An independent provider in the North Tyneside area

5. Mrs P complains about the care, treatment, and advice an independent provider in the Newcastle area (the Service) provided to her husband, Mr P, on 12 September 2019 when he was experiencing a subarachnoid haemorrhage (bleeding in the space between the brain and the tissues that cover it often leading to headaches requiring immediate treatment). She says the Service failed in its duty of care in the advice it provided during the telephone calls.

6. She specifically complains about the care, attitude, and inappropriate advice given by the Service operator and clinician.

7. Mrs P says both her and her husband have been made to feel upset, frustrated, and felt Mr P should have been directed to A&E much earlier.

8. By bringing this complaint to us, Mrs P seeks a financial remedy.

9. On 8 September 2019, Mr P started to feel unwell with pain and headaches. On the morning of 12 September 2019, he saw his GP. That afternoon, Mrs P called the Service as she was worried about her husband as he was acting out of character.

10. The 111 operator went through the details and symptoms and advised a clinician would call them back. A clinician called back that afternoon and provided advice on what he should do based of his presenting symptoms.

11. The clinician advised Mr P to give the medication he had been prescribed by the GP time to work but was concerned about Mr P not being able to keep the medication down due to vomiting. The clinician asked Mr P to call his GP and inform them he has taken the medication, has vomited, and to ask his GP what else he should do.

12. The clinician advised Mr P to call them back if he experienced any new symptoms. They also advised that if his condition got worse or changed he should go to A&E. The clinician asked Mrs P to keep an eye on him becoming drowsy, unresponsive, or if he had a fit and to call 999 if this was the case.

13. Mr P attended hospital later that day suffering from a subarachnoid haemorrhage and he was discharged after imaging was taken.

17. On 12 September 2019, Mrs P became worried about her husband and called the Service. She says the Service call handler was rude and dismissive and the clinician who called her husband back failed in their duty of care in the advice they provided.

18. We are sorry to hear about the upset and distress Mrs and Mr P experienced, and we appreciate how worried Mrs P was about her husband given the symptoms he had.

19. The transcripts of the calls indicate Mrs P called the Service on 12 September where she initially spoke to a call handler. Mrs P advised Mr P was vomiting at the time of the call and confirmed he had lifted a heavy bag the previous Sunday when he noticed he had pain in the back of his head and neck. The pain did not settle over the next few days and he had severe nausea. Mrs P advised Mr P had attended his doctor’s surgery that day who were very helpful.

20. The call handler triaged Mr P and made sure he was conscious and asked relevant assessment questions to Mrs P including ‘has he been bleeding red blood very heavily in the last 2 hours?’ which Mrs P replied ‘no.’ The call handler asked Mrs P to put her hands on Mr P’s chest or abdomen to check whether his temperature was hot, warm, cold, or clammy. Mrs P said he had a very hot temperature all night.

21. The call handler asked if Mr P had any unusual symptoms before the injury happened and whether he became more breathless than usual since the injury. Mrs P confirmed he had been stressed and had rushed around a lot during this period. She also confirmed he had been making funny noises with his breath that previous night and his blood pressure was 160/104.

22. The call handler advised Mrs P a clinician would call them back as soon as possible within the next half an hour. They checked the details of the injury and symptoms and noted the correct telephone number for the call back.

23. In 2019, the NHS 111 Service used a clinical decision support system called ‘NHS Pathways’ which supports call handlers and clinicians in undertaking triage and clinical assessment. The NHS Pathways is used to link clinical questions and care advice, leading to clinical endpoints. Based on the answers given, the most appropriate clinical response with a specific level of care and the time frame is reached.

24. Emergency situations are dealt with by asking questions about consciousness, breathing, choking, fitting, and serious conditions. Depending on the answers provided, a call handler will go through Modules 0–2 where further assessment becomes too complex for a non-clinical Health Advisor to safely triage and clinical input is required.

25. We can see from the transcript provided, the call handler used NHS Pathways appropriately and effectively and this supported their decision making that escalation to a clinician was necessary.

26. Our adviser said the call handler did an appropriate assessment, asked relevant questions about Mr P’s condition, and escalated the matter to a clinician appropriately.

27. A nurse clinician called Mrs P back, checked Mr P’s details, then did a full assessment to check his condition and symptoms.

28. The clinician asked how many times Mr P had vomited that day and what else was happening. Mr P confirmed he had vomited two times that day and he had spoken to the doctor earlier regarding shooting pains in his head ‘like a heartbeat in his head’ stating it had been continuous. He said the doctor gave him pain killers, but they had not worked.

29. The clinician asked Mr P what was new that day which prompted a call to the Service since visiting his GP. Mr P said it was his wife who called, and the pain had not changed for a few days and confirmed he had seen his GP earlier that day. The clinician did a thorough assessment and asked several questions to check Mr P’s food intake, whether he had had a further head injury, and checked his general feeling.

