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
Source spread
Where this theme appears
Inappropriate Emergency Call Transfers has been flagged across 8 independent accountability sources:
89 PFD reports
1 CQC action
11 HMICFRS recs
12 PPO recs
7 IOPC recs
1 Scottish FAI
40 PHSO decisions
1 LGO/SPSO decision
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 (89) — showing 50 strongest matches
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
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 (Edward Timpson MP): The Department for Education acknowledges the concern about paediatric first aid training and states that it is a statutory requirement for early years providers. They are consulting on reinforcing the …
Response (North West Ambulance Service NHS Trust): NWAS describes its recruitment and training processes for Emergency Medical Dispatchers (EMDs), including a six-week training course and continuing education requirements. All EMDs are required to undergo CPR recertification every …
Response (Department of Health): The Department of Health acknowledges the concerns, notes that training of nursery staff is the DfE's responsibility and NWAS is responsible for selection/training of call takers. They report that NWAS …
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 (South Central Ambulance Service): South Central Ambulance Service has extended Rapid Response Vehicle cover to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. Rota match versus demand has also been reviewed. They have developed a …
Responded
Gianna Khan
Concerns: The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead of being seen by a doctor in the A&E Department, and that the Clinical Commissioning Group had refused a full triage before streaming patients.
Response (Luton NHS Clinical Commissioning Group): Luton CCG will share findings with Luton Clinical Commissioning Group, LHS has accepted NICE Guidance CG176, LHS will cooperate with NHS England investigation and is resubmitting its 'Risk and Serious …
Responded
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
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
Sonielia Holmes
Concerns: The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to respond to messages requesting advice and review of the patient.
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.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): The Trust has undertaken training with senior members of the CICU Team, who are now competent in the placement of iGel tubes. A policy of using end tidal carbon monoxide …
Responded
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
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.
Response (HM Prison and Probation Service): HM Prison and Probation Service has completed a DVD covering principles of safe restraint, medical complications, and actions to take when prisoners conceal items in their mouths, which will be …
Response (London Ambulance Service NHS Trust): The London Ambulance Service has augmented its computer system with additional gate information for HMP Pentonville and shared learning about confirming addresses when taking calls from prisons in a team …
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.
Response (East Midlands Ambulance Service): EMAS has increased its frontline resources, implemented a 'hear and treat' system, and introduced a single Ambulance Technician vehicle in East Lincolnshire. These initiatives aim to increase ambulance availability for …
Responded
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
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
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.
Response (North West Ambulance Service NHS Trust): The North West Ambulance Service describes its existing 'Paramedic Pathfinder' algorithm and referral process to Acute Visiting Services, asserting it is a considered and auditable system.
Response (Haughton Thornley Medical Centres): The practice will ensure that when accidents happen with Thomas and Amy Senior and Tony Swales, they will obtain more information surrounding the circumstances of the fall and will clearly …
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.
Response (Magenta Living): Magenta Living updated their community alarm operator procedures to proactively provide medical history to the ambulance service, trained staff on the new procedure, and will include this in future inductions. …
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.
Response (Lisa Day Response2): LAS agreed a process with NHS 111 to electronically flag calls with clinical concerns; this system was introduced on 14 March 2016. Training bulletin TB 02/16 and flowchart v2.0 give …
Response (Lisa Day): London Central & West Unscheduled Care Collaborative (LCW UCC) has raised concerns regarding additional scripting of condition-specific information for type 1 diabetes with the National NHS Pathways team. Changes to …
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.
Response (Birmingham and Solihull NHS Trust): The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust …
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
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
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
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.
Response (South Western Ambulance Service NHS Trust): South Western Ambulance Service NHS Trust provides context on the ambulance delay and describes the NHS England Ambulance Response Programme (ARP), a clinically led review of call coding systems being …
Overdue
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.
Response (Warwickshire Police): Warwickshire Police have trained staff on threat, harm, risk, and vulnerability using the National Decision Making model and are seeking to introduce a system change to alert priority incidents out …
Responded
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.
Response (London Ambulance Service): The London Ambulance Service states that based on their understanding of the call records, no changes to the questions asked of 999 callers would have enabled them to triage the …
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.
