Emergency dispatch algorithm flaws (medication)
Emergency dispatch algorithms failing to account for blood-thinning medication in head injury cases, delaying appropriate response.
94 items
6 sources
1 inquiry
Source spread
Where this theme appears
Emergency dispatch algorithm flaws (medication) has been flagged across 6 independent accountability sources:
1 inquiry rec
55 PFD reports
11 HMICFRS recs
1 Scottish FAI
11 PHSO decisions
15 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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.
PFD Reports (55) — showing 50 strongest matches
Winston Llewellyn Johns
Concerns: Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Overdue
Refat Hussain
Concerns: Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Response (Care UK): Care UK acknowledges the coroner's concerns regarding access to patient information and describes existing systems for receiving information from GPs, including post-event messages, Special Patient Notes, Summary Care Records, and …
Responded
James Sutton
Concerns: The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.
Overdue
Toni Skillington
Concerns: The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.
Overdue
Clare Bain
Concerns: Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat treatment.
Response (South Western Ambulance Service NHS Foundation Trust): The ambulance service will issue further guidance for clinicians on methadone overdose, highlighting the characteristics of methadone and the need for hospital transfer even after initial treatment. They are also …
Responded
Linda Lloyd
Concerns: Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider the effects of warfarin on patients.
Overdue
Sharon Butcher
Concerns: There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
Response (HM Prison and Probation Service): HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where …
Overdue
Hayden Norton
Concerns: After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or that he had been informed of a screening test for aortic aneurysm; furthermore, there was a delay in calling an emergency ambulance because HMP Dartmoor lacked an emergency code protocol.
Response (Dorset Healthcare University NHS Foundation Trust): The Trust has implemented new policies and procedures to improve service provision and provides a AAA screening programme. HMP Dartmoor now has an emergency code protocol in place.
Overdue
Barbara Patterson
Concerns: The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Response (Department of Health): NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of …
Response (CQC): The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance …
Response (North East Ambulance Service NHS Trust): The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Responded
Yusuf Abdismad
Concerns: Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.
Overdue
Elizabeth Lester
Concerns: The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.
Responded
Monica Lewis-Hinds
Concerns: The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.
Overdue
Caragh Melling
Concerns: The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.
Overdue
Christopher Fields
Concerns: Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical delays in response times for seriously injured patients.
Response (North West Ambulance Service NHS Trust): North West Ambulance Service is exploring ways to minimise lengthy waits during high demand periods and has secured funding for additional frontline staff and new vehicles. It defends its coding …
Response (Department of Health): The Department of Health disagrees with the coroner's concern, stating the call was correctly coded based on the information available at the time and the algorithm used is appropriate. They …
Response (Greater Manchester Police): Greater Manchester Police gave management action to an officer for lack of documentation, and addressed errors in recording inaccurate information. They propose to report back on wider work around vulnerability …
Response (NHS England): NHS England is conducting a review of ambulance coding systems and trialling a new system, taking into account previous similar calls and coroner's reports. Recommendations are expected in autumn 2016.
Responded
Barry Hodges
Concerns: Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.
Response (South Yorkshire Ambulance Service): The ambulance service has implemented a "Call Alert" system to highlight unallocated incidents, reduced timeframes for resourcing amber calls, and introduced performance frameworks to audit staff. They review delayed response …
Responded
Susan Longden
Concerns: The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Response (NHS England): NHS Digital acknowledges that the question about a recent surgical procedure or operation is not specifically asked in a sub-section of their abdominal pain pathways and are reviewing how this …
Responded
Marie Millward-Winter
Concerns: Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Response (North West Ambulance Service NHS Trust): The Ambulance Service argues the Regulation 28 report was issued prematurely because they were not notified of the inquest date or granted Interested Person status. They maintain the EMT acted …
Overdue
Terrence Smith
Concerns: The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially misleading information, impacting emergency response.
Overdue
Alexander Davidson
Concerns: NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Response (National Institute for Health and Care Excellence): NICE will reconsider the scope of their guideline on pancreatitis (NG104) when it is next reviewed, to consider lipase/amylase testing in young people.
