An independent provider in the City of Bristol area

6. Mrs E complains about the care and treatment the Private Provider provided to her father, Mr O, in 2023. The Private Provider was contracted by the Trust at the time events took place.

7. She specifically complains the attending paramedic failed to correctly interpret the results of an ECG which both organisations now acknowledge suggested a left coronary main stem occlusion. She says the attending crew therefore failed to provide her father with all the information he needed to make an informed decision about his care. She also believes they should have taken him to hospital based on his other symptoms alone.

8. Mrs E further complains about how the complaint about what happened was handled. She specifically complains:

• the Private Provider says it carried out its own investigation into what happened shortly after events took place, but it did not share the outcome of this with the family or the Trust at the time • the attending crew have given inaccurate accounts of what happened • the Private Provider provided contradictory information about what training the paramedic has undertaken since events took place • it took a year for the paramedic to complete all the training highlighted by the investigation into what happened and • the complaints process took too long to complete.

9. Mr O was very sadly found dead the day after events took place. Mrs E believes her father would not have died had he been taken to a Primary Percutaneous Coronary Intervention (PPCI) centre for urgent treatment.

10. She has told us her father’s death has had a huge impact on the whole family, and it has left them all feeling angry that the lack of action by the attending crew led to his death. She says the way her complaint was handled has left the whole family feeling more distressed.

11. Mrs E would like the Private Provider and the Trust to acknowledge the failings led to her father’s death, put in place service improvements and pay the family a financial remedy.

12. Mr O was 71 years old. He had aortic stenosis, peripheral arterial disease and chronic obstructive pulmonary disease (COPD). Aortic stenosis is narrowing in the aortic valve restricting blood flow from the heart. This can cause chest pain, fatigue and shortness of breath.

13. Peripheral arterial disease is a progressive disorder where narrowed or blocked blood vessels affect blood circulation, mainly in the legs. Mr O had his left leg amputated in August 2021 and his right in August 2022 due to peripheral arterial disease. COPD is a group of lung conditions that cause breathing difficulties.

14. Mr O had been in contact with Mrs E about feeling unwell in the days leading up to events. This prompted her to visit him. She then contacted his GP Practice for advice, and they advised her to call 999. She telephoned 999 at 11.36am and spoke with a call handler at the Trust.

15. The Trust assigned an ambulance operated by the Private Provider at 11.40am and it arrived on scene at 11.55am. Mr O had an ECG (a medical test that records the electrical activity of the heart) during this visit. The ambulance crew left Mr O at home with Mrs E at 1.22pm. We understand she then left soon after.

16. One of Mr O’s sons found him seemingly unconscious the following day having been unable to reach him by telephone. A family member telephoned 999 and spoke with a call handler who dispatched an ambulance operated by the Trust. We understand Mr O’s son performed CPR until the ambulance arrived.

17. On arrival, the paramedic very sadly found Mr O had been dead for some time. The cause of death was: 1a) pulmonary oedema (excess fluid in the lungs), 1b) left ventricular failure (left ventricle fails to pump blood efficiently), 1c) ischemic heart disease (narrowed arteries reduce blood flow) and 2) infective exacerbation of COPD.

Care and treatment

22. Mrs E complains the attending paramedic failed to correctly interpret the ECG and both organisations now say it suggested left coronary main stem occlusion. This is a life-threatening emergency where the left main coronary artery, which supplies blood to a large portion of the heart, becomes blocked.

23. Mrs E says the attending paramedic therefore failed to provide all the information Mr O needed to make an informed decision about his care. She also disputes they advised Mr O to go to hospital or contact his GP. She believes the attending paramedic should have taken Mr O to hospital based on his other symptoms alone.

Mrs E’s 999 call:

24. We have listened to Mrs E’s 999 call to the Trust. In this, she says Mr O has been experiencing chest pain for two days. She says he has shortness of breath and fatigue. She also says he is sweating, his voice has ‘gone a bit funny’ and he ‘looks awful’.

25. Mrs E says Mr O does not want an ambulance and does not want anything. She says he told her to ‘fuck off’ when she suggested telephoning 999 for an ambulance but she thinks he needs one. She says she has spoken with his GP Practice, and they told her to phone 999.

