Healthcare Safety Investigation Branch -
This investigation aims to support improvements in the delivery of NHS 111 and other telephone triage services during a national health care emergency. The investigation uses real patient safety incidents involving patients and their families who dialled NHS 111 (and were either managed through NHS 111 or the Covid-19 Response Service) for advice during the Covid-19 pandemic. These are referred to as ‘reference events’ and support examination of the national issues. The four reference events used in this report occurred in the early months (March–June 2020) of the pandemic, but the report also highlights learnings and developments from later in the pandemic. It highlights the importance of ‘stand-up’ services and clear communication across the NHS and to the public when they are accessing telephone triage services in times of national emergencies.