South East Coast Ambulance Service NHS Foundation Trust

3. Mr A complains about the care and service provided to his partner, Ms B, by the NHS Trust on 9 and 10 October 2023. Specifically:

• there were severe delays with call backs from the NHS 111 service • lack of observations and documented medical history taken by the ambulance crew during the first attendance • lack of ability and knowledge from the paramedic regarding Ms B’s condition • inadequate communication by the ambulance crew regarding the extent of Ms B’s condition.

4. Ms B died unexpectedly, and Mr A will have to live with this for the rest of his life. He is currently undergoing counselling as his mental health was severely affected by what happened. Mr A feels guilty as he was blamed by some of Ms B’s family for not insisting that she went to hospital in the original ambulance that was sent. Mr A has reported feelings of suicide and is receiving support for this.

5. As a set of outcomes, Mr A wants a sincere apology from the Trust. He wants the Trust to learn from this complaint so no one else must go through what he has gone through. He also wants improvements to the 111 service so that call backs are made if promised.

6. Ms B was 48 years old, and the partner of Mr A. Ms B became unwell on 6 October 2023 with flu-like symptoms. She had a complex medical background of early liver cirrhosis, chronic pancreatitis, low BMI, low albumin levels, history of alcohol dependency and mental health difficulties including low mood.

7. By 9 October 2023, Mr A was concerned that Ms B’s symptoms were worsening. He called 111, and they agreed to call him back in an hour, but no callback was received. Mr A called 111 again on 10 October 2023. They told him they had requested a GP visit for Ms B, so Mr A called the GP to be told they were closed for training, but someone would call him back. No callback was forthcoming, so Mr A called 111 again.

8. It agreed to send an ambulance to check Ms B. The ambulance crew took some basic observations, but Mr A says they did not take a full medical history or oxygen saturations when they should have done. The crew wanted to take Ms B to hospital, but she did not want to attend unless it was entirely necessary due to her spending many weeks in hospital previously due to her other conditions. Ms B was unconvinced there was an urgent reason to attend hospital, so she declined, and the ambulance left.

9. Approximately two hours later, Ms B’s condition deteriorated rapidly. Mr A called 999 and she was taken to hospital, but she sadly died shortly after arriving at hospital. The cause of Ms B’s death was respiratory failure/pneumonia.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the NHS Trust has already done enough to put right the impact of these events.

Events on 9 and 10 October 2023

14. Mr A says there were severe delays with call backs from the NHS 111 service at this time.

15. The NHS Trust acknowledged in its complaint response that there were some shortcomings in terms of how it handled 111 calls on 9 and 10 October 2023. It apologised for the delays and provided assurances that the relevant members of staff will receive feedback on the outcome of audits on the calls and will be provided with any additional learning and support, as necessary.

16. Our adviser has reviewed the relevant evidence including the call recordings and concurs with the NHS Trust that there were some delays in the call backs to Mr A from the 111 service. It is noted that at the time, the NHS Trust was operating at clinical escalation level 4. This indicates there was a high demand for its services.

17. Therefore, we have considered the impact of these delays and how the NHS Trust managed Mr A’s calls on 9 and 10 October 2023. Our adviser says the records indicate the 111 service offered to re-triage Mr A’s calls (to give the call back additional priority if clinically indicated), but he declined this offer.

18. Looked at in isolation, our adviser says the acknowledged delays had the potential to have a negative impact on Ms B’s situation because if the call backs to Mr A had been more prompt, in theory, an ambulance could have attended to Ms B quicker than it did. Having said this, we do not know if there would have been any delays with the ambulance reaching Ms B or whether she would have been compliant in accepting treatment and/or attending hospital.

19. Therefore, while there is some indication of failings by the NHS Trust regarding how it managed call backs from the 111 service at the time and potential related injustice for Mr A and Ms B, this was due to a wider systemic issue of high demand for services which was affecting the NHS Trust at the time. The NHS Trust has acknowledged the delays in its complaint response and apologised. It has also taken what we consider to be appropriate remedial action in accordance with what we would expect to see in the circumstances. We appreciate that Mr A was worried about the delays with call backs, but we consider this matter has already been appropriately addressed and there is no further action for us to take.