26. In answer to the call handler’s questions, Mrs E says Mr O is awake and breathing but agitated. She says he is ‘slurring a bit’, his voice is ‘not right’, he is breathing heavy/hard, he is ‘quite pale’, and he has what feels like indigestion. Listening to the call, it is clear from Mrs E’s tone of voice she is concerned about him.

27. Mrs E tells the call handler her father is a double leg amputee. She explains he had one leg amputated in the summer for a vascular issue and had heart problems during surgery. She also says his heart went ‘funny’ in the summer, he has a heart murmur, and he is on aspirin.

28. The call handler explains they need to speak with Mr O to ask him some questions. In response, she says, ‘this is not going to go well’ as he is ‘very difficult’. She also warns there may be some swearing. However, she explains he is frightened of hospitals as he nearly died in the summer.

29. Mr O says, ‘For God’s sake!’ when Mrs E says she is on the phone with 999. She tells him they need to get him checked out and he responds with ‘Whatever!’. He then answers all the call handler’s questions and says he has had some cold sweats and felt a bit sick at times. He also takes aspirin when the call handler directs him to.

Mr O’s GP notes:

30. Mr O’s GP notes confirm Mrs E contacted the Practice before she telephoned 999. She told them he had chest pains and was sweating. The notes also say they advised her to contact 999 though Mr O did not want her to do so.

31. The GP notes say Mr O had been listed for surgery due to cubital tunnel syndrome following a hospital appointment in December 2022. This is a condition that affects the ulnar nerve in the elbow leading to pain, tingling and numbness in the fingers.

32. The GP notes show Mr O had been in recent contact with both the Practice and local hospital. He had been asking about what had happened during the surgery to amputate his right leg as he wanted to make sure he had appropriate anaesthesia in his upcoming surgery.

Mrs E’s account to us:

33. Mrs E told us Mr O lived in a small flat and provided photographs to show the size of the open-plan kitchen and living area. She says he was sat in the living area with the ambulance crew while she was sat on the worktop in the kitchen. She says she could see her father and the ambulance crew and heard everything that was said.

34. Mrs E says neither member of the ambulance crew told her or Mr O he needed to go to hospital. She also says they did not tell them to contact his GP Practice. We understand from Mrs E that she left Mr O’s address soon after the ambulance crew as she did not think he was unwell based on what they had said.

35. Mrs E has provided us with WhatsApp messages between her and her sister on the day in question. A message at 12:19pm says ‘I am sat on the work surface in the kitchen’. A message at 12:20pm says ‘Not sure they are finding much but they are doing an ECG now!!!’. A further message at 12:34pm then says, ‘They are saying everything is fine!!!!’.

The attending paramedic’s notes from the time:

36. The attending paramedic’s notes say Mrs E had contacted 999 as her father was complaining of chest pain/tightness. They say Mr O denied chest pain but did say his chest felt slightly tight. They also say Mr O told them it was ‘all a lot of fuss about nothing’.

37. The notes say Mr O told them he had a poor appetite and had been day napping as he was unable to sleep at night due to feeling short of breath. They say he told them he had been experiencing these symptoms for three days and his GP Practice had advised Mrs E to call 999.

38. The notes list the ‘presenting complaint’ as ‘circulation/chest’ and the ‘chief complaint’ as ‘chest pain’. They also say Mr O’s pulse was irregular. They show the ambulance crew completed Mr O’s observations at 12.00pm and 12.22pm and used these to calculate his NEWS.

39. NEWS determines the degree of illness of a patient and helps guide the response. A score of 0-4 is low (assessment by a registered nurse), 5-6 is medium (urgent review by a clinician skilled in acute illness) and 7+ is high (emergency assessment by a clinical team skilled in critical care).

40. The notes say Mr O’s NEWS was initially 3 due to a slightly low systolic blood pressure of 100mmHg (normal being 111-219mmHg) and an elevated heart rate of 104bpm (normal being 51-90bpm). His NEWS then dropped to 1 as his systolic blood pressure rose to 113mmHg though his heart rate remained elevated at 99bpm.

41. The notes say Mr O was alert and orientated, slightly pale with good work of breathing. They say he had slightly audible breathing sounds, but his chest was clear with no wheeze, crackles or abnormal sounds. They also say he was very slightly tachycardic (heart rate over 100bpm), but an ECG showed normal sinus rhythm (regular heartbeat).