Response (NHS England): NHS Pathways reviewed the question regarding dark brown or black vomit and concluded removing 'coffee-grounds' could result in over-referral. As part of routine review and governance procedures, they are conducting …
Overdue
Christopher Williams
Concerns: The report highlights an ambulance arriving outside of Trust guidelines, a call handler's failure to escalate the patient's worsening condition and incorrect algorithm use, and a communication breakdown about an arranged hospital bed, potentially delaying treatment.
Response (East of England Ambulance Service NHS Trust): East of England Ambulance Service NHS Trust has recruited 491 frontline staff and has a further 270 frontline offers of employment in process. They are also in communication with the …
Responded
Alf Rewin
Concerns: No specific safety concerns were identifiable from the provided administrative text.
Response (NHS England): NHS Digital is requesting that ambulance trusts review their internal assurance processes regarding the management of patients who have self-harmed. NHS Digital agreed that all services should review the identification …
Responded
Allan Davies
Concerns: The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly and endangering lives.
Response (NHS England): NHS England highlighted the issue of triaging overdose cases to ambulance services and asked them to ensure robust clinical oversight is in place for self-harm and suicidal patients. A new …
Response (NHS England): NHS Digital (NHS Pathways) is deploying Release 18 which includes a new disposition code (Dx0124) to highlight potential overdose/suicide cases. They also reference a letter from NHS England to Ambulance …
Responded
Anna Hedman
Concerns: A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an emergency situation.
Overdue
Ashley Walker
Concerns: A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not available on the ambulance.
Response (West Midlands Ambulance Service): Following a communication error, WMAS has instructed all staff to remove the WISER app from work devices unless trained. They have also produced further guidance in relation to Individual Chemical …
Responded
Mitica Marin
Concerns: A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; this is a recurring issue, reducing survival prospects.
Response (Resusciation Council UK): Resuscitation Council UK disagrees with recommending defibrillators start in automatic mode, arguing manual mode results in greater chance of return of spontaneous circulation and supports the remedial actions taken by …
Response (London Ambulance Service NHS Trust): London Ambulance Service investigated the incident and found that Paramedic A did not recognise that Mr Marin was in ventricular fibrillation. LAS has updated guidance, provided human factors training, and …
Response (Association of Ambulance): The Association of Ambulance Chief Executives (AACE) acknowledges the need for prompt defibrillation and issued revised guidance in June 2019 advocating for the use of automatic mode by solo responders. …
Response (Dept. Health and Social Care): The Department of Health and Social Care acknowledges the concerns regarding defibrillator default settings, but states that factory settings must cover a wide range of applications and individual ambulance services …
Response (Stryker Corporation Physio Control): Stryker argues that the coroner's concerns about the LP15 device defaulting to manual mode are inaccurate, as the device can be configured to power on in either automatic or manual …
Responded
Faiza Ahmed
Concerns: No specific concerns are detailed in the provided text, which refers only to the jury's determination.
Response (the Department of work and Pensions): The DWP believes its processes were followed correctly but will issue a reminder to all staff about guidance related to suicidal ideation.
Response (the London Ambulance Service): Following the incident, the involved crew undertook Reflective Learning, and a Clinical Update reinforcing the assessment of Capacity was published. A new Operational Management Structure was implemented, including Stakeholder Engagement …
Response (the Metropolitan Police): The Metropolitan Police will ensure that the future structure and resourcing model of Sapphire teams meets the demands of increased reporting levels and promotes a supportive working environment, and invest …
Responded
Zoe Knight
Concerns: Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve awareness and earlier diagnosis has not been implemented.
Response (NICE 2020): NICE acknowledges the concerns and notes that existing guidance (CG95) flags points where healthcare professionals should consider aortic dissection. They note that topic experts decided against including more detailed guidance, …
Responded
Jack Goodwin
Concerns: The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.
Response (NHS England): NHS England will explore adding guidance to ambulance call scripts to advise callers to go to the nearest emergency department (noting that not all hospitals have them) if they choose …
Responded
Martin Sullivan
Concerns: The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.
Response (Clinical Commissioning Group): The Clinical Commissioning Group provides information and context regarding the MPDS algorithm, the identification of ineffective breathing, ambulance performance data, and staffing levels within NWAS, without stating planned actions.
Response (NHS England): NHS England will hold a learning event with all ambulance services and triage system providers to share best practice and ensure ambulance services utilise triage systems safely and effectively in …
Responded
Mark Holden
Concerns: A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.