20. Mr A says there was a lack of observations and documented medical history taken by the ambulance crew during the first attendance on 10 October 2023.

21. We have considered what should have happened when the crew attended Ms B. Our adviser says the relevant guidance is the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance used by ambulance crews in such circumstances. There is evidence in the records that the JRCALC guidance for dealing with a medical emergency in an adult was followed as the crew undertook and documented a primary and secondary survey including one set of observations from Ms B after she initially refused because she did not wish to attend hospital. The paramedic also attempted to take Ms B’s oxygen saturation levels, but they were unable to get a reading due to how cold her hands were.

22. While the records indicate that Ms B’s observations were documented on the Patient Care Record (ePCR) and on an advice sheet given to Mr A, our adviser says there is a lack of documented information regarding Ms B’s medical history and medication, but the NHS Trust has acknowledged this and apologised in its complaint response. It has also provided assurances that learning points for ensuring adequate information about medical history is recorded has been raised with the paramedic and the supporting crew member.

23. We know that Mr A was concerned about this and there are some indications of failings by the NHS Trust as regards the crew’s record keeping. The NHS Trust has apologised for this and already taken what we consider to be appropriate remedial action in the circumstances. As such, there is no further action for us to take.

24. Mr A says there was a lack of ability and knowledge from the paramedic regarding Ms B’s condition.

25. The NHS Trust said in its complaint response that the paramedic showed good knowledge and understanding of Ms B’s condition, as well as recalling information that matched the evidence documented in the ePCR completed during the second attendance.

26. Having considered the relevant records, our adviser says it is not expected for ambulance crews to have the same diagnostic abilities as clinical staff at a hospital. For example, it is not their role to provide a diagnosis of the patient’s condition. The key issue was the ambulance crew identified that Ms B was sufficiently unwell to require attention at hospital. They were unsure of the cause, but their advice based on her flu-like symptoms and medical background, was to attend hospital. Ms B did not wish to attend hospital, so the crew respected her wishes and left a ‘worsening symptoms’ leaflet for safety netting purposes which was appropriate.

27. Given this, there are no indication of failings by the NHS Trust on this point and therefore no further action for us to take.

28. Mr A says there was inadequate communication by the ambulance crew regarding the extent of Ms B’s condition.

29. The NHS Trust said in its complaint response that appropriate conversations took place with Ms B about the problems with her observations and the need to go to hospital, but she declined.

30. We have considered what should have happened regarding communication when the ambulance crew reached Ms B. Our adviser says the crew should have explained to Ms B about the problems with her observations and why they thought she needed to attend hospital for further assessment.

31. There are a number of documented references in the records about the crew’s rationale for taking Ms B to hospital, such as the problems with her observations. The records indicate that Ms B understood this and that the crew determined that Ms B had mental capacity to make this decision, but she did not wish to attend hospital. We do not know how this was put to Ms B and we recognise that Mr A feels more could have been done, but it would have been unprofessional for the crew to persist in telling Ms B to attend hospital if she had made it clear that she did not wish to attend which she had.

32. Given this, there are no indication of failings by the NHS Trust on this point and therefore no further action for us to take.

33. In summary, we appreciate this is a tragic set of circumstances and Ms B’s death was unexpected. We acknowledge the significant impact these events had and continue to have on Mr A, who was Ms B’s partner, as he had to witness what happened to her in October 2023. We hope that Mr A continues to get support in relation to these events to help him recover. Our consideration of Mr A’s complaint has concluded that the only course of action that may have changed the sad outcome for Ms B would have been if she had agreed to attend hospital more promptly on 10 October 2023. Even then, our adviser says we can never be sure if this would have made any difference for Ms B.

1. We have carefully considered Mr A’s complaint about the NHS Trust.

-We have decided the NHS Trust has already done enough to put right the impact of these events on Mr A.

2. We appreciate that Ms B’s sad death was unexpected and a great shock to Mr A. We recognise that Mr A’s mental health has been severely affected by what happened. This is ongoing and Mr A will have to live with the trauma of these events for the rest of his life. We consider the NHS Trust has already taken appropriate remedial action to put right the impact of these events on Mr A.