Response (Maritime Coastguard Agency): The Maritime Coastguard Agency has updated guidance and modified training packages. All Coastguard tactical commanders attend JESIP courses and strategic commanders attend MAGIC courses; every officer completes online JESIP training. …
Response (Northumberland Fire and Rescue Service): Northumberland Fire and Rescue Service reaffirmed procedures for 999 calls, implemented joint working principles with blue light partners, and trained staff in JESIP. Future plans involve including HM Coastguard and …
Response (Northumbria Police): Northumbria Police and the North East Ambulance Service are considering expert advice from Mountain Rescue regarding phone tracking software. HM Coastguard is considering improving their Airwave capability to facilitate communication. …
Overdue
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.
Response (NHS England): NHS England reports that SWAST has raised concerns with NHS Pathways about prioritizing incidents involving patients who are alone and/or have dizziness with major haemorrhage. SWAST is also increasing the …
Response (South Western Ambulance Service NHS Foundation Trust): South Western Ambulance Service NHS Foundation Trust implemented a virtual telephony system and a 'hunt group' to improve call handling and clinical support accessibility. As a direct result of this …
Responded
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.
Response (West Midlands Ambulance Service): West Midlands Ambulance Service has provided further education and refresher training around head injuries during NHS Pathways updates. The Trusts Director of Clinical Commissioning and Service Development has also written …
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.
Response (Devon Cornwall Police): Devon and Cornwall Police have reviewed their grading and deployment policy and operational practices regarding call grading and incident creation. They have also put in place training packages for staff, …
Responded
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
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
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.
Response (London Ambulance Service NHS Trust): The London Ambulance Service reports that the Emergency Medical Dispatcher involved in the incident has been subject to performance management and given additional training. They have undertaken a review of …
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.
Response: The Welsh Ambulance Services NHS Trust and Cardiff and Vale University Health Board confirmed the continued actions of reminding CCC Clinical Leads to address Protocol 23 cases promptly, approach the …
Response (Welsh Government): The Welsh Ambulance Services NHS Trust (WAST) is considering options to increase capacity on its clinical support desk and exploring options for third sector organisations to support delivery of welfare …
Responded
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.
Response: The Health Board reports improvements in ambulance response times and highlights several initiatives to improve the timeliness of releasing crews at the hospital, including practitioners reviewing WAST calls and additional …
Response (Welsh Ambulance Services): The Welsh Ambulance Services NHS Trust acknowledges concerns and has completed and continues to work on strategic and operational quality improvements in patient safety, including training of Clinical Contact Centre …
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
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
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.
Response (South Wales Police): South Wales Police have developed a procedure for call handlers that incorporates guidance highlighting the presumption that 'life is not extinct' in hanging scenarios. This procedure is now part of …
Response (College of Policing): The College of Policing will amend learning standards for contact management staff within the next month to reflect the importance of preserving life. They have also asked for a summary …
Responded
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.
Response (East Midlands Ambulance Service NHS Trust): EMAS acknowledges exceeding response times and states that additional funding was agreed to address this. The funding will be used for clinical staff, ambulances, and other resources to improve response …
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
John Scott
Concerns: No specific concerns text was provided for summarization.
Response (NHS England): NHS Pathways is undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage process, including utilizing risk factors and specific questions …
Response (South East Coast Ambulance Service NHS Trust): South East Coast Ambulance Service has discussed the coroner's concerns with NHS Pathways, who are reviewing care instructions and considering amendments to the Pathways script for inclusion in version 18 …
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.
Response (Wiltshire Police): Wiltshire Police states that staff briefings have been sent out reminding 999 call handlers to use the three-way call process when needed. They also state that further revisions of the …
Responded
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.
Response (East Midlands Ambulance Service NHS Trust): EMAS has issued bulletins to frontline staff and control centers clarifying procedures for safe discharge of lower acuity calls, mental capacity assessments for patients refusing transport, and CAT access to …
Response (Associaion of Ambulance Chief Executives): AACE will request that JRCALC review UK ambulance service clinical practice guidelines relating to the management of patients that have misused alcohol, including alcohol withdrawal, its presentation and management, and …
Responded
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.
Response: London Ambulance Service outlines the operational policy for dispatch of resources in any category of call, and provides details of the systems in place to identify caller location. It also …
Overdue
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
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
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
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
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
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
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.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service NHS Trust has expanded its Healthcare Professional (HCP) triage team, enabling them to filter HCP calls and escalate urgent clinical discussions. They use the Medical Priority …
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
HMICFRS Recommendations (11)
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
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 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 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 emergency calls more quickly to provide …
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 emergency calls made to the force …
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 attend most calls within …
Recommendation
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 …
Recommendation
PEEL 2023-25 CoC Recommendations: Surrey Police
Cause of concern: The force’s response to incidents needs to improve. Recommendation: Within six months, Surrey Police should make sure that repeat callers are routinely identified by call handlers.
