South Central Ambulance Service NHS Foundation Trust

3. Mrs X complains about South Central Ambulance Service NHS Foundation Trust (SCAS) regarding the care provided to her son, Y, on 25 April 2023.

4. Mrs X says SCAS ambulance crews failed to provide any treatment or take any clinical observations despite several attendances due to him refusing help. She says her son’s capacity to make these decisions was compromised and crews failed to consider this.

5. She says her son died due to these failings.

6. Mrs X seeks compensation for the loss of her son’s life.

7. On 25 April 2023 Mrs X returned home after a weekend away to find her son, Y, who was 24-years old and lived with her, unwell. Y was acting out of character, shouting and crying out in pain, and Mrs X found some damage in the house and some dark vomit in the bathroom. She called the Ambulance Service several times following this discovery.

8. The first ambulance attendance was at approximately 2.22pm. The Police were also in attendance at that time as Mrs X called them too. Y refused to be examined or accept any help from the ambulance crew. He refused to go to hospital. The crew explained they were concerned for Y’s welfare, as he may have vomited blood and this could indicate life threatening conditions, but that without his consent they could not impose care upon him. The crew provided advice to Y and Mrs X on what to do if his condition should not improve before leaving Mrs X’s home.

9. The second ambulance attendance was at approximately 7.19pm following Mrs X’s continued concerns about Y continuing to suffer bouts of dark vomit and being in pain. Again, Y refused almost all assessments or help and refused to go to hospital. On this occasion Y allowed his pulse to be checked only and his heart rate was slightly elevated but within normal range for an adult.

10. As before, the crew explained their concerns for Y’s welfare and urged him to let them take him to hospital or alternatively he travel there independently. Y maintained his position on refusing all assistance. The crew explained the limits on what they could do without consent to Mrs X, provided advice on what to do if Y’s condition should change, and left after approximately half an hour.

11. The following day, on 26 April Mrs X found Y had collapsed in the afternoon and she made two 999 calls. Y was taken to hospital by emergency air ambulance, but sadly he had suffered a cardiac arrest and did not survive. A subsequent post-mortem report found a high level of alcohol in Y’s blood, which it concluded would have been significantly higher the day before, possibly at that time at toxic levels.

12. A toxicology report found no other substances except trace levels of sleep aid and antihistamine medications, enough to indicate therapeutic use only. The post-mortem found signs of bleeding in Y’s throat, and separately in his abdomen around his pancreas.

13. The Coroner concluded ‘a prolonged period of binge drinking on alcohol caused fatal acute pancreatitis with death following onset of pulmonary oedema and lung congestion’. In simple terms this means alcohol misuse had led to Y suffering a fatal organ failure some-time after he had stopped drinking.

17. Mrs X’s central complaint is that the ambulance crews attending on 25 April should have done more to help her son. She accepts that he refused any help from emergency services, and by her own account he also would not accept help from her. His cause of death is not disputed. However, she says that his behaviour was out of character, and he was acting with reduced capacity to make rational decisions at the time. She believes there should have been grounds to intervene, and act against his will despite his refusal, to save his life.

18. Mrs X cites a number of reasons for her view on this. She explains that her son’s judgement was affected by alcohol, and she suspected that he had also taken some of his brother’s mental health medication. She also says his voice had changed and was higher pitched than usual and his behaviour was out of character.

19. We have carefully reviewed the Trust’s records, including the accounts of the ambulance crew staff. These show that the crews were aware that Mrs X informed them Y had potentially been drinking for the past five days and not eating or hydrating well. The crews saw evidence of dark vomit and recognised that this could be a sign of Y having vomited blood.

20. The Coroner’s conclusions establish that the dark vomit identified on 24 April was from bleeding in the throat caused by retching. This was apparently not directly linked to Y’s later death, which was due to a separate injury. Y’s pancreas haemorrhaged after some time due to damage caused by the high levels of alcohol consumed in the days before.

21. Pancreatitis is the medical term for inflammation of the pancreas, in this case due to alcohol toxicity. In severe cases can be fatal as this scan cause the organ to fail. This would have been impossible to confirm at the time as Y refused any examination, but as it is a common complication of alcohol misuse it would have been suspected, along with other serious consequences of heavy drinking, by the ambulance crews on both occasions.

22. What is clear is that the ambulance crews shared Mrs X’s high level of concern for Y’s welfare and all parties wanted him to receive medical care and be taken to hospital. Mrs X says that, knowing the danger her son may have been in, the crews should have done more than provide advice. We asked our adviser what options a crew would have in such a situation. They explained the following:

23. Ambulance crews much work in line with both legislation (MCA and HRA, which they are legally bound to abide by, and professional guidance (JRCALC 2019 and MHACP), as well as any relevant local guidance from their employing Trust.

