Manchester University NHS Foundation Trust

North West Ambulance Service NHS Trust (NWAS)

5. Miss X complains about the delays in North West Ambulance Service NHS Trust attending her father, Mr X, on two occasions in December 2021. In particular she complains, • there was a delay of over an hour following a call on 3 December 2021 at 2.42pm when he was taken ill whilst driving • there was a delay of over 2 hours following a call from SFT staff at about 11.30pm on 3 December requesting a transfer to the MFT hospital.

6. Miss X believes that if there had not been any delays in the ambulances attending her father, he would have received earlier treatment, and his internal bleed may not have gone on for as long, resulting in organ failure. Miss X also says the loss of her father has caused her severe trauma, loss of sleep, weight loss and anxiety resulting in her receiving counselling.

7. Miss X is seeking an acknowledgement of failings, an apology for the impact of these failings and service improvements.

Stockport NHS Foundation Trust (SFT)

8. Miss X complains that Stockport NHS Foundation Trust took too long to reach a decision to transfer her father, Mr X, to the MFT hospital for life saving surgery. She also says there were delays on the part of SFT staff in calling for an ambulance to enable her father’s transfer.

9. Miss X believes that the delays contributed to her father's ongoing bleeding, which ultimately resulted in his organs shutting down and his subsequent death. She believes that more timely action by SFT may have changed her father's outcome. Miss X also says the loss of her father has caused her severe trauma, loss of sleep, weight loss and anxiety, resulting in her receiving counselling.

10. Miss X is seeking an acknowledgement of failings, an apology for the impact of these failings and service improvements.

Manchester University NHS Foundation Trust (MFT)

11. Miss X complains that the surgeons at Manchester University NHS Foundation Trust were not ready when her father, X, attended the hospital on 4 December 2021 which resulted in a delay in him being operated on.

12. Miss X considers this delay contributed to her father's ongoing bleed, which resulted in him subsequently dying from organ failure. Miss X says the loss of her father has caused her severe trauma, loss of sleep, weight loss and anxiety, resulting in her receiving counselling.

13. Miss X is seeking an acknowledgement of failings, an apology for the impact of these failings and service improvements.

14. Mr X was driving his car on 3 December 2021 when he became unwell. He had become dizzy and experienced back pain, and had pulled over to the side of the road. A passerby telephoned NWAS at 2.42pm requesting an ambulance. The passerby made a second call at 2.53pm.

15. The ambulance arrived at 4.01pm and transferred Mr X to a SFT hospital where he was treated in the emergency department (ED). At 7.45pm his care was transferred to the surgical team, although he remained in the ED. At 9.20pm the SFT and MFT surgical teams agreed that Mr X was to be transferred to an MFT specialist unit for intervention radiology and/or surgery.

16. SFT staff called NWAS at approximately 11.35pm to request an emergency ambulance to transfer Mr X to the specialist unit.

17. SFT staff made follow up calls at 12.29am and 1.12am and a clinician at NWAS advised the next available ambulance would be dispatched to the hospital. The ambulance arrived at 1.30am and transported Mr X to the MFT specialist unit where he arrived at approximately 2am.

18. Mr X had his operation at 7am on 4 December but sadly died on 6 December. The main cause of death is recorded as,

• Major Internal Haemorrhage • Atraumatic Splenic Rupture secondary to splenic infarct • Systemic Thromboembolism associated with Old Myocardial Infarct

19. A major internal haemorrhage means there is significant bleeding internally. ‘Atraumatic splenic rupture’ refers to a rupture of the spleen, an organ which plays an important role in the body’s immune system. ‘Systemic thromboembolism’ refers to the blockage of certain arteries, usually by blood clots. A ‘myocardial infarct’ is when blood flow to a part of the heart muscle is blocked, causing tissue damage or death due to lack of oxygen. It is ‘old’ when the event took place some time ago, i.e. by at least a number of weeks.

North West Ambulance Service NHS Trust (NWAS)

25. Miss X complains about the delays in NWAS attending her father. NWAS has provided a response setting out an explanation for the categorisation of the calls and the delays in attending.