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 (7)
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 …
PHSO Casework Decisions (40)
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-001508 — North West Ambulance Service NHS Trust
Mr B complains that the Trust failed to assess and prioritise his partner's symptoms, failed to send an ambulance when required, and advised not to call 999 should her condition deteriorate.
NHS in England
Aug 2022
P-002269 — Humber and North Yorkshire Integrated Care Board
Mrs A complains the ICB wrongly decided to send carers instead of paramedics when her husband fell.
NHS in England
Oct 2023
P-002774 — North West Ambulance Service NHS Trust
Mrs S complains the Trust’s 111 service did not correctly handle a call it received from her son in January 2021 and this contributed to his death.
NHS in England
Jul 2024
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
P-004129 — West Midlands Ambulance Service University NHS Foundation Trust
Mrs A complains that the Trust did not take her husband to hospital on 18 January 2025 because the ambulance crew judged his condition to be low risk, advised him to make an appointment with his GP instead and told him going to the hospital would make him worse.
NHS in England
Oct 2025
P-004266 — London Ambulance Service NHS Trust
Mrs O complains about the service her sister, Ms I, received from the Trust. Mrs O complains the Trust incorrectly triaged Ms I's phone calls (999 call, 111 call and the GP call) on three separate occasions.
NHS in England
Nov 2025
P-004665 — An independent provider in the City of Derby …
The K's complain WMAS and 111 incorrectly categorised their mother's symptoms, 111 did not give an estimated time for ambulance arrival and the ambulance took too long to arrive. They also complain about aspects of WMAS's complaint responses.
NHS in England
Jan 2026
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-001217 — Yorkshire Ambulance Service NHS Trust
Mrs A complains about the care and treatment provided to her late mother by the Yorkshire Ambulance Service NHS Trust on 19 December 2018. She says the Clinical Advisor who was involved in the 999 telephone calls failed to prioritise the response from the Trust which meant that an ambulance …
NHS in England
Nov 2021
P-001627 — South Central Ambulance Service NHS Foundation Trust
Mrs A complains on behalf of her mother, Mrs T, about what happened when she called 111 in January 2021. Mrs A complains staff asked unnecessary questions and failed to send an ambulance despite Mrs T's symptoms.
NHS in England
Partly Upheld
Nov 2022
P-002372 — East of England Ambulance Service NHS Trust
Mrs A complains the Trust incorrectly categorised her father’s 999 call making the wait time for an ambulance even longer.
NHS in England
Dec 2023
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.
NHS in England
May 2024
P-002766 — South Central Ambulance Service NHS Foundation Trust
Miss M complains South Central Ambulance Service NHS Foundation Trust incorrectly categorised a 111 call made for her father when he was suffering from gastrointestinal haemorrhage.
NHS in England
Upheld
Jul 2024
P-003664 — A practice in the Forest of Dean area
Mrs N complains that when Mr N attended his GP practice with foot pain on 2 December 2024, the receptionist did not review his medical history or seek any clinical advice. He was advised to ring NHS 111 and was not seen by a GP.
NHS in England
Jul 2025
P-004019 — Yorkshire Ambulance Service NHS Trust
Miss A complains about the care provided to her father, Mr B, by Yorkshire Ambulance Service NHS Trust (the Trust) when he was suffering a heart attack on 3 April 2023. Miss A also complains about the way in which the Trust handled her complaint.
NHS in England
Not Upheld
Sep 2025
P-004372 — South East Coast Ambulance Service NHS Foundation Trust
Miss E complains the Trust did not categorise her fathers 999 call correctly
NHS in England
Nov 2025
P-004391 — A practice in the Dorset area
Ms R complains about the triage and assessment of her mother when she contacted the Practice with chest infection. She says the Practice should have arranged an urgent home visit or called an ambulance.
NHS in England
Dec 2025
P-001290 — West Midlands Ambulance Service University NHS Foundation Trust
Mrs C complained about how West Midlands Ambulance Service University NHS Foundation Trust handled 999 calls in relation to her son.
NHS in England
Partly Upheld
Feb 2022
P-001699 — A practice in the Lancashire area
Miss B complains the Practice did not check up on her uncle's health, or diagnose his condition, but put it down to his pre-existing cancer. She also complains it did not refer him to the eye hospital and it requested an ambulance under the wrong category.