Overdue
Hannah Royle
Concerns: The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call handlers and an inadequate system for disabilities. The public is also misled about the service's diagnostic capabilities.
Response (South East Coast Ambulance Service): SECAmb issued a "Hot Topic" learning update to all 111 call handling staff in October 2021, emphasising the need to identify and refer complex cases to clinicians and provided training …
Response (NHS England): NHS Digital provides background information on the NHS Pathways clinical decision support software and its governance, deferring to other organisations to address specific concerns raised in the report.
Overdue
Colin Swain
Concerns: CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation of breathing upon turning. This highlights a need for clearer guidance on managing such scenarios.
Overdue
Keith Hopwood
Concerns: Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private ambulance was dispatched due to miscategorization, leading to further delays.
Response (Department of Health and Social Care): The Department of Health and Social Care outlines measures to support ambulance services, including increasing NHS bed capacity and expanding the use of virtual wards. They also highlight the Adult …
Responded
Esma Guzel
Concerns: The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.
Response (Royal College of Paediatrics and Child Health): The RCPCH acknowledges the concerns and will share the report with its Quality in Clinical Practice committee for further discussion to identify opportunities to prevent future deaths, and will continue …
Response (Royal College General Practitioners): The RCGP acknowledges the concerns, outlines educational material for GPs in training, and welcomes changes to the 111 out-of-hours algorithm. They support investment in primary care infrastructure to improve data …
Response (NHS England): NHS Digital reports that the 111 algorithm was modified and provides detail on the governance structure overseeing NHS Pathways, including independent oversight, consistency with NICE guidelines, and a process for …
Responded
Roy Middleton
Concerns: The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.
Overdue
Kenneth Adams
Concerns: The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for persistent bleeding or medication effects, leading to dangerous treatment delays.
Response (International Academics of Emergency Dispatch): The International Academies of Emergency Dispatch acknowledges the delayed EMS response and identifies contributing factors, including high call volume and Careline's limited information. They suggest that a serious hemorrhage code …
Response (Surrey County Council and Surrey Borders Partnership NHS Foundation Trust): Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council are reviewing the cross-agency SCARF process, including information sharing and confidentiality, through a project group. A meeting has already …
Response (Kingston upon Hull City Council): Kingston upon Hull City Council is planning several measures: relocating taxi ranks, designing a signalized crossing, relocating a crossing facility, considering footpath widening, and implementing a 20mph zone. These are …
Responded
Rashdah Bhatti
Concerns: Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths from handlers not following MPDS protocols.
Response (Welsh Ambulance Service NHS Trust): Following an internal audit, the Welsh Ambulance Service will issue a reminder to all call handlers regarding the use of Post-Dispatch Instructions (PDIs), specifically related to haemorrhage/laceration calls, and will …
Responded
Glyn Ackerley
Concerns: The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.
Response (NHS England): NHS England explains the NHS Pathways system and its governance, noting that NHS Pathways is owned by DHSC and that all reports received are discussed by the Regulation 28 Working …
Responded
Lucas Pollard
Concerns: A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.
Response (East of England Ambulance Service NHS Trust): East of England Ambulance Service NHS Trust is integrating the Critical Care desk function into all three control rooms. They are reviewing the End of Shift Policy to ensure clinical …
Responded
Jane Walker
Concerns: Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Response (Drug Misuse Unit): The NHS England Task & Finish Group on Analgesia is considering recommendations from the Manchester Arena Inquiry regarding paramedics administering mucosal fentanyl lozenges. The group has been provided with a …
Responded
Fern Foster
Concerns: Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes for on-scene administration, potentially preventing deaths.
Response (NHS England): NHS England describes the role of the Emergency Call Prioritisation Advisory Group (ECPAG) in managing ambulance service prioritisation, referencing the NHS Pathways product and its alignment with clinical standards. They …
Response (NARU): NARU will review evidence from a West Midlands Ambulance Service trial and a proposed Yorkshire Ambulance Service project at the forthcoming NARU Clinical Subgroup in September, with the aim of …
Response (AACE): AACE and NASMeD will await the outcome of the NARU clinical subgroup meeting regarding toxicological incidents and the potential role of methylene blue and look to support and improve clinical …
Overdue
Margaret Huntley
Concerns: Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.