Categorisation of emergency calls at 2.42pm and 2.53pm on 3 December 2021

26. The relevant guidance which applies here is the NHS England ‘Ambulance Response Programme’.

27. In line with the ambulance response programme a category 1 call is for people with life threatening injuries and illnesses. Typical examples of a category 2 response would be for someone having a heart attack or a stroke.

28. The first call was made by a passerby at 2.42pm who had found Mr X unwell in his car. We have listened to a recording of the first 999 call and the evidence indicates this was categorised correctly as a category 2.

29. Mr X can be heard in the background of the call and is able to respond clearly and provide information to the caller.

30. Our paramedic adviser said there is nothing on this call that indicates a category 1 response was required. A category 1 response would typically be for somebody who is not breathing or has a similar level of severity of their condition.

31. NWAS also categorised the second 999 call made by the passerby at 2.53pm a category 2 response.

32. Mr X can again be heard in the background of the call responding to the caller and was breathing effectively. The additional information provided did not include anything that would require a category 1 response.

33. These two calls were correctly categorised and there is no evidence of failings on the part of NWAS.

Categorisation of calls from Stockport Foundation NHS Trust on 3 and 4 December 2021

34. The relevant NHS England guidance that covers a request for a transfer between hospitals is the ‘National framework for inter-facility transfers’.

35. We have listened to the recordings of the calls between staff at SFT and NWAS. The caller answers yes to the question ‘Is there a need for an immediate intervention that cannot be carried out at the current facility and is the patient at immediate risk of death or life-changing loss of a limb or sight?’. This was in line with the above framework. Our paramedic adviser said NWAS correctly assigned a category 2 response.

36. Within the framework it indicates that typical examples of a category 2 interfacility transfer include patients going to theatre for immediate neurosurgery, stroke thrombolysis or surgery for a ruptured aortic aneurysm.

37. NWAS confirmed to the SFT nurse the category of response and advised due to current pressures on the service the likely response time could be up to two and a half hours.

38. Our paramedic adviser confirmed the category 2 was a clinically appropriate categorisation and consistent with the national framework. Examples of a category 1 interfacility transfer include cardiac arrest, anaphylaxis and acute severe life-threatening asthma in an urgent care facility. Our paramedic adviser said whilst Mr X was severely unwell, he did not meet the threshold to receive a response of this urgency.

39. The follow up call at 12.29am on 4 December was escalated to a clinician, in line with the national framework, who took action to prioritise the response. In this case, they did so by requesting that the incident was the next to be tasked before older category 2 incidents. We understand from our paramedic adviser this was good practice. The incident still remained as a category 2 incident, which was correct.

40. The third call, made at 1.12am, was escalated to a clinician who did, on this occasion, upgrade to a category 1 incident. Our paramedic said this was done based on the information provided during that call and the clinical opinion of the healthcare professional working within the control room, and the evidence shows this was a reasonable action to take.

41. Having considered the available evidence, we have found these calls were correctly categorised in line with guidance.

Delays

42. The 999 calls made by the passerby and SFT staff to NWAS were correctly categorised as category 2. The above NHSE guidance indicates these should be responded to in an average time of 18 minutes. However, the call from the passerby at 2.42pm was responded to at 4.01pm, which is an hour over the average response time.

43. The SFT staff made the initial call at about 11.35pm and it was over two hours later when the ambulance arrived. Again, this exceeded the average response time of 18 minutes.

44. NWAS said in its response dated 30 June 2022 that there was severe high demand on the services at the time of the two incidents which was outstripping resources. It said patient safety measures had been implemented within its Emergency Operations Centre to try to manage the increase in demand as safely as possible. NWAS apologised that the ambulances arrived outside of the expected timescale for a category 2.

45. Our paramedic adviser said The Association of Ambulance Chief Executives (AACE) released a review of national ambulance service data in January 2022 covering the date in question.

46. This report indicated that across the ambulance sector demand increased and response times worsened. Hospital handover was delayed in 60% of all handovers and the length of delays was increasing. Nationally, 44,000 ambulance operational hours were lost in December compared to 5,000 in February of the same year.

47. The report from 3 December 2021 indicates that in the Greater Manchester area throughout the day and night there were sufficient double crewed ambulances (DCAs) in the area.

48. At 1.50pm there were 25 incidents at category 2 that had been waiting over 40 minutes. It is recorded there were increased call volumes at this time in the log.