24. ‘Capacity’, as defined by MCA is ‘the ability of an individual to make decisions regarding specific elements of their life’. In simple terms, ‘capacity’ is the ability to make a decision at the time it needs to be made, according to JRCALC. Before ambulance crews can provide treatment to or for a conscious patient, it is mandatory they have the patient’s consent first.

25. Patients must have mental capacity to give or withhold consent. Mental capacity is central to determining whether treatment and care can be given to someone who refuses, except in a few exceptional circumstances outlined in MCA. This is mandatory for both JRCALC guidance and MCA law.

26. MCA lays out five key principles, the first of which is that ‘every person must be assumed to have capacity unless it is proved otherwise’. HCA legally protects an individual’s right to refuse. The threshold for overriding this is high.

27. MCA requires that, for someone to be considered to have capacity, the answer must be ‘yes’ to the following four questions: • Does the patient understand the information relevant to the decision?

• Can the patient retain the information long enough to make a decision?

• Can the patient weigh or use the information to come to a decision?

• Can the patient communicate a decision?

28. If the answer is yes to all these questions, then the patient is able to make a decision, and no further assessment is needed.

29. In order to determine if a person lacks capacity, there are four main questions set out in MCA that must be considered when assessing a person’s capacity. These are: • What is the decision that needs to be made?

• Is the person able to make that decision?

• Is there a disturbance or impairment of the functioning of a person’s mind or brain (temporary or permanent)?

• If present, is the impairment or disturbance sufficient to cause the person to be unable to make that particular decision at that particular time?

30. The second key principle of MCA says patients must be supported to make a decision before anyone concludes that they cannot. This may involve ‘delaying’ a decision until any impairment may be reduced.

31. Finally, another key principle of MCA is ‘a person should not be considered as unable to make a decision solely because they make an unwise decision’. This means capacity should not be confused with an assessment of the reasonableness of a person’s decision. A person is entitled to make a decision that others may perceive as unwise, eccentric or irrational, as long as they have the capacity to do so.

32. In line with this, JRCALC mandates that, if an adult is mentally capable of making a decision, then their decision must be respected, even if a refusal may risk permanent injury to that person’s health or even lead to premature death.

33. Our adviser highlighted that JRCALC includes an exception to this. When an apparently irrational decision is based on a misperception of reality (for example someone experiencing hallucinations, delusions, or disordered thinking) the patient may not truly be able to understand, and this would require further assessment to confirm patient understanding.

34. JRCALC also identifies that determining impairment of the mind or brain when alcohol or drugs is involved is often a complicating factor. JRCALC recognises a person may be aware of their behaviour or decisions they make, but they may be less aware, or less concerned, about the consequences of these than they would otherwise be. JRCALC acknowledges judging capacity in such circumstances is difficult and subjective. Consideration needs to be given to balance of risk of getting a judgement on capacity wrong, and any clinical risks of not intervening.

35. Bearing this advice in mind, we would expect the ambulance crews to abide by the three MCA principles set out above and the JRCALC guidelines.

36. For a patient who is conscious and refusing care, it was appropriate for the crew not to immediately try and act in what they considered Y’s best interests. What they should have done is consider if Y had capacity to give informed consent, consider his wishes, and try to gain his consent before any further assessments could be made.

37. On each occasion the crews established initially that Y was alert and able to respond verbally. Y was also recorded on both crew attendances as having a Glasgow Coma Score (GCS) of 15. This is the highest possible score and indicates his eye, verbal, and motor responses were all normal. We can see that Y was not confused or unconscious.

38. He was, however, consistently refusing all offers of assistance or to follow any advice given. The records indicate he also refused to cooperate with his mother, Mrs X, who was trying to get him to agree to go to hospital. Mrs X’s account is consistent with these details, so there is no disagreement that this was the situation each ambulance crew encountered upon arrival.

39. The Trust’s records indicate both crews were aware of the fact that Y had consumed alcohol. However, he did not appear drunk, was not confused and was alert and orientated, and he understood the ambulance crews were advising him to be assessed and potentially go to hospital.

40. MCA requires the presumption of capacity unless proven otherwise. The records show that the crews considered the four questions required under the first MCA principle to decide if Y had capacity. Y was able to understand information relevant to the decision, he retained this long enough to make a decision, he was able to come to a decision, and he communicated this to the crews on both occasions. Nothing in Mrs X’s account indicates a reason that would call Y’s capacity into question.