Response (NHS England): NHS England is working with the Association of Ambulance Chief Executives (AACE) to ensure patients inform 999 call handlers or healthcare professionals if they are steroid dependent; NHS England's National …
Response (Association of Ambulance Chief Executives): AACE expresses condolences and explains its role in supporting ambulance services with national policy and guidelines. They highlight existing JRCALC guidance and raise concerns about the validity of flagging patient …
Response (NE Ambulance Service): NEAS has taken several actions including reviewing and updating clinical practice guidelines to highlight steroid dependency and adrenal insufficiency, updating the NHS Pathways system to improve recognition of steroid dependency, …
Responded
Amanda Gainford
Concerns: Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.
Response (NHS England): NHS England acknowledges the concerns raised and highlights the National Framework for healthcare professional ambulance responses, which allows HCPs to challenge ambulance call categorisation. They also state all Reports to …
Overdue
Aran Bradbury
Concerns: The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower category response because mental health history overshadowed drug ingestion, delaying critical aid.
Response (NHS England): NHS England has asked ambulance trusts to confirm compliance with NHSE guidance and has escalated the issue with the 25-C codes to the International Academies for Emergency Dispatch for rapid …
Response (AACE): AACE states that the primary ownership of the concerns regarding 999 call categorisation lies with NHS England and that they have liaised with NHS England to ensure the matters of …
Overdue
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Response (NHS England): NHS England detailed several actions taken to address the coroner's concerns, including: implementing a 'Complex Call' process to ensure clinicians assist health advisors with medication/medical related triaging, and providing 'Hot …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the coroner's concerns regarding the NHS Pathways system and patient information sharing, noting that NHS England is responding to the specific concerns …
Overdue
Joel Colk
Concerns: NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.
Response (NHS England): NHS England explains that the NHS Pathways system is a triage tool, and adjustments would be made if national guidance changes. They note that carrying specific medications like Methylene Blue …
Response (SECAmb): SECAmb expresses condolences and explains their protocols, but disputes the need for changes regarding overdose categorization and the provision of specific medications like methylene blue, citing clinical feasibility and national …
Responded
Jeffrey Tyler
Concerns: Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored condition.
Response (Welsh Government): The Welsh Government outlines plans to introduce new ambulance call categories and a rapid clinical screening process by senior paramedics or nurses. A national group of clinical and operational leads …
Overdue
John England
Concerns: The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential surgical emergency.
Response (NHS England): NHS England will discuss details of the case with the NHS England AMPDS clinical coding sub-group, in collaboration with PDC, to determine if there are opportunities to improve the assessment …
Responded
Miles Robinson
Concerns: The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.
Overdue
Oscar Keenan
Concerns: Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.
Response (NHS England): NHS England acknowledges the concerns about the NHS Pathways algorithm and details its function. It highlights existing access to clinical support for health advisors and refers to work by the …
Response (Unity Health): The practice has amended its process for new baby registrations, including removing the 'unregistered babies' folder and updating the Docman system to allow electronic rejection of incorrectly sent correspondence.
Response (South Central Ambulance Service): The trust has already taken several actions including auditing the call, sharing learning through various channels, and providing training to staff. They have also reviewed and amended the NHS Pathways …
Response (CQC): The CQC contacted the provider, Unity Health, who confirmed they reviewed their processes and implemented a new system for creating a new profile when they are notified about a birth. …
Responded
HMICFRS Recommendations (11)
PEEL 2021-22 CoC Recommendations: Wiltshire Police
Cause of concern: The force is failing to understand and promptly identify vulnerability at the first point of contact. Recommendation: Wiltshire Police should, within three months:- improve the process of risk assessing callers to identify those that are vulnerable or …
Recommendation
PEEL 2018-19 CoC Recommendations: Sussex Police
Cause of concern: Sussex Police is failing to manage risk effectively. In the force control room, some vulnerable victims are left without police attendance for considerable periods of time. Some victims may not be getting through to the police at …
Recommendation
PEEL 2021-22 CoC Recommendations: Staffordshire Police