42. The notes say Mr O was going to contact his GP that afternoon and had been discharged into the care of a relative with advice on what to do if his condition worsened. The auto-generated ‘patient declaration’ signed by Mrs E says:

‘I confirm that I have been assessed and/or treated by an Ambulance Clinician; The information recorded here has been explained to me and I confirm that I understand the advice given to me; I have accepted treatment and been advised that hospital would be inappropriate.’

The Trust’s notes from the following day:

43. The ambulance crew’s notes say family members had been trying to contact Mr O since 1.30pm. They say one of his sons went to check on him at around 8pm and found him knelt next to the toilet with his head in the bowl. The ambulance crew thought Mr O had died following a vomiting episode.

44. The notes say Mr O had been experiencing episodes of chest pain and shortness of breath for three days. However, he told Mrs E he would decline hospital admission and ambulance attendance. They say he had asked her to call his GP, but they advised her to contact 999. They noted he had not taken his usual medications for two days due to vomiting.

45. The notes say it appears Mr O refused hospital admission though they queried if he had capacity as Mrs E said he had been acting strangely, had slurred speech and was not making sense verbally. They noted Mrs E said she had left Mr O’s home at 1.30pm the day before.

46. The Trust’s paramedic submitted an incident report via its internal adverse incident reporting platform due to concerns about the ambulance that attended the day before. They uploaded a photo of the ECG print-out the first ambulance crew had left at Mr O’s home.

47. The incident report says the ECG showed ischaemic changes (changes in the heart’s activity due to reduced blood flow). It also queries whether Mr O had capacity as Mrs E had said he had new confusion, slurred speech and was not recalling information correctly.

48. The incident report says the previous ambulance crew had told Mrs E her father’s pupils were not reacting normally. It also says Mrs E said the previous crew had ‘not really’ advised hospital admission and told her, ‘he wouldn’t go if we asked him anyway’.

The Private Provider’s investigation into what happened:

49. The Private Provider’s report says the attending paramedic’s documentation is of a ‘very poor standard’ and missing a lot of information. It notes there is no refusal form or information about a refusal. It says the notes say the ECG showed sinus rhythm when it indicates possible ischaemic changes and suggests left coronary main steam occlusion.

50. The report says, based on the information provided, Mr O had capacity and did not want to go to hospital. However, it questions whether the attending paramedic provided Mr O with all the information he needed to make a decision. It also questions whether they knew what the ECG showed and what assessment they used to determine capacity.

51. The report says the software their ambulance crews use does not have a specific box to record when a patient refuses to go to hospital. It says it is therefore common for crews to wrongly select the option that says the patient accepted treatment and had been advised hospital would be inappropriate.

52. The report also says the attending paramedic could have used internal support networks for advice. It says they needed training in ECG recognition and diagnosis, documentation and record taking, policies and procedures (specifically covering acute coronary syndrome and refusal of care) and additional and alternate care pathways.

The attending paramedic’s statements:

53. There is an undated statement from the attending paramedic within the Private Provider’s report. This says it was a challenging job as Mr O was outwardly hostile at times. It says he refused to go to hospital, so they tried to contact his GP, but the Practice was closed.

54. The statement says it would have taken another hour to contact Mr O’s GP, so they left him in Mrs E’s care, and they ‘felt’ she would contact the surgery when it reopened. They said they were not entirely comfortable with this but felt between a rock and a hard place.

55. The attending paramedic acknowledged their record keeping should have been more thorough and they should have asked Mr O to sign to say he was refusing to go to hospital. They also said they would consider waiting on scene to speak with the GP were this situation to arise again.

56. There is then a further statement by the attending paramedic dated a few days after events took place. This says before they were even through the door Mr O told them he did not want them there and he would not be going to hospital under any circumstances. It also says he said he was a naturally angry man who shouted a lot.

57. The statement says Mr O agreed to be checked over but said they would not be taking him to hospital regardless of what they found. It says he was alert, orientated and begrudgingly answered questions clearly and concisely. It says he did not have slurred speech, and they could not remember either him or Mrs E mentioning this.

