Inappropriate Emergency Call Transfers
87 items
1 source
Non-clinical staff inappropriately transferring emergency calls without clear inter-service criteria, leading to delays or misdirection.
Cross-Source Insight
Inappropriate Emergency Call Transfers has been flagged across 1 independent accountability source:
87 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (87)
Lucy Thornton
Concerns: Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Pending
Theo Tuikubulau
Concerns: Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on the system used.
Overdue
Adam Hussain
Concerns: The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.
Response: NHS England acknowledges the concerns and notes that a system-wide After-Action Review has been facilitated by the Integrated Care Board, with outcomes to be monitored by various governance bodies. They …
Response: East Midlands Ambulance Service has implemented several changes, including deploying senior clinicians in their Clinical Hub, ensuring clinicians review all information before transferring calls, and ceasing manual ITK push transfers …
Response: NEMS has ceased manually pushed calls, updated its Clinical Triage Guideline, introduced daily reviews of Category 3 calls, and established a Clinical Triage working group. They are also developing a …
Response: The ICB facilitated a system-wide After-Action Review, ceased some automatic call transfers to NEMS, reviewed and redefined the Urgent Care Clinical Hub service specification, and developed new analytics capabilities for …
Responded
Jake Hartwright
Concerns: The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, and transfer criteria between services are unclear.
Response: NHS England acknowledges the concerns and notes that a system-wide After-Action Review has been facilitated by the Integrated Care Board, with outcomes to be monitored by various governance bodies. They …
Response: East Midlands Ambulance Service has implemented several changes, including deploying senior clinicians in their Clinical Hub, ensuring clinicians review all information before transferring calls, and ceasing manual ITK push transfers …
Response: NEMS has ceased manually pushed calls, updated its Clinical Triage Guideline, introduced daily reviews of Category 3 calls, and established a Clinical Triage working group. They are also developing a …
Response: The ICB facilitated a system-wide After-Action Review, ceased some automatic call transfers to NEMS, reviewed and redefined the Urgent Care Clinical Hub service specification, and developed new analytics capabilities for …
Responded
Lewis Bates
Concerns: Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an inappropriate police response.
Response: Greater Manchester Police commits to drafting new policy and guidance by April 2026 to define "reasonable enquiries" and address advising callers to contact medical professionals. They will also provide revised …
Responded
Margaret Bailey
Concerns: Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.
Overdue
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
David Gifford
Concerns: Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Responded
Elaine Tarbuck
Concerns: The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Responded
Charlotte Alderson
Concerns: Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Responded
Paul Alexander
Concerns: Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.
Responded
Sophie Cotton
Concerns: Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.
Responded
Lachlan Campbell
Concerns: Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to significant delays in patient care. The lack of police-to-hospital conveyance options for urgent cases is also a concern.
Responded
Wyllow-Raine Swinburn
Concerns: Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in call handling.
Responded
Elan Adams
Concerns: Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, posing a significant safety risk.
Responded
Dean Bray
Concerns: Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.
Overdue
Simon Boyd
Concerns: Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.
Responded
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.
Overdue
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.
Responded
Robert Fray
Concerns: NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led to delayed and misdirected ambulance dispatch.
Responded
Paul Dow
Concerns: Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.
Responded
Donna Smith
Concerns: The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.
Responded
Tammy Watkins
Concerns: Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Responded
Sandra Finch
Concerns: Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time limits or prioritization creates dangerous delays.
Responded
Maria Whale
Concerns: There was a critical failure in emergency response, with ambulance services delaying attendance for a gravely ill patient deemed low priority despite severe pain. Out-of-hours GP services also failed to provide adequate advice, pain relief, or expedite hospital admission.
Responded
Levi Alleyne
Concerns: Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked both bystander and emergency service safety and delayed life-saving treatment.
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
Josephine Barker
Concerns: Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate system for prioritizing high-risk calls and monitoring patient deterioration.
Overdue
Sarah Gilbert-Jones
Concerns: Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.
Responded
Eva Wheeler
Concerns: Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.
Responded
Richard Boateng
Concerns: Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.
Responded
Steve Cooke
Concerns: Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up with contacts, led to a severely unwell patient not being located.
Responded
Karl Bolam
Concerns: Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he could contact someone for assistance, a script deficiency later partially addressed.
Responded
Sarah Ferneyhough
Concerns: Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure to review full call details.
Overdue
Joan McIndoe
Concerns: The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not adequately reassessed.