Cause of concern: The force needs to improve how it identifies and assesses vulnerability at first point of contact. Recommendation: Within three months, Staffordshire Police should make sure that vulnerable and repeat callers are routinely identified, as are other people …
Recommendation
PEEL 2021-22 CoC Recommendations: Staffordshire Police
Cause of concern: The force needs to improve how it identifies and assesses vulnerability at first point of contact. Recommendation: Within three months, Staffordshire Police should make sure that call handlers use and correctly record structured initial triage and risk …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The inconsistent application of an effective THRIVE (threat, harm, risk, investigation, vulnerability and engagement) risk assessment by call handlers, accompanied by the absence of victim needs assessments and the limited extent to which repeat victims are identified …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The inconsistent application of an effective THRIVE (threat, harm, risk, investigation, vulnerability and engagement) risk assessment by call handlers, accompanied by the absence of victim needs assessments and the limited extent to which repeat victims are identified …
Recommendation
PEEL 2021-22 CoC Recommendations: Gwent Police
Cause of concern: The force needs to improve how it answers calls for service, identifies vulnerability at first point of contact and attends incidents within its published time frames. Recommendation: Within three months, Gwent Police should make sure that vulnerable …
Recommendation
PEEL 2021-22 CoC Recommendations: Sussex Police
Cause of concern: Non-emergency callers often have to wait in a queue or for a call-back, and call handlers frequently fail to use a structured approach to assess their risk or vulnerability Recommendation: Within six months the force should make …
Recommendation
PEEL 2023-25 CoC Recommendations: Suffolk Constabulary
Cause of concern: The constabulary needs to improve the time it takes to answer emergency and non-emergency calls. Recommendation: Within six months, Suffolk Constabulary should:- make sure it can answer a greater proportion of non-emergency 101 calls so that caller …
Recommendation
PEEL 2021-22 CoC Recommendations: Metropolitan Police Service
Cause of concern: The force needs to improve how it answers calls for service and how it identifies vulnerability at the first point of contact. Recommendation: Within nine months the force should make sure it can answer a larger proportion …
Recommendation
PEEL 2021-22 CoC Recommendations: Gwent Police
Cause of concern: The force needs to improve how it answers calls for service, identifies vulnerability at first point of contact and attends incidents within its published time frames. Recommendation: Within six months, Gwent Police should make sure it can …
Recommendation
PHSO Casework Decisions (11)
P-003096 — NHS England
Mrs H complains the NHS Pathways triage system used for all NHS 111 calls is flawed, as it fails to recognise the possibility of sepsis for a caller who reports recent surgery and chemotherapy.
NHS in England
Oct 2024
P-001051 — North West Ambulance Service NHS Trust
Miss A complains that North West Ambulance Service NHS Trust (the Trust) incorrectly categorised the first 999 call the family made, when her father, Mr R, was taken ill. Miss A also complains the ambulance did not arrive with adrenaline, the treatment with adrenaline was delayed and it was not …
NHS in England
Upheld
Apr 2021
P-001421 — North West Ambulance Service NHS Trust
Mrs O complains that the North West Ambulance Service NHS Trust did not send an ambulance for her father and did not provide her with accurate information when she made an emergency call to it in February 2020.
NHS in England
Upheld
Jun 2022
P-003783 — South East Coast Ambulance Service NHS Foundation Trust
Mrs V complains that on the 28 March 2023, the Ambulance Trust failed to dispatch an ambulance following a 999 call and instead completed a welfare call. This meant her mother Mrs I did not receive the treatment needed that day. She also complains that the Trust provided the telephone …
NHS in England
Aug 2025
P-003777 — Gloucestershire Hospitals NHS Foundation Trust
Mr S complains about the Trust's ED triage process. He complains the Trust did not triage him as quickly as it should have, did not provide help when he deteriorated. He also complains the Trust failed to provide CCTV when he requested it.
NHS in England
Partly Upheld
Aug 2025
P-004337 — North West Ambulance Service NHS Trust
Miss A complains North West Ambulance Service NHS Trust failed to identify the cause of her mother’s condition and provide appropriate treatment to prevent her suffering a cardiac arrest. Miss A says her mother may not have died if the Trust had performed an ECG and taken her to hospital …
NHS in England
Not Upheld
Nov 2025
P-002829 — London Ambulance Service NHS Trust
Mrs B complains the Ambulance Service delayed answering her 999 call and it took paramedics too long to arrive at her property.
NHS in England
Not Upheld
Jul 2024
P-003399 — London Ambulance Service NHS Trust
Miss Y complains the Trust incorrectly categorised a 999 call, which led her father’s avoidable death. Miss Y also complains the Trust then told her its offer of a financial remedy had lapsed when she came to claim it.