58. The statement says Mr O denied chest pain and said his daughter was making a fuss over nothing. It says Mr O said the only problem he had was being unable to sleep for three nights as his breathing had been bad and that is why he had sent Mrs E to see his GP.

59. The statement says based on the ECG and other questioning they suggested taking him to hospital as chest tightness should always be checked. It says he swore loudly and said he was not going to hospital ‘no matter what’ and he knew he might die, and he should not be alive anyway.

60. The statement says they asked Mr O if they could contact his GP Practice and he agreed. It says they tried to contact the Practice, but it was 12.30pm and they were closed from 12.00pm to 2.00pm. It says they tried three or four times to use the Practice’s ‘back door’ number but there was no answer.

61. The statement says they spoke with Mrs E, and she was happy to contact the Practice herself at 2pm. They refer to a recent push to empower relatives to contact GPs. They say there was plenty of discussion with Mrs E though she was at times in the adjoining kitchen or other parts of the property.

62. The statement says they could not recall if Mrs E was in the room when they discussed going to hospital. It says Mr O had fallen asleep by the time they had spoken with Mrs E about contacting his GP, so she signed on his behalf due to his annoyed state which she said was normal.

63. The statement says it was made clear to Mrs E she was signing as a witness to Mr O’s refusal to go to hospital. They said her signature did not save at first, so they clarified what she was signing before she signed again. They said at no point did Mrs E try to persuade Mr O to go to hospital or tell them she thought he needed to go.

The emergency care assistant’s (ECA) statement:

64. There is a statement from the attending ECA dated a few days after events took place. This says Mrs E warned them on arrival that Mr O did not really want them there. It says he then said, ‘I’m an angry man who often shouts and I don’t need you!’ when they tried to introduce themselves.

65. The statement says Mr O said ‘She called you, I didn’t’ when they asked why they had contacted 999 but he did allow them to take his observations. It says he told them he would not be going anywhere. It also says Mr O had capacity and knew the day, month, etc.

66. The statement says Mr O denied having any pain including chest pain. It says his pupils were slow to react and the attending paramedic asked them to do an ECG. It says the attending paramedic asked Mr O several times if he would go to hospital and he declined. It also says the attending paramedic tried to contact his GP three or four times.

67. The statement says Mr O was very vocal and seemed passionate and angry. It says his speech was not slurred but he did go off on tangents. It says he fell asleep towards the end of the visit but woke up when needed. It says the attending paramedic gave Mrs E advice on what to do if his condition worsened and she was to contact his GP.

The Trust’s Review Learn Improve (RLI) investigation:

68. The Trust’s RLI report includes much of the same information as the Private Provider’s report. It says the ECG showed abnormalities suggestive of left coronary main stem occlusion meaning Mr O needed urgent treatment. It says Mr O’s chest tightness was not identified as an acute concern based on the attending paramedic’s incorrect interpretation of the ECG and the absence of other symptoms of a heart attack.

69. The report says the attending crew deemed Mr O had capacity to refuse admission. It says, as the attending paramedic did not recognise the left coronary main stem occlusion, they did not provide Mr O with all the relevant information. It says it cannot be determined if this would have influenced his decision.

70. The report concluded the root cause of the incident was Mr O’s anger and unwillingness to go to hospital despite the attending crew’s attempts to convince him otherwise. It also says education and training were a factor. The Trust produced an action plan outlining various training needs.

What we found:

71. The JRCALC guidelines say paramedics should ask about the history of a patient’s complaint, the background to the complaint, their past medical history, family history, social history, any medications they are taking, any allergies, etc. Our paramedic adviser said the attending paramedic only partially assessed Mr O.

72. Mrs E told the 999 call handler Mr O had chest pain, and the attending paramedic recorded chest pain as his chief complaint. Mr O also told the attending paramedic he had chest tightness. We know Mr O had both legs amputated due to peripheral arterial disease which shows his circulation was very poor.

73. Despite this, the records indicate very little exploration of chest pain by the attending paramedic. The ‘history of presenting complaint’ section only says Mr O’s chest felt slightly tight and he had been day napping as he was unable to sleep at night due to feeling short of breath.

74. The attending paramedic’s assessment was also not in line with the Trust’s coronary policy which says:

‘3.2 Early identification of the presence of chest pain, or where pain free on assessment when their last episode of chest pain was, is essential. In order to ascertain if the chest pain may be of cardiac origin consider the following:

• History of chest pain.