49. We understand from our paramedic adviser that the evidence clearly supports that demand was higher than there was capacity to meet it. Whether that was because demand was higher than anticipated, or whether other operational factors such as hospital handover delays were reducing capacity within the ambulance service to respond is impossible to determine.

50. The indications are NWAS did have sufficient operational ambulances for the forecasted demand in the Greater Manchester area. This indicates that, regardless of whether it was increased demand, reduced operational capacity or both, the factors involved were not within the control of NWAS.

51. Our paramedic adviser has confirmed NWAS’ Regional Operations Centre’s report supports an appropriate level of escalation through the patient safety plan was enacted in a timely fashion. NWAS, on the date in question, was managing its significant service pressures correctly and in line with its guidance.

52. In view of the above, we have found whilst there were delays in the ambulances responding there is no evidence that this was due to any failings on the part of NWAS.

53. In summary, we recognise that Miss X believes that the ambulance delays contributed to her father’s outcome and we can understand her reasons for that. However, having considered the available evidence, we have found there is no evidence of failings regarding the categorisation of the calls and the delay in attending Mr X. Therefore, we do not uphold this complaint.

Stockport NHS Foundation Trust (SFT)

54. Miss X complains that SFT staff took too long to reach a decision to transfer her father to the MFT hospital for life saving surgery. She also says there were delays on the part of SFT staff in calling NWAS for an ambulance to enable her father’s transfer.

55. The ambulance crew who attended to Mr X in his car took him to a SFT hospital. Nursing staff took Mr X’s observations on arrival, and these showed he had low blood pressure (hypotension). He also had oxygen saturations of 94% on 8 litres of oxygen, indicating he may have had lower than normal oxygen levels. His heart rate was normal, but our EM adviser notes he was on beta-blockers, which would explain why did not have a raised heart rate despite his low blood pressure.

56. An ED doctor carried out a RAT (rapid assessment and treatment) assessment of Mr X. At 5.16pm the nursing notes mention that an ED consultant performed a bedside ultrasound to look for the presence of an abdominal aneurysm, which would clinically have fit this picture of sudden onset of pain to the back associated with low blood pressure. The doctor prescribed metaraminol, which was started to maintain Mr X’s blood pressure, and intensive care staff were called to assess him.

57. The ED doctor made an initial differential diagnosis for the cause of Mr X’s symptoms of an aortic dissection (a tear in the inner layer of the body’s main artery) or ruptured aneurysm (where a weakened area in a blood vessel wall bursts). Our EM adviser said the clinical picture fitted with this potential diagnosis.

58. The ED team had quickly recognised this as a possible cause for the symptoms and ordered a CT aortogram (the recommended investigation for the diagnosis of a dissection or ruptured aneurysm) in a timely way. Our EM adviser said the importance of the ED in suspecting this diagnosis was outlined by the RCEM in an article published on 25 September 2019. This has since been formalised by the RCEM Best Practice Guideline ‘Diagnosis of Thoracic Aortic Dissection in the Emergency Department’ in January 2024.

59. The CT aortogram report came back at approximately 7pm and showed the possibility of a splenic haematoma (a collection of blood within the spleen). At this point a code red/major haemorrhage policy was instigated. This is a process by which the laboratory will release blood products quickly to patients who are very unwell and require blood urgently. Tranexamic acid (to help with clotting) and beriplex were also administered to help reverse the effects of the anticoagulant that Mr X was taking as a regular medication.

60. The available evidence shows that as soon as the ED team received the CT scan and identified the potential for a splenic rupture they contacted the general surgeons. This is line with GMC guidance (paragraph 15) which says,

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs.’

61. The surgical team attended the ED to assess Mr X. Our surgeon adviser said the surgical team’s initial assessment of Mr X and its decision making were appropriate and in line with the above guidance. Mr X had significant bleeding from his spleen and required blood transfusion and IV fluids to stabilise him.

62. Our surgeon adviser said that Mr X’s significant co-morbidity, including anticoagulation and poor exercise tolerance, meant that he was a high-risk candidate for an operation. His risk of dying with an operation was calculated by the team to be over 30%.