NHS in England
Mar 2025
P-003492 — London Ambulance Service NHS Trust
Miss U complains that after her son was stabbed in March 2022, the paramedic did not assess him properly and wrongly said no hospitals would accept him due to him kicking and being distressed, but this was due to his shock and epileptic seizure.
NHS in England
Mar 2025
P-004030 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs W complains the Trust did not diagnose her husbands leukaemia before discharge and failed to provide timely treatment for sepsis and leukaemia complications the following month when he attended the ED.
NHS in England
Partly Upheld
Sep 2025
P-003271 — London Ambulance Service NHS Trust
Miss T complains about the Trust’s response to her requests for help in January 2022 when she contacted 111 and 999. She says 111 incorrectly categorised the ambulance response twice and the ambulance took too long to arrive.
NHS in England
Not Upheld
Jan 2025
LGO / SPSO Decisions (15)
PSOW-202207867 — Welsh Ambulance Services NHS Trust
Mr W complained that Welsh Ambulance Services NHS Trust had failed to respond to the complaint he submitted in July 2022. The Ombudsman decided that there had been a delay in WAST’s response and this had caused inconvenience and frustration for Mr W. The Ombudsman decided to settle the complaint …
PSOW (Public Services Om…
Health
Mar 2023
PSOW-202105404 — Welsh Ambulance Services NHS Trust
Ms A complained that her late father, Mr B, not being taken to the local hospital by the first ambulance crew adversely affected his treatment and investigation for a suspected stroke. Ms A said that her father’s condition had deteriorated and the following day he was very confused. He had …
PSOW (Public Services Om…
Health
Upheld
Mar 2023
202000766 — Scottish Ambulance Service
C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2022
PSOW-202105080 — Welsh Ambulance Services NHS Trust
Miss D complained about her late father, Mr D’s, treatment by the Health Board and the Trust. She complained that as her father was at the end of life exceptions should have been made to visitor restrictions that were in place due to Covid-19 to allow family to visit him, …
PSOW (Public Services Om…
Health
Upheld
Jul 2022
PSOW-202203456 — Welsh Ambulance Services NHS Trust
Mrs A complained about the late arrival of an ambulance, which led to the sad death of her daughter, Mrs B, at her home. She was also concerned about the attitude of the attending paramedic and the Trust’s failure to respond to her concerns about that in its complaint response. …
PSOW (Public Services Om…
Health
Oct 2022
PSOW-202302966 — Welsh Ambulance Services University NHS Trust
Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, …
PSOW (Public Services Om…
Health
Mar 2025
PSOW-202306104 — Welsh Ambulance Services University NHS Trust
Mrs A complained about a lack of care and treatment by the Welsh Ambulance Services University NHS Trust (“the Trust”) for her son, Mr B, on 14 December 2022. The Ombudsman’s investigation considered the handling of 2 999 calls, the standard of record keeping by the attending paramedic, and whether …
PSOW (Public Services Om…
Health
Mar 2025
20-012-668c — West Midlands Ambulance Service NHS Foundation Trust (20 …
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
201103489 — Scottish Ambulance Service
Ms C complained about an accident she had while being transported by the Scottish Ambulance Service (the service) to a clinic appointment. Ms C said that the driver had taken his finger from the remote-control button operating a stair-lift while Ms C was sitting on it in a wheelchair. The …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2012
201203148 — Scottish Ambulance Service
Mrs C said that her husband (Mr C) experienced a seizure while driving his taxi, and an ambulance was called. After Mr C was assisted out of the taxi and into the ambulance, Mrs C alleged that the ambulance staff used unreasonable restraint, which resulted in a compression fracture (when …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2013
201705035 — Scottish Ambulance Service
Mr C complained on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably. Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2018
201707301 — Scottish Ambulance Service
Mr C complained that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2018
201708212 — Scottish Ambulance Service
Mrs C complained about the length of time that her mother (Mrs A) had to wait for an ambulance. We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
201703342 — Scottish Ambulance Service
Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2018
202304529 — Scottish Ambulance Service
C complained that the Scottish Ambulance Service (SAS) unreasonably delayed in dispatching an ambulance for their late parent (A) and, as a result, this had an adverse impact on A’s care and treatment. C questioned why an SAS call handler initially advised them that an ambulance was not needed, when …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2025