• Presence of cardiovascular risk factors (diabetes, family history, PAD, chronic renal disease).

• History of diagnosed ischaemic heart disease and any previous treatment.

• Previous investigations for cardiac chest pain.

• The nature of the pain assessed through SOCRATES (site, onset, character, radiation, associated symptoms, time, exacerbating factors and severity) or PQRST (provokes, quality, radiates, severity, time).’

75. Overall, the attending paramedic did not carry out a thorough assessment of Mr O’s chest pain or breathlessness. Their assessment was not to an acceptable standard and was not line with either the Trust’s local policy or national guidance. This a failing.

76. Linked to this, the attending paramedic’s record keeping was poor. The JRCALC guidelines set out what information should be recorded. However, the attending paramedic’s notes include very little detail about Mr O’s history, presentation, social history or medication.

77. Our paramedic adviser said Mr O’s observations were quite stable. However, Mrs E said he had chest pain, and he said he had tightness in his chest. Mr O had also not eaten for around three days, he had vomited, he had shortness of breath, and he was clearly lethargic as he fell asleep while the ambulance crew were in his home.

78. Our paramedic adviser said these factors alone (i.e. - excluding the results of the ECG) indicate Mr O needed to go to hospital for further investigation to rule out an acute condition. Added to this, Mr O had undergone two leg amputations due to poor circulation which was an added risk factor.

79. Our paramedic adviser said the markers for left coronary main stem occlusion are quite subtle on the ECG. However, the attending paramedic should have recognised the ECG was not normal and suggested ischaemia. They said the attending paramedic therefore should have recognised Mr O needed to go to hospital to investigate this further.

80. Our paramedic adviser said the ECG changes alongside Mr O’s vague presentation may have represented something non-acute such as known ischaemic heart disease, particularly with his history of peripheral arterial disease. However, the attending paramedic had no previous ECG for comparison so should have erred on the side of caution.

81. The ESC guidance and NICE guideline say patients with suspected left main coronary artery occlusion or severe multi-vessel acute coronary syndrome should be treated as medical emergencies. They should have immediate admission to a coronary care unit or PPCI, urgent angiography (a procedure to restore blood flow) and aggressive medical therapy.

82. Our paramedic adviser said if the attending paramedic was unsure what the ECG showed, they could have contacted the Trust, the local hospital or the local PPCI centre for advice. We find the misinterpretation of the ECG to be a failing. The attending paramedic should have been able to identify the results were concerning.

83. There are clearly two very differing accounts of what happened when the Private Provider’s ambulance crew attended in 2023. Mrs E says the crew did not advise her or Mr O he may have had an issue with his heart and needed to go to hospital for further investigation.

84. In statements taken after Mr O’s death, the attending paramedic says they did recognise Mr O needed to go to hospital as he reported chest tightness. They say they advised him of this, but he refused to go. They also say they directed Mrs E to phone his GP Practice. This is consistent with the ECA’s statement.

85. Having carefully considered the available evidence outlined in paragraphs 24-70, we think it supports Mrs E’s account. This includes the recording of her call to 999, the GP records, the records from the time, as well as the photographs and WhatsApp messages she has provided.

86. During the 999 call, Mrs E said her father had been experiencing chest pain for two days. She said he had shortness of breath, his breathing was heavy or hard, and he was fatigued. She also said he was pale, sweating, his voice was ‘not right’, he was ‘slurring a bit’ and he looked ‘awful’. The GP records support this.

87. Listening to the call, we can hear Mr O was unhappy Mrs E had called 999. However, he spoke with the call handler, answered their questions, offered information about how he was feeling and took aspirin when directed. We also note he was engaging with the NHS shortly before his death about surgery he was due to undergo.

88. The attending paramedic’s contemporaneous notes make no mention of Mr O’s capacity, that he might possibly have a heart issue, they thought he needed to go to hospital or that he refused to go. There is also nothing to say they told Mrs E Mr O needed to go to hospital either.

89. In statements taken after his death, the ambulance crew say they advised Mr O chest tightness should be checked in hospital, but he refused to go. Mrs E disputes this. She says she would have tried to persuade him to go if the crew had told her father he needed to go to hospital. She has provided WhatsApp messages that support this.