63. In view of the risk, it was reasonable and in line with the above GMC guidance to refer him to a specialist centre (in this case, an MFT hospital) for non-surgical treatment i.e. embolisation (an X-ray guided technique to seal the bleeding vessels and stop the bleeding).

64. The surgical team began discussions with the MFT team to transfer Mr X for interventional radiology. Consideration was also given to whether Mr X should remain at the SFT hospital and have an operation to remove his spleen, but after consideration of his co-morbidities by the surgical team it was felt that, as this was major surgery, he would not be fit enough and would not survive it.

65. At 9.20pm the SFT general surgical consultant received confirmation from MFT staff that they would accept Mr X there for intervention. It is recorded in the notes that the SFT surgeon discussed the matter with an interventional radiologist and an on-call consultant at MFT. The plan was also discussed and agreed with an Hepato-Pancreato-Biliary (HPB) surgery consultant at the specialist unit. The records indicate that Mr X was initially to be transferred to the HDU (high dependency unit), which provides a level of care between a general ward and an intensive care unit. There then appears to be a delay of 2 hours, at which point the ED consultant at the SFT hospital documented Mr X could now be transferred to the ED at the MFT hospital. The delay seems to be due to miscommunication regarding the availability of an HDU bed. We have considered this delay further in paragraphs 73-75 below.

66. Once the MFT staff had confirmed that Mr X could be transferred, the SFT nursing staff requested a blue light ambulance transfer at about 11.30pm and this was graded as a category 2 response, which was in keeping with the clinical picture at the time.

67. There was a further delay of 2 hours before an ambulance arrived to collect Mr X for transfer to the MFT hospital. During this time nursing staff contacted NWAS to expedite this transfer at 12.29am and 1.12am, and the final call asking for an upgrade to a category 1 transfer appears to have facilitated this. Discussions with Mr X’s family explaining what the situation was, and the risks, were also clearly documented

68. It appears that during the time Mr X was at SFT’s hospital he was receiving constant care from initially the ED and critical care team and subsequently the anaesthetic and surgical team. His blood pressure, although low, was maintained throughout his time in ED, and his haemoglobin level was also maintained by transfusing 4 units of whole blood prior to transfer.

69. An appropriate and timely decision was also made by the surgical team to transfer Mr X to the MFT hospital for specialist intervention. Furthermore, once the decision was made to transfer Mr X to the MFT hospital there were no delays on the part of SFT staff in trying to arrange the ambulance.

70. In summary, having considered the available evidence, we have found there no evidence of failings regarding the care and treatment provided to Mr X by SFT or in the transfer to the MFT hospital. Therefore, we do not uphold this complaint.

Manchester University NHS Foundation Trust (MFT)

71. Miss X complains about the delay in the transfer of Mr X from the SFT hospital to the MFT hospital. She also complains that, because the MFT surgical team were not ready for her father, there was a delay in his operation being carried out. MFT says there was a miscommunication between departments. However, it said that this had no bearing on the treatment he received.

72. Miss X is concerned there was a delay in her father being transferred from the SFT Hospital to the MFT hospital after the decision for him to be transferred was made. The ambulance responses were outside the target times but, as indicated above, our view is there was no failing on the part of the ambulance service in view of the demand on its resources at that time.

73. There is an indication that there was a potential two-hour delay in Mr X being transferred from the SFT hospital as SFT understood the MFT hospital did not have an HDU bed available. MFT has told us that this was not the case and it has provided evidence to show there was an HDU bed available at that time.

74. However, the SFT records do show that the staff were informed by MFT staff that there was no bed on the HDU, which was the reason Mr X was being transferred to the Resuscitation team in the ED at MRI. MFT has said that its own paper records do not record what was said between the SFT surgeon and its own HPB surgeon at 9.20pm.

75. We have thought about what we might say here, based on the evidence available to us. We do not have any evidence from MFT as to what was said during that call. However, we have a record from SFT clearly showing it understood that MFT was telling it no HDU bed was available. This indicates that communication from MFT was not effective in this instance. Therefore, we are left to take a view that on the balance of probabilities there was a miscommunication on the part of MFT staff regarding the availability of an HDU bed, which resulted in a delay in Mr X’s transfer. We have found this was a failing and not in line with the GMC’s ‘Good Medical Practice’, section 49(b), which says clinicians should ‘communicate clearly’ with others providing care.