Responded
Karen Bingham
Concerns: Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.
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.
Responded
Helen Sheath
Concerns: Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
Responded
Christina Lawal
Concerns: Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information that callers remote from the patient cannot provide, risk inadequate and delayed emergency response.
Overdue
Paul Mclean
Concerns: Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking clear protocols for urgent upgrades when airways are compromised. There's also no pathway for updating prison staff or facilitating dialogue with hospital EDs on call categorisation.
Responded
Ian Bean
Concerns: An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.
Overdue
Alf Rewin
Concerns: No specific safety concerns were identifiable from the provided administrative text.
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
William Moody
Concerns: The 999 call system caused confusion and delays in emergency response for a mental health crisis at home due to unclear agency responsibilities and lack of public awareness.
Overdue
Ffion Jones
Concerns: The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.
Overdue
Gladys Furnival
Concerns: The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.
Overdue
Robert Cobbina
Concerns: Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location signage for a person in the river, causing significant delays in emergency response.
Overdue
Graham Smith
Concerns: The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.
Responded
Aidan Ridley
Concerns: Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.
Responded
Matthew Lewis
Concerns: Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
Responded
Jack Hubbard
Concerns: The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency response.
Overdue
Olive Johnson
Concerns: Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call regrading.
Responded
Mark Harris
Concerns: Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.
Overdue
Diane Greenslade
Concerns: Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in medical intervention.
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.
Responded
Richard Barrett
Concerns: Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks further delayed critical intervention.
Responded
Olive Nutt
Concerns: Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.
Responded
Andrew Crane
Concerns: Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised emergency response.
Overdue
Derek Dudley
Concerns: A community alarm operator ended a call with an elderly man who had fallen before he could get up, without checking for emergency contacts. This raises concerns about fall response protocols and subsequent safety.
Overdue
Reginald Dixon
Concerns: An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.
Responded
Mark Banks
Concerns: Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check on the deceased's wellbeing.
Responded
David Lee
Concerns: The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for medical assistance.
Overdue
Colin Sluman
Concerns: Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for call handlers.
Responded
Joshua Smith
Concerns: Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.
Overdue
Patricia Mercieca
Concerns: Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response from emergency call system users.
Responded
Luisa Mendes
Concerns: Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.
Responded
William Nute
Concerns: Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident scene and increased risk of death.
Overdue
Ratidzai Sangare
Concerns: Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. Agency staff had limited access to telephones for emergencies.
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.
Responded
Mia Gibson
Concerns: Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to critical delays in emergency response and hospital transfer.
Overdue
Luke Ayres
Concerns: Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.
Responded
Lisa Day
Concerns: The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in a diabetic.
Responded
Ronald Volante
Concerns: Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating a need to revisit the training manual and methods.
Responded
Thomas Collins
Concerns: The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.
Responded
Christopher Smith
Concerns: A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.
Overdue
Mrs Withers
Concerns: Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.
Overdue
Stuart Knight
Concerns: Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
Responded
Adil Habib
Concerns: 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.
Overdue
Samia Shara
Concerns: There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.
Overdue
Mark Hudson
Concerns: Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Responded
Sonielia Holmes
Concerns: Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient lives at risk due to lack of specialist advice.
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
Gary Million
Concerns: Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with incomplete address information and inadequate communication protocols with BT. Subsequent investigations and revised protocols were also insufficient and poorly implemented.
Overdue
Gianna Khan
Concerns: A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, indicating a critical failure in triage protocols, which was impeded by the CCG.
Responded
Clive Gould
Concerns: Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.
Response: SCAS has extended Rapid Response Vehicle cover to 24 hours in three counties and adjusted crew rotas to better match demand. They have also developed a Clinical Support Desk to …
Responded
Millie Elizabeth Thompson
Concerns: Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric life-saving kits.
Response: The DfE confirms that paediatric first aid training is a statutory requirement for early years providers and is undergoing a consultation to reinforce the need for a first-aid trained staff …
Response: North West Ambulance Service detailed its robust EMD recruitment and training process, which includes paediatric resuscitation. They also confirmed that all their emergency response vehicles are already equipped with a …
Response: The Department of Health defers responsibility for nursery staff training to the DfE and ambulance call taker training to NWAS. Regarding paediatric life-saving kit, they confirmed that NWAS emergency vehicles …
Pending
David Selman
Concerns: An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.
Overdue