90. In their statements, the ambulance crew say the attending paramedic directed Mrs E to contact her father’s GP Practice. She also disputes this. The evidence shows Mrs E was clearly concerned about Mr O. We therefore consider it very unlikely she would have left him alone had the ambulance crew said he needed to go to hospital.

91. In their statements, the ambulance crew speak about how difficult and angry Mr O was and that he refused help. Mrs E accepts he could be difficult, and we can hear he was unhappy in the 999 recording. We recognise dealing with him may not have been straightforward but there is no record of his refusal.

92. In their statement, the attending paramedic says Mrs E was in the adjoining kitchen or other parts of the property implying she could not hear what was said. She has provided WhatsApp messages that say she was sat on the worktop in the kitchen. She has also provided photographs that show how small the space is.

93. Overall, based on the quantity and weight of Mrs E's evidence, we are persuaded her account is a compelling one. Based on the evidence we have seen, we do not accept the attending paramedic identified the risks to Mr O or that he needed to go to hospital.

94. We consider it far more likely the attending paramedic failed to recognise Mr O needed to go to hospital. This is because they did not fully assess him and misinterpreted the results of the ECG. They therefore wrongly left him at home with Mrs E who was falsely reassured he was okay. These are serious failings.

The Private Provider’s clinical investigation report

95. Mrs E complains the Private Provider did not share its report with the family at the time.

96. The Trust’s paramedic raised an incident the day after events took place. The Trust then emailed the Private Provider requesting an investigation three days later. We find it reasonable the Private Provider did not contact Mr O’s family at the time. The Trust contracts the Private Provider, and it asked the Private Provider to investigate and respond to the Trust.

97. Mrs E also complains the Private Provider did not share its report with the Trust at the time.

98. Our Principles of Good Administration say organisations should create and maintain reliable and usable records as evidence of their activities. The Private Provider’s report is dated 12 days after events took place, but the date does not appear to be correct based on other evidence we have seen.

99. We can see an email from the Trust to the Private Provider around a month after events took place asking for staff statements. The Private Provider replied the same day saying, ‘the initial investigation process has been started’ and ‘an urgent statement has been requested’. This suggests the Private Provider had not yet started its investigation.

100. We have been unable to determine for sure when the Private Provider first shared its report with the Trust. The Trust cannot locate a record of receiving a copy prior to March 2024 and the metadata says this document was created a few days earlier. However, we can see the Private Provider shared some information with the Trust before this date.

101. We can see the ambulance crew’s statements and the attending paramedic’s notes from the time formed part of the Private Provider’s investigation. They are listed within the Trust’s RLI report. We can also see reference to the Trust having the staff statements in an internal email two months after events took place.

102. We can appreciate why this raises concerns for Mrs E and undermines her trust in the Private Provider. We have asked the Private Provider about these inconsistencies. It told us it does not think the date on its report is correct, but it has been unable to give us the correct date. This is clearly not in line with our Principles of Good Complaint Handling.

103. However, we can see the Trust carried out its own investigation and issued a final report. The Trust’s report, for all intents and purposes, supersedes the Private Provider’s report. Therefore, we do not think what happened amounts to a failing or that it had a serious impact on the overall outcome.

The Trust’s RLI investigation

104. Mrs E complains the Trust’s RLI investigation took too long to complete.

105. The Trust’s paramedic raised an incident the day after events took place, and the Trust contacted the Private Provider three days later asking it to investigate. The Trust contacted the Private Provider again around a month later asking for staff statements. We can see it had received these statements after a further month.

106. The Trust discussed the incident internally and decided to start a RLI investigation. This decision took 42 working days. The Trust’s RLI policy says draft investigations should be completed within 35 working days of an investigation being confirmed. This suggests taking 42 working days to start an investigation is far too long.

107. The Trust signed off its RLI report around eight months after events took place and shared it with Mrs E later that month. The Trust then met with Mrs E two months later to discuss concerns she had about the report. It added her account to the report and reissued it the following month.

108. As already stated above, the Trust’s RLI policy says investigations should be completed within 35 working days. The Trust took around 97 working days to complete its investigation into Mr O’s care and treatment. This is well over the 35 working days set out in the Trust’s RLI policy.