41. Based on this we see that, under MCA, Y should have been considered to have capacity to make decisions and, under JRCALC, his decision to refuse assistance had to be respected. As such the ambulance crews on both occasions would have been bound, by law, to not intervene further beyond trying to change his mind and provide advice. We see that is what they did. To do otherwise would have been a breach of the law and Y’s right to refuse.

42. Our adviser explained that the more serious and complex the decision, the greater level of capacity is required to make that decision. In this case they explain the decision in question was fairly straightforward. This was, whether Y would agree to be assessed by the ambulance crews and/or potentially go to hospital. As such, our adviser says Y would not need a high level of capacity to make such a decision.

43. The records indicate that on each occasion the crew followed JRCALC guidance by considering Y’s alcohol consumption in their capacity assessments and decision making. Both crews believed Y had the mental capacity at each attendance to understand they were concerned about him and wanted to take him to hospital, and that he understood his decision was against medical advice.

44. Our adviser also noted that the records show that Y refused multiple times, on two separate occasions several hours apart, to be assessed or to go to hospital. They said, if Y had been affected by alcohol or drugs during the initial attendance, the effect of these would have significantly lessened by the time of the second attendance, approximately five hours later.

45. This also shows that the ambulance crews applied the second principle of MCA cited above by ‘delaying’ a decision until any impairment may be reduced. The evidence demonstrates a consistent thought process over time by Y on his wishes not to be assessed by the ambulance crews or attend hospital. This further underlines the lack of evidence to support a view that he lacked capacity to make decisions due to intoxication.

46. We then considered the third principle and associated JRCALC guidance. The records confirm that both crews, and Mrs X, were concerned that Y was making an unwise decision, and felt that his refusal may have risked him coming to serious harm. MCA specifically states this is not grounds for questioning a person’s capacity to make decisions, and JRCALC requires that Y’s decision be respected. As such the crews were duty bound to not intervene further despite being concerned that Y was making an unwise decision that may be risking his life.

47. We considered if there was any indication that Y’ perception of reality was impaired, as this appears to be the only factor left that could have provided grounds to question capacity. Again, there is no evidence to support this was the case in both the ambulance crew’s accounts, or Mrs X’s. Our adviser also was of the view that they could find no evidence Y was impaired in this way at those times. His decisions did not appear to be influenced by hallucinations, delusions, or disordered thinking.

48. We appreciate how distressing it was for Mrs X to witness her son needing medical help but refusing to accept it. It is understandable that she would hope there would be some way to intervene against his will for his own good to save his life. In the absence of any cooperation the only way to do this would be to physically restrain a patient.

49. Our adviser explained that are limited circumstances where a person can be detained under MHA. The criteria for these are outlined in MHACP and would require the person to be established as lacking capacity and requiring immediate care or physical control. These situations usually would often involve a person suffering from a known history of mental health disorder.

50. The burden of evidence needed to justify overriding a person’s legal rights would be significant. It would require the Police to work with doctors, social workers, and Approved Mental Health Professionals (for example a psychiatrist), often requiring a warrant from a magistrate’s Court.

51. Our adviser explained that none of these criteria would be directly relevant in Y’s case, as he passed the tests for having capacity by some margin, but this serves to illustrate the high threshold needed to impose care on a person who refuses it. Sadly, there was no opportunity for the ambulance crews to do more on both occasions even though they wanted to. What we are seeing is this was not borderline a situation where there was any chance a case could be made for emergency services to intervene physically.

52. We were very sorry to learn of Mrs X’s extremely traumatic experience and the circumstances of her son, Y’s, death. Having carefully reviewed the actions of the ambulance crews that attended her home on 25 April 2023 we could find no indication of failings. It appears the law is very specific about the limitations of what can be done when a patient refuses care. The ambulance crews were powerless to do more for Y in light of his reluctance to allow any assessment or hospital treatment.

53. For this reason, we have decided we should not consider this complaint further. We hope that our findings help to explain why the crews could not do more on 25 April to help prevent what happened the next day.

1. We have carefully considered Mrs X’s complaint about South Central Ambulance Service NHS Foundation Trust. We have seen no indication that anything went seriously wrong with the actions of the ambulance crews who attended Mrs X’s home as they were sadly restricted in what they could legally do for her son, Y.

2. We were very sorry to learn of the events surrounding Mrs X’s complaint and how traumatic these were for her and her family. We hope our findings reassure her that sadly the emergency services who attended had no options available to them to do more for Y, despite wanting to help more.