Health Secretary Shona Robison last night demanded action after a man died while waiting for an ambulance – because the call handler did not pass on the note with his details.
The alarm was raised when the man went into cardiac arrest at a house in Aberdeen early in the morning last month.
But at the time, the ambulance service was suffering a computer blackout and the call went through to the control room in South Queensferry.
The call handler scribbled down the man’s details, and told the caller how to carry out CPR until an ambulance arrived.
But it later emerged the note had not been passed to the dispatch team, and by the time the error was realised and an ambulance arrived 33 minutes later, it was too late to save the man.
It is understood calls are meant to be handled by local control rooms – which for the north and north-east would be in Inverness – when the IT system is down.
Last night, ambulance chiefs confirmed an investigation had been launched but stressed the circumstances into the incident were “extremely unusual”.
Health Secretary Ms Robison demanded the findings be acted upon to avoid another “tragic” incident.
She said: “I am deeply concerned to hear about this tragic incident and my thoughts are with the family and those affected.
“I have spoken directly to the chief executive of the ambulance service to ensure that a full and urgent review of this case is undertaken, and made clear that its findings must be acted upon.”
The incident happened at about 2.45am on May 19.
A Scottish Ambulance Service spokeswoman confirmed an investigation had been launched and that recommendations would be addressed.
She said: “We received a call at 2.46am on Friday May, 19 to attend an address in Aberdeen and arrived at 3.19am.
“CPR advice was provided by our call handler.
“The response time is longer than we would expect, and the incident was reported by the ambulance control centre staff involved.
“We are currently undertaking a full investigation of the events. Initial findings indicate that the circumstances around this incident were extremely unusual.
“We have contacted the patient’s family to offer our sincere condolences and to hear their recollection of the response as part of our investigation.
“We will share our findings with the patient’s family and address any recommendations.”
An insider described it as a “disaster waiting to happen.”
They said: “Each control room should be receiving emergency calls in their area when the system is down.
“Callers receive a less than effective service during blackouts.
“The mood in the control room that night was very sombre.”
North East MSP Lewis Macdonald said there were wider issues for concern in the incident.
He said: “It is quite surprising that the call was answered in Edinburgh, ordinarily it would be answered in Inverness as that is the one that covers Grampian.
“The question would be who is meant to be taking calls from Grampian during the early hours of the morning.
“The ambulance service needs to do an investigation into why the information did not reach the crewmen and what difference this would have made to the outcome.
“Given there are concerns around the police and the fire control rooms being moved to the central belt those questions must be answered.”