properly assess and diagnose his condition, made an incorrect ambulance request, and mishandled her complaint.
NHS in England
Jan 2023
P-003853 — A practice in the Sandwell area
Mr S complained the Practice failed its duty of care after his father's fall. A receptionist reportedly offered no advice or referral, potentially missing a brain haemorrhage cause.
NHS in England
Jul 2023
P-002251 — London Ambulance Service NHS Trust
Mr B complained about severe delays and incorrect categorization of his wife's 999 call, leading to a prolonged ambulance wait and impacting her subsequent hospital treatment.
NHS in England
Oct 2023
P-002289 — North East Ambulance Service NHS Foundation Trust
Mrs A complained the ambulance crew failed to properly assess her condition or take her to hospital, leading to delayed sepsis/meningitis treatment.
NHS in England
Nov 2023
P-002670 — A practice in the Hartlepool area
Mrs E complained about an incorrect referral to gastroenterology instead of ENT and being wrongly removed from the Practice's patient register, causing distress.
NHS in England
Jun 2024
P-002829 — London Ambulance Service NHS Trust
Mrs B complained the London Ambulance Service delayed answering her 999 call and ambulance arrival for her husband's heart attack, potentially impacting his survival.
NHS in England
Not Upheld
Jul 2024
P-003325 — Imperial College Healthcare NHS Trust
The Practice and Trust allegedly made wrong diagnoses and provided incorrect care for abdominal pain. LAS declined hospital transport, causing prolonged pain and a more invasive operation.
NHS in England
Feb 2025
P-003400 — North West Ambulance Service NHS Trust
Mrs E complained the Trust incorrectly categorised 999 calls, provided wrong ambulance wait times, and advised her to take her husband to A&E, leading to treatment delays and his death.
NHS in England
Mar 2025
P-003399 — London Ambulance Service NHS Trust
Miss Y complained the Trust incorrectly categorised a 999 call, causing an ambulance delay that led to her father's avoidable death, and later withdrew a compensation offer.
NHS in England
Mar 2025
P-003492 — London Ambulance Service NHS Trust
Miss U complained a paramedic's inadequate assessment of her stabbed son led to an incorrect hospital transfer delay, possibly affecting his outcome and contributing to his death.
NHS in England
Mar 2025
P-003944 — Bradford Teaching Hospitals NHS Foundation Trust
Mrs P complained the Ambulance Trust and Trust ignored concerns about her son's blocked shunts, misdiagnosed him, delayed diagnosis and treatment, and delayed his transfer, leading to his death.
NHS in England
Sep 2025
P-003973 — South East Coast Ambulance Service NHS Foundation Trust
Mrs L complained the Trust did not take her concerns seriously about her brother's breathlessness and heart condition, resulting in him not being conveyed to hospital and dying at home.
NHS in England
Sep 2025
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.
NHS in England
Sep 2025
P-004024 — South Western Ambulance Service NHS Foundation Trust
The Trust incorrectly categorised 999 calls and delayed sending an ambulance for her husband, which Mrs L believes caused irreparable heart damage and his subsequent death.
NHS in England
Sep 2025
P-004542 — South East Coast Ambulance Service NHS Foundation Trust
Mrs F complained paramedics failed to take her to hospital and communicated poorly, leading to a perforated appendix and multiple abscesses.
NHS in England
Dec 2025
P-001258 — A medical practice in the London Borough of …
Dr B complained the Practice and Trust failed to prescribe anticoagulants, and the Ambulance Service missed stroke symptoms, leading to his mother's stroke and subsequent death.
NHS in England
Partly Upheld
Jan 2022
P-002805 — East of England Ambulance Service NHS Trust
Mr G complained about multiple missed opportunities to diagnose heart problems, including an unacted-on X-ray and a failed ambulance attendance, leading to a delayed heart failure diagnosis.
NHS in England
Jul 2024
P-003393 — A practice in the West Suffolk area
Miss F complained a GP failed to recognize her friend needed emergency care during a telephone consultation, leading to her friend's preventable death. She sought service improvements and accountability.
NHS in England
Mar 2025
P-003510 — A practice in the City of Bristol area
Mr D complained the Practice did not take appropriate action when his father reported chest pain and shortness of breath, believing a home visit or hospital referral would have prevented his death.
NHS in England
Apr 2025
P-003628 — North East Ambulance Service NHS Foundation Trust
Miss J complained about ambulance call handling delays and insufficient advice for her father's cardiac arrest, believing it reduced his survival chances and caused distress.
NHS in England
Partly Upheld
Jun 2025