109. We can see the Trust apologised its investigation took longer than anticipated in its cover letter to its RLI report. The letter says it was important the report was reviewed before being finalised. This suggests this was the cause of the delay, but it does not appear this was the case.

110. Overall, the Trust took significantly longer than its own policy states to carry out its RLI investigation in this case. It took 42 working days to start the investigation and then 97 working days to complete it. We have not seen any evidence there was a good reason for the delay.

111. We can see the Trust contacted Mrs E by phone to inform her of its RLI investigation shortly after it began. The Trust then contacted her by phone on four times with updates. Mrs E also contacted the Trust by phone on one occasion.

112. Our Principles of Good Administration say organisations should do what they say they are going to do. If they make a commitment to do something, they should keep to it or explain why they cannot. They also say organisation should meet their published service standards or let customers know if they cannot.

113. We do not think the Trust kept Mrs E appropriately updated during its investigation. There was no contact for a three-month period, and the records suggest it provided Mrs E with very little information on progress. The notes of the call after the three-month gap say there was no update, for example.

114. Overall, we found the Trust took significantly longer to investigate what happened to Mr O than its own policy sets out. It also failed to keep Mrs E appropriately updated during its investigation. This is a failing.

Complaint handling

115. Mrs E complains the complaints process took too long to complete.

116. We can see Mrs E raised a formal complaint with the Private Provider around 11 months after events took place. It shared this with the Trust the following day and she then had a meeting with the Trust the following months. She received a written response from the Trust a month later and the Private Provider later the same month.

117. Mrs E contacted the Private Provider with outstanding concerns the next months and received a written response from the Trust around three months later. This means the complaints process took just over 6 months in total. The NHS complaints regulations say organisations must issue an initial written complaint response within six months.

118. We therefore do not find the length of time Mrs E waited for complaint responses was unreasonable. However, we think the organisations should have coordinated their complaint handling better so only one organisation was communicating directly with Mrs E.

119. This would have been in line with our Principles of Good Complaint Handling which say organisations should ensure complaints about more than one organisation are dealt with in a co-ordinated way with other providers. This may have also prevented the issues outlined below from taking place. We do not consider this amounts to a failing.

The attending paramedic’s training

120. Mrs E complains the Private Provider has given her and the Trust contradictory information about what training the attending paramedic has received since events took place. She also complains it took a year for the attending paramedic to complete all the necessary training.

121. The Private Provider’s report recommended the following training for the attending paramedic: personal continuing professional development, assessment of their ECG recognition and awareness, monitoring with their documentation and review of their mandatory training.

122. However, the Trust’s RLI report says the attending paramedic suggested they had not had any further training since events took place. They also said the Private Provider did not provide clinical refresher days and responsibility for all clinical training was placed on individual members of staff to do in their own time and at their own expense.

123. The RLI report said the Private Provider told the Trust the attending paramedic had been compliant with mandatory e-learning and attended a simulation day. It also said it had implemented more support for ECG recognition as well as case studies and quizzes. However, the attending paramedic told the Trust they had not completed any additional training.

124. The private provider’s complaint response says the attending paramedic had attended an annual development day and completed an ECG assessment.

125. The Trust’s second complaint response says the attending paramedic received training in policies and procedures, ECG recognition and diagnosis and documentation and record keeping the same month events took place. It also said they received additional ECG training around 11 months after events took place and attended an annual development day focused on ECG recognition around a year after events took place.

126. We have asked the Private Provider to confirm what training the attending paramedic received following the incident. It told us what the attending paramedic said to the Trust is confusing as its records indicate training sessions took place on the dates provided. It shared copies of the following certificates all dated later the same month events took place:

• ‘ECG Recognition assessment’ • ‘JRCALC+ Updates’ • ‘Cardiac quick quiz CPD’ and • ‘ECG Case Study’.

127. The Private Provider also told us the attending paramedic did an ECG assessment 11 months after events took place and attended an annual development day focused on ECG recognition a year after event took place. However, it was unable to provide any evidence to support this. We have tried to contact the attending paramedic but had no response.

128. Our Principles of Good Complaint Handling say organisations should provide clear, accurate and complete information. The Private Provider provided the Trust with information the attending paramedic later told the Trust was untrue. Both organisations then shared this information with Mrs E without addressing the clearly conflicting accounts.