76. Our EM adviser said once the MFT team had accepted Mr X for intervention at 9.20pm he should have been transferred without delay. This did not happen due to the miscommunication about the HDU bed.

77. The ambulance calls and MFT response suggest that there was no communication between its receiving surgical team and its ED. However, our surgeon adviser said Mr X was accommodated in the ED resuscitation area appropriately after he arrived around 2am.

78. The records indicate that Mr X’s surgical intervention started around 7am. Our surgeon adviser explained that both the RCS guidelines on emergency surgery and the WSEM study group recognise that delays to surgery can cause adverse outcomes. The WSEM recommend that surgery (or embolisation) in such a case as this be commenced within one hour of the decision to intervene. We recognise that this is not always possible, but we consider a 5-hour delay to be excessive and we have not seen evidence that there was good reason for this delay. In total, there was an approximately 9-and-a-half-hour interval between the decision to intervene at 9.20pm and the intervention taking place at 7am the following morning. Our surgeon adviser said Mr X was a very high-risk patient with evidence of cardiovascular instability.

79. We have found there was a two-hour delay in arranging the transfer of Mr X from the SFT hospital to the MFT hospital due to poor communication on the part of MFT staff regarding the availability of an HDU bed. We recognise that the timeliness of the transfer was still dependent on the availability of an ambulance, but the evidence available suggests that Mr X would have arrived at the MRI earlier than he did if that miscommunication had not occurred, which may have reduced the time before his operation started.

80. There was then a further 5 hours delay after his arrival at the MFT hospital before his operation began at about 7am. We have considered the impact these the delays may have had on his outcome.

81. We understand from our surgeon adviser that it is likely that these delays contributed to the adverse outcome in this case. The delays in transfer due to the poor communication about the availability of an HDU bed, and then delays at the MRI before commencing surgery, meant that Mr X’s risk of death increased. His mortality risk increased from 30%, as calculated by SFT staff at 8.40pm, to 47% as calculated by MFT staff at 4am.

82. Our surgeon adviser explained an earlier operation may have improved Mr X’s chances of survival. Mr X had very significant other medical conditions and frailty, but the delays are very likely to have reduced his chances of survival.

83. We cannot say that on the balance of probabilities his outcome would have been different if his operation had been carried out earlier, as even if Mr X had received surgical intervention in a timely manner his mortality risk was still significant. However, Miss X has been left with uncertainty and feelings that her father was not given the best chance of a positive outcome. This will be a source of significant distress for her, and we do not underestimate that. Miss X says the loss of her father has caused her severe trauma, loss of sleep, weight loss and anxiety, resulting in her receiving counselling.

84. MFT has not fully acknowledged the failings in care provided to Mr X or the significant impact this has had on Miss X. We have therefore made recommendations below to address this.

85. In summary, we have found there were failings on the part of MFT regarding delays in transferring Mr X due to poor communication regarding the availability of an HDU bed, and delays in carrying out his operation. We are unable to say that his outcome would have been different but for these failings, but we can see an impact to Miss X that has not yet been put right. Therefore, we partly uphold this complaint.

1. We have not found failings on the part of North West Ambulance Service NHS Trust (NWAS) or Stockport NHS Foundation Trust (SFT). We do not uphold the complaints about these trusts.

2. We have found failings on the part of Manchester University NHS Foundation Trust (MFT). These relate to poor communication regarding Mr X’s transfer from the SFT hospital and delays carrying out the operation on 4 December 2021.

3. However, whilst we have identified failings we are unable to conclude that but for these Mr X’s sad outcome would have been any different. However, these failings would have caused uncertainty and distress for Miss X which will be a source of ongoing upset for her.

4. MFT has not fully recognised the failings in the care provided to Mr X or the impact this has had on Miss X. Therefore, we partly uphold the complaint. We have made the following recommendations,

• Within one month of the date of our final report MFT should write to Miss X to acknowledge the failings summarised in paragraph 85 and to apologise for the significant impact these have had on her. The letter should also set out the actions the Trust has taken since 2021 to prevent the failings from occurring again. This should include how the actions have been measured and monitored.