South East Coast Ambulance Service NHS Foundation Trust

3. Mr E complains about the care and treatment his mother, Mrs E, received from the Trust in September 2024.

4. Specifically, Mr E said the Trust did not categorise his calls as an emergency.

5. Mr E said as a result of the incorrect categorisation the Trust did not send an ambulance quickly enough and his mother did not get the treatment she needed in time. He is reminded of the traumatic events of his mother’s death on a daily basis. Her death has caused him significant grief and distress.

6. Mr E is looking for financial remedy, an explanation and an apology.

7. In September 2024, at 9.29am, Mr E telephoned 999 requesting for an ambulance for his mother, Mrs E. She was experiencing shortness of breath.

8. At 10.07am, Mr E telephoned 999 again, requesting an ambulance. The line cut off and the Trust we unable to complete the triage assessment.

9. At 11.07am, the Trust telephoned Mr E to complete the unfinished clinical assessment. A Trust nurse categorised the call as a category 2. Shortly after the call, an ambulance arrived at Mrs E’s home. The paramedics entered the home and sadly, Mrs E had died.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that anything has gone wrong with Mr E’s complaint.

14. In September 2024 at 9.29am, Mr E telephoned 999, and requested an ambulance for his mother, Mrs E. She was experiencing shortness of breath. The Trust asked Mr E the triage questions. Based on the triage, the Trust said Mrs E must speak with a local service, specifically her GP, within one hour.

15. Mr E said his mother was unable to leave the home as she could not get out of bed. The Trust said it would arrange for a nurse from the ambulance service to call Mr E to complete a clinical assessment.

16. At 10.07am, Mr E telephoned 999 again, to request an ambulance. The Trust began to go through the triage questions with Mr E again. It put the call on hold so it could speak with a clinician. While the phone was on hold, the line cut off. It had not finished the triage assessment. The Trust was unable to complete the triage assessment. The call was not categorised.

17. At 11.07am, the Trust telephoned Mr E to complete the unfinished clinical assessment. Mr E said his mother was fighting for breath. The nurse categorised the call as category 2. A category 2 is a serious but not immediately life threatening. It requires rapid assessment and urgent on scene investigation. Shortly after the call, an ambulance arrived at Mrs E’s home. The paramedics entered the home and sadly, Mrs E had died.

18. Mr E described the Trust call handlers as robotic. He feels the Trust did not treat his mother’s medical circumstances as an emergency.

19. In the Trust response , it said it uses a system called NHS Pathways. This is the clinical decision support system that all NHS services use to triage and determine what help patients need.

20. The Trust said it triaged Mr E’s first call as a category 3. A category 3 call is an urgent, non-life-threatening medical which can include patients being treated from their home. It requires a response within 120 minutes. It agreed a nurse would call Mr E back.

21. The Trust apologised for Mr E’s experience. It accepted no failings in its actions.

22. We got advice from a paramedic (our adviser), with dispatch experience to advise on this case.

23. Our adviser explained that call handlers are not medically trained. Because of this, they do not work towards clinical guidelines. Call handlers at this Trust use the system NHS Pathways.

24. NHS Pathways is a telephone and digital triage, clinical decision support system that asks a variety of questions. These questions link to care and advice which leads to a clinical care point. This could be an ambulance response, or a referral to an alternative service such as a GP, A&E, or a pharmacy.

25. The system begins with questions which rule out serious conditions first. The answer provided determines the next questions. In Mrs E’s circumstances, she was having shortness of breath. This would generate more questions around breathing. The system continues to ask questions until it reaches the end. The system will provide advice to the individual or it will categorise the call for a priority.

26. For the system to work correctly, the call handler must ask the questions as they are written.

27. It is the call handler’s responsibility to make sure the system works correctly.

28. At the end of assessment, the system informs the call handler on the clinical recommendation.

29. If a caller refuses the recommendation, the call handler will finish the assessment. The system will refer the case to a clinician. These cases are worked in chronological order. A clinician will telephone the caller back to confirm what happened in the initial assessment, and clarify what was said. The clinician will decide on an alternate recommendation.

30. PHSO Principles of good administration standards explains organisations should provide effective services and use appropriately trained and competent staff.

31. Our adviser explained Mr E telephoned at 9.29am and requested an ambulance. He said his mother was experiencing shortness of breath. The Trust began to triage Mrs E by asking the questions using the NHS Pathways system.

32. During the initial call, the Trust asked, ‘is she so breathless that speaking more than a few words is impossible’ Mr E answered ‘no’. During the call, Mr E said he believed his mother was having an anxiety episode. Based on the answers Mr E provided, the Trust recommended Mrs E must speak with her GP within one hour. Our adviser confirmed the correct questions were asked in line with NHS Pathways.

33. Mr E refused to do this because he said his mother was unable to leave the home. The Trust said it would get a clinician to call Mr E back. Our adviser confirmed this is what they would expect to see in this circumstance.

34. Mr E telephoned for an ambulance again at 10.06am. The Trust began to triage Mrs E by asking the NHS Pathways system questions. When the Trust asked Mr E about his mother’s difficulty breathing, he said that speaking more than few words is impossible for her. The call handler continued the assessment. During the call, the Trust placed the call on hold. This was so the adviser could speak with a clinician, as the system would have flagged up that Mr E was already waiting for a call back.

35. Our adviser explained it was appropriate to place the call on hold, as it had already flagged Mr E required a call back following the earlier call.

36. While the call was on hold, the phone line disconnected. We cannot identify why this happened. Because the phone call ended, the Trust did not complete the assessment. The NHS Pathways does not give a recommendation on an uncompleted assessment. This call was not categorised. Despite this, we have seen the NHS pathways tool was used to the best of the operative’s ability.

37. Our adviser explained when this happens, a clinician should call the patient back. They told us there is no way to prioritise a call back. They are done in chronological order. Mr E was already flagged to receive a call back, after his earlier call.

38. We also recognise there is no indication Mr E called the Trust back, when the line was disconnected.

39. A nurse from the Trust called Mr E at 11.07am. They asked the same questions from the second call and confirmed if it was still impossible for her to speak more than a few words. Once the Trust confirmed Mrs E was fighting for breath, NHS Pathways generated questions which would rule out a category 1 call such as choking, swelling to throat, or an asthma attack. Mr E answered no to these questions. The Trust recommended Mrs E was a category 2 and dispatched an ambulance. This has a response time of an average of 18 minutes.

40. Shortly after the call ended an ambulance arrived. Sadly, Mrs E had died.

41. Our adviser says that on all occasions the Trust used the NHS Pathway system correctly. Nothing Mr E disclosed on the calls would require a category 1 ambulance. The Trust categorised the calls appropriately using the correct system. We have seen no indication of failings in the Trust’s assessment and categorisation of the calls.

42. From what we have seen, we are satisfied the Trust acted in line with the NHS Pathways system, and PHSO Principles of good administration. The Trust asked the questions correctly and the call handler inputted the answers, as they were given. We are satisfied this resulted in the Trust’s recommendations on the calls being the correct.

43. We recognise that this was a very difficult time for Mr E. It can be very stressful when you witness a loved one in distress. We do not underestimate the impact this had on Mr E.

44. We recognise how difficult it can be to make a complaint. We would like to thank Mr E for bringing his concerns to us.

1. We have carefully considered Mr E’s complaint about South East Coast Ambulance Service NHS Foundation Trust (the Trust). We were very sorry to hear about the death of Mrs E and the events leading up to her death. We understand these events were very distressing for Mr E.

2. We have seen no signs anything went wrong how the Trust categorised Mr E’s calls when he requested for an ambulance.