30. The clinician asked if he had had diarrhoea, checked the colour of his vomit was clear, and checked the medication he had taken was Valium. Mr P confirmed he had no diarrhoea, his vomit was clear, and he had taken Valium. The clinician checked whether he had any injuries in the last four weeks which he said he had not.

31. The clinician said if he had seen a GP earlier and the symptoms had not changed, they were unsure why Mrs P had called the Service. Mr P said his wife was worried. The clinician went through the assessment questions asking if he had any crushing pain or severe pain in his chest, upper back, or upper abdomen, or if he had any pain in his arm, neck, jaw, or shoulder. Mr P confirmed he had pulled his back.

32. The clinician checked if Mr P had a lopsided face, whether he could use his arms and legs, noticed any weakness in any part of his body, or had difficulty with speech. Mr P replied that he could use his arms and legs, he did not have a lopsided face, difficulties with speech, or any weakness.

33. After the assessment concluded, the clinician recommended Mr P call his GP again as soon as possible and within the next 12 hours, and if he became drowsy, unresponsive, or had a fit, Mrs P should call 999 immediately.

34. The NMC Code says you should put the interests of people using or needing the service first and make their care and safety the main concern. You should make sure their needs are recognised, assessed, and responded to.

35. Our adviser said the NICE guidance on Subarachnoid haemorrhage is the most appropriate guidance for the time of Mr P’s assessment in understanding his symptoms despite Mr P being subsequently diagnosed with a Non-Aneurysmal Subarachnoid Haemorrhage (NASH). The guidance post-dates the event, but it is helpful to understand the relevant symptoms and condition. The presenting symptoms are common between a ruptured aneurysm and non-aneurysmal subarachnoid haemorrhage, and we can see this formed the basis of an assessment in which this was suspected.

36. The NICE guidance says the primary indicator for a subarachnoid haemorrhage is sudden onset ‘thunderclap’ severe headache, peaking in intensity over 1-5 minutes and several other non-specific symptoms including neck pain or stiffness, nausea and vomiting, reduced conciseness, seizure, or painful neck flexion on examination. It says people with subarachnoid haemorrhage can present with a range of non-specific symptoms and signs and are at greater risk of a diagnosis being missed.

37. Our adviser said the clinician provided a structured assessment appropriate with Mr P’s presenting symptoms, which started with vomiting and headache, blood pressure, trauma, and musculoskeletal causes, which was to assess whether he had any signs of a subarachnoid haemorrhage.

38. Our adviser said the assessment did not highlight any red-flag indicators of a subarachnoid haemorrhage, such as the swift onset of thunderclap headaches, and as such the recommendations and advice provided was appropriate given Mr P’s presenting symptoms.

39. The assessment included a differential diagnosis of his headache such as high blood pressure, trauma, and musculoskeletal causes.

40. We consider the Service acted in line with the NMC Code in its assessment on 12 September, as the clinician assessed, recognised, and responded to Mr P’s needs at the time and provided appropriate advice in relation to Mr P’s presenting symptoms.

41. Mrs P also says the Service’s call handler and clinician were rude and dismissive.

42. The NMC Code says people should be treated with kindness, respect, and compassion and you should recognise when people are anxious or in distress and respond compassionately and politely.

43. Whilst we have not got the call recordings so cannot listen to the calls ourselves, we have got a copy of the transcript which shows exactly what was said during the calls. We do not consider from the transcripts that there are any indications that the call handler or the clinician were rude or dismissive.

44. As we have not seen anything which demonstrates rude or dismissive behaviour in either of the transcripts of the telephone calls, we consider the Service acted in line with the NMC Code, and we have not seen any indications of failings.

45. We appreciate how worried Mrs P was about her husband and the pain and discomfort Mr P was in at the time.

46. We consider the Service provided the correct care and advice to Mr P given his presenting symptoms and provided further advice should his condition worsened. We have not seen any indications that the Service’s call handler or clinician were rude or dismissive.

47. We therefore have seen no indications of failings in the care, treatment, and advice provided to Mr and Mrs P on 12 September, and we will take no further action on this complaint. We hope our decision brings Mr and Mrs P some reassurance and clarity and we understand how important this complaint is to Mrs and Mr P. We wish both Mrs and Mr P the best of health for the future.

1. We have carefully considered Mrs P’s complaint about an independent provider in the Newcastle area (the Service). We are sorry to hear about the upset and frustration she has been through and the impact the experience had on her and Mr P.

2. We consider the advice provided by the Service on 12 September 2019, when Mrs P called when her husband was unwell, was appropriate and in line with relevant guidance.

3. We have seen evidence which confirms the telephone assessment on 12 September was structured around Mr P’s presenting symptoms and provided recommendations and advice proportionate to Mr P’s condition. We can also confirm there were no obvious red-flag indicators that would suggest the need for an immediate emergency hospital admission based on Mr P’s presentation.

4. We also do not consider that the attitude of the call handler or clinician was inappropriate. We have not seen any indications of failings in this complaint, and we will take no further action.