129. We found both organisations provided Mrs E with conflicting information about the attending paramedic’s training. We can therefore appreciate why she questions what they have said and remains concerned about the attending paramedic’s practice. We found this amounts to a failing by both organisations.

Impact of failings

130. Our cardiology adviser said the ECG from the 999 attendence shows ST depression indicating significant myocardial ischaemia. This means the heart may not have been receiving sufficient blood flow and oxygen which can lead to a heart attack. Our cardiology adviser said the ECG showed significant ischaemic changes.

131. Our cardiology adviser confirmed the ECG indicates Mr O had high risk acute coronary syndrome and likely left main stem occlusion. Patients with left main stem occlusion can present with severe chest pain, shortness of breath, excessive sweating, low blood pressure, fluid in the lungs and irregular heartbeat. This is a medical emergency.

132. Our cardiology adviser confirmed treatment would be primary percutaneous coronary intervention. This is minimally invasive and involves the use of catheter to open blocked coronary arteries, restoring blood flow to the heart. It is often used over clot-busting drugs due to its effectiveness in reducing mortality and complications.

133. The EuroIntervention, Circulation and JACC journal articles indicate the mortality rate for patients with left main stem occlusion is 60-80% without PCI and 20-30% with PCI. In other words, there was up to 70-80% chance Mr O would have survived had the ambulance crew taken him to hospital and he received treatment.

134. We have carefully considered whether Mr O would have agreed to go to hospital had the attending paramedic told him his symptoms and the ECG indicated he may have had a serious heart issue needing hospital treatment. We have also taken into consideration the fact Mrs E was present to help them persuade him to go.

135. We think Mr O would have more than likely agreed to go to hospital had the attending paramedic given him the right advice. Both organisations seem to accept he had capacity and we think the 999 call recording shows he was lucid. We think his recent contact with his GP and local hospital about his upcoming surgery shows he cared about his health.

136. Our cardiology adviser said Mr O would have been assessed to see if he was a candidate for treatment. He would have had an examination, blood tests to see how his heart was functioning and a chest X-ray. As he did not go to hospital, we do not know what his assessment would have found. However, we recognise he had significant co-morbidities.

137. Overall, we cannot say Mr O’s death was avoidable as we cannot be sure he would have been a candidate for treatment. However, the failings in his care were a significant contributory factor in his death and there was a missed fair chance of survival. At the very least, he would have been in hospital receiving appropriate support when he deteriorated.

138. We recognise the delays in the Trust’s RLI investigation would have been very distressing for Mrs E and her family. The Trust had contacted them to say there were concerns about Mr O’s care and they were waiting to find out what had been found. We think the Trust’s poor communication would have made this worse.

139. We also recognise the conflicting information about the attending paramedic’s training has left Mrs E questioning how seriously both organisations have taken what happened. It has also left her with concerns about whether what happened to her father could have happened to somebody else. We appreciate this has caused her further distress.

1. Mrs E complains about the care and treatment the Private Provider gave her father, Mr O, in 2023. We found the attending paramedic failed to appropriately assess his presenting symptoms or correctly interpret an electrocardiogram (ECG). This meant they did not recognise Mr O needed to go to hospital.

2. Mrs E also complains about how both organisations investigated events. We found some failings in the Trust’s internal investigation and how both organisations responded to Mrs E’s complaint. The Trust did not carry out its internal investigation in line with local policy, and both organisations provided conflicting information.

3. Mr O was very sadly found dead soon after events took place. We cannot say his death was avoidable. However, the failings in his care were a significant contributory factor in his death and there was a missed fair chance of survival. We recognise the other failings we have found have added to Mrs E’s distress. We therefore partly uphold this complaint.

4. We recommend both organisations write to Mrs E to acknowledge the failings we have found and apologise for the impact they have had on her. They should also outline what actions they will take to stop these failings from happening again. We further recommend the Trust pays Mrs E £6,000.

5. We cannot begin to imagine what a difficult time this has been for Mrs E and her family. We also recognise how difficult it can be to raise a complaint about the care a loved one received and to then keep pursuing this while trying to grieve their loss. We hope our report brings the family some answers and sense of closure.