Inappropriate Emergency Call Transfers
Non-clinical staff inappropriately transferring emergency calls without clear inter-service criteria, leading to delays or misdirection.
162 items
8 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
William Nute
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.
Matched on
terms: call, emergency, transfer
PFD report
81match
Clive Gould
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.
Matched on
terms: call, inappropriate
PFD report
81match
Luke Ayres
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.
Matched on
terms: call, emergency
PFD report
81match
David Lee
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.
Matched on
terms: call, emergency, inappropriate
PFD report
77match
Millie Elizabeth Thompson
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.
Matched on
terms: call, emergency
PFD report
77match
Reginald Dixon
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.
Matched on
terms: call, emergency
PFD report
77match
Andrew Crane
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.
Matched on
terms: call, emergency
PFD report
77match
Robert Cobbina
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.
Matched on
terms: call, emergency
PFD report
77match
William Moody
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.
Matched on
terms: call, emergency
PFD report
73match
Samia Shara
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.
Matched on
terms: call, inappropriate
PFD report
73match
Mrs Withers
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.
Matched on
terms: call, emergency
PFD report
73match
Mia Gibson
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.
Matched on
terms: emergency, transfer
PFD report
73match
Luisa Mendes
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.
Matched on
terms: call, inappropriate
PFD report
73match
Colin Sluman
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.
Matched on
terms: call, emergency
PFD report
73match
Derek Dudley
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.
Matched on
terms: call, emergency
PFD report
73match
Diane Greenslade
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.
Matched on
terms: call
PFD report
73match
Jack Hubbard
The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency response.
Matched on
terms: call, emergency
PFD report
73match
Christina Lawal
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.
Matched on
terms: call, emergency
PFD report
69match
Gary Million
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.
Matched on
terms: call
PFD report
69match
Christopher Smith
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.
Matched on
terms: call
PFD report
69match
Thomas Collins
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.
Matched on
terms: inappropriate
PFD report
69match
Patricia Mercieca
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.
Matched on
terms: call, emergency
PFD report
69match
Olive Nutt
Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.
Matched on
terms: call
PFD report
69match
Graham Smith
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.
Matched on
terms: call, emergency
PFD report
69match
Anna Hedman
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.
Matched on
terms: call, emergency
IOPC learning recommendation
69match
Recommendation - Cheshire Constabulary, December 2022
The IOPC recommends that Cheshire Constabulary should ensure that the procedures for call handlers to escalate incidents are set out clearly in force policy. This follows an IOPC review of a Serious Injury investigation, where a man took an overdose following several calls to the police expressing concern for his welfare, over a number of hours. A local...
Matched on
terms: call
PHSO casework decision
69match
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.
Matched on
terms: call, emergency
HMICFRS recommendation
68match
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 of non-emergency 101 calls so that caller attrition levels are reduced and kept as low as possible.
Matched on
terms: call, emergency
HMICFRS recommendation
68match
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 answer a greater proportion of non-emergency 101 calls so that caller attrition levels are reduced and kept as...
Matched on
terms: call, emergency
PPO recommendation
68match
The Governor
The Governor should ensure that when staff call a medical emergency code, they promptly provide information about a prisoner’s condition to the control room so that they can pass this information to the Ambulance Service.
Matched on
terms: call, emergency
PFD report
65match
Joshua Smith
Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.
Matched on
terms: emergency
PFD report
65match
Richard Barrett
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.
Matched on
terms: call
PFD report
65match
Gladys Furnival
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.
Matched on
terms: emergency
PFD report
65match
Paul Mclean
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.
Matched on
terms: call
HMICFRS recommendation
64match
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 sure it can answer a greater proportion of non-emergency 101 calls so that caller attrition levels are reduced...
Matched on
terms: call, emergency
HMICFRS recommendation
64match
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 abandonment levels are reduced and kept as low as possible.
Matched on
terms: call, emergency
PPO recommendation
64match
The Governor of HMP Belmarsh
The Governor should write to the Ombudsman, setting out what improvements have been made to ensure that: • control room staff call an ambulance immediately and provide all possible information required, remaining on the line until an ambulance is dispatched; and; • there are no delays in escorting ambulance and paramedics in an emergency.
Matched on
terms: call, emergency
PHSO casework decision
64match
P-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 administered within the appropriate timeframe, that when the...
Matched on
terms: call, transfer
IOPC learning recommendation
63match
Recommendations - Essex Police, September 2019
The IOPC investigated a complaint relating to the information given by call handlers in the force control room (FCR) to callers. Essex Police procedure on responding to incidents states that, for emergency graded incidents, callers should be given an estimated time of arrival (ETA). However, this complaint related to a call which was graded as ‘significant’. The policy...
Matched on
terms: call, emergency
PFD report
61match
Adil Habib
Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.
Matched on
terms: call
PFD report
61match
Ronald Volante
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.
Matched on
terms: call
PFD report
61match
Mark Banks
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.
Matched on
terms: call
PFD report
61match
Aidan Ridley
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.
Matched on
terms: call
IOPC learning recommendation
60match
Recommendation - Avon and Somerset Constabulary, June 2025
The IOPC recommends that Avon and Somerset Constabulary should put in place a process to ensure the control room telephone number is displayed to callers during a threat-to-life incident or a voice message is left enabling them to call back if their initial call is missed. This recommendation follows a review where Avon and Somerset Constabulary received a...
Matched on
terms: call, emergency
PPO recommendation
60match
The Director at Parc
The Director at Parc should ensure that control room staff call an ambulance immediately they receive a medical emergency code.
Matched on
terms: call, emergency
PPO recommendation
60match
The Director and Head of Healthcare
control room staff call for an ambulance immediately when a medical emergency code is called
Matched on
terms: call, emergency
PHSO casework decision
60match
P-002601 - South Central Ambulance Service NHS Foundation Trust
Mrs T complains about the way the Trust handled the emergency call her father made in September 2022. She complains the call was not put through to the ambulance service immediately, about how the call was handled and that it took too long for the ambulance to arrive.
Matched on
terms: call, emergency
HMICFRS recommendation
59match
PEEL 2023-25 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The constabulary needs to improve the time it takes to answer emergency and non-emergency calls. Recommendation: Within six months, Gloucestershire Constabulary should make sure it can answer a greater proportion of emergency calls more quickly to provide a better service for the public.
Matched on
terms: call, emergency
PFD report
57match
Christopher Fields
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.
Matched on
classifier match
PFD report
57match
Matthew Lewis
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.
Matched on
terms: call