NHS in England
Jan 2023
P-003853 — A practice in the Sandwell area
Mr S complains about how the Practice acted when his father called after having a fall. He says his father was asked if it was an emergency and he was not given any advice.
NHS in England
Jul 2023
P-002251 — London Ambulance Service NHS Trust
Mr B complains the Trust told him to call 111 instead of 999. He then says the Trust agreed his wife needed an ambulance but there were delays with it arriving.
NHS in England
Oct 2023
P-002289 — North East Ambulance Service NHS Foundation Trust
Mrs A complains an ambulance crew failed to properly assess her condition and do the right tests, they should have taken to her to hospital and the complaint responses contain lies to cover up what the ambulance crew did.
NHS in England
Nov 2023
P-002670 — A practice in the Hartlepool area
Mrs E complains the Practice incorrectly referred her on a two-week pathway to the gastroenterology department at her local hospital instead of to the ear, nose and throat (ENT) department. She also says she was incorrectly removed from the patient register.
NHS in England
Jun 2024
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-003325 — Imperial College Healthcare NHS Trust
Mr A complains about the actions of three organisations during March 2023 when he had abdominal pain and vomiting. He complains the Practice did not diagnose the condition, the Trust made a wrong diagnosis and would not reassess him the next day, and the Ambulance Trust would not take him …
NHS in England
Feb 2025
P-003400 — North West Ambulance Service NHS Trust
Mrs E complains the Trust did not categorise the 999 calls she made appropriately, provided the incorrect information to her about ambulance response times and suggested she take her husband to hospital herself.
NHS in England
Mar 2025
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-003944 — Bradford Teaching Hospitals NHS Foundation Trust
Mrs P says both the Trust and the Ambulance Trust delayed diagnosing, treating, and transferring her son, Mr P, due to miscommunication and misdiagnosis.
NHS in England
Sep 2025
P-003973 — South East Coast Ambulance Service NHS Foundation Trust
Mrs L complains about her interactions with the Trust on 21 and 22 May 2024. She complains that despite her brother's significant deterioration after a GP appointment, and his breathlessness and heart condition, the Trust failed to take these concerns seriously.
NHS in England
Sep 2025
P-004067 — East of England Ambulance Service NHS Trust
Mr L complains the Trust did not correctly triage a 999 call made for his late friend, and when he was transferred between hospitals, the ambulance crew would not take his wheelchair.
NHS in England
Sep 2025
P-004024 — South Western Ambulance Service NHS Foundation Trust
Mrs L complains on 1 March 2024, the Trust failed to provide appropriate care to her husband Mr L. She complains several telephone calls to the Trust for an ambulance were categorised incorrectly and the Trust took nearly three hours to send an ambulance for her husband.
NHS in England
Sep 2025
P-004542 — South East Coast Ambulance Service NHS Foundation Trust
Mrs F complains paramedics from South East Coast Ambulance Service NHS Foundation Trust failed to take her to hospital for further investigations and communicated poorly towards her on 13 July 2024.
NHS in England
Dec 2025
P-001258 — A medical practice in the London Borough of …
Dr B complained the GP Practice and Hospital Trust did not start his mother on medication for atrial fibrillation (irregular heartbeat). He also complained the Ambulance Service did not recognise his mother was having a stroke.
NHS in England
Partly Upheld
Jan 2022
P-002805 — East of England Ambulance Service NHS Trust
Mr G complains that between October and December 2019 doctors at the Practice and the Trust failed to identify his worsening heart failure. He also complains the Ambulance Trust failed to send an ambulance despite a 999 call.
NHS in England
Jul 2024
P-003393 — A practice in the West Suffolk area
Miss F complains a GP at the Practice failed to recognise that her friend, Mrs G, needed emergency care during a telephone consultation in July 2023.
NHS in England
Mar 2025
P-003510 — A practice in the City of Bristol area
Mr D complains about the care and treatment the Practice provided to his father on 14 December 2021. He complains it did not take appropriate action when he reported chest pain and shortness of breath and that a GP should have visited him at home, arranged for him to go …
NHS in England
Apr 2025
P-003628 — North East Ambulance Service NHS Foundation Trust
Miss J complains about the Trust’s handling of calls about her father after he collapsed and a delay in starting CPR.
NHS in England
Partly Upheld
Jun 2025