South East Coast Ambulance Service NHS Foundation Trust

4. Mrs I complains the Trust did not correctly categorise her call request for an ambulance for her daughter, Miss T, on 2 November 2023.

5. Miss T died on 2 November 2023. Mrs I believes had the Trust listened to her concerns and completed an appropriate assessment it would have recognised her daughter required immediate medical attention, and it would have upgraded her to a category one. She says then an ambulance would have arrived sooner, and her daughter’s death may have been prevented. She says this has caused her distress and compounded her grief.

6. As an outcome to her complaint Mrs I is seeking an apology, service improvements and financial compensation.

7. This brief background is only intended to place the key events related to this complaint in context, not to provide a full account of everything that happened.

8. Miss T was 53 years old. She lived in a ground floor flat on her own. She had previous medical conditions including lupus (a chronic autoimmune disease where the immune system attacks healthy tissues, leading to inflammation), leukaemia (a type of blood cancer) and rheumatoid arthritis (an autoimmune disease affecting joints in the body).

9. Miss T telephoned her mother on 2 November advising she was feeling unwell. Mrs I telephoned the Trust for an ambulance and for assistance.

10. Miss T sadly died on 2 November 2023.

11. Her death certificate lists her cause of death as, I(a) Acute Myocardial Infarction (heart attack), II Leukaemia and Lupus.

15. 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 seen indications that something has gone wrong.

16. Mrs I says from around 6.30am onwards on 2 November, she was telephoning the Trust for help, and it informed her an ambulance was on its way. She says from around 7.30am, her daughter’s condition was continuing to deteriorate, and she telephoned the Trust to chase when its ambulance would arrive.

17. She says the Trust advised her to perform cardiopulmonary resuscitation (CPR - an emergency procedure used to maintain blood flow and oxygen to vital organs when the heart stops beating) on her daughter.

18. In its response the Trust said it completed an internal investigation of Mrs I’s complaint, where her calls to the Trust were audited. It said Mrs I’s three calls to the Trust were appropriately categorised. It acknowledged, during Mrs I’s last call with the Trust, there was a 30 second delay in upgrading the category response from two to a one, and informing Mrs I to commence CPR.

19. It explained during that period, it was experiencing high demand for its service in the area and this contributed to the wait times for an ambulance.

20. The Trust also said it experienced some difficulty locating Miss T’s flat and it had to ask members of the public for directions. It apologised for Mrs I’s experience of its service and said it would share this complaint with its staff for wider learning.

21. Mrs I does not agree with the Trust’s stance that it was difficult to find her daughter’s flat. She recalls giving them precise directions to locate the building.

22. We considered the evidence from Mrs I and the Trust’s complaint file with the help of our paramedic adviser.

23. During Mrs I’s first call to the Trust we note Miss T had symptoms of diarrhoea, vomiting and shortness of breath. The Trust documented this as a category two response.

24. Our paramedic adviser explains the highest likely triage of these symptoms, would fall within a category two response. They further explain additional red flag symptoms such as a patient collapsing, unconsciousness or an inconsistent breathing pattern would escalate to a category one response. Miss T was not presenting with these symptoms during the first call.

25. The Trust’s categorisation of Mrs I’s first call is in line with the ARP guidelines. It defines a category one response as immediately life-threatening, for example where a patient is going into cardiac arrest. It defines a category two response as serious conditions such as suspected cardiac chest pain or significant respiratory distress.

26. Mrs I’s first call to the Trust was documented appropriately as a category two response. This is in line with ARP guidelines and we have seen no evidence the Trust should have considered a category one response at this point.

27. During Mrs I’s second call to the Trust we note Miss T’s breathing pattern had worsened and she had a tightening pain in her chest. The Trust documented this as a category two response.

28. Our paramedic adviser says chest pain in a conscious and breathing patient would be triaged as a category two response. They note the Trust has identified appropriate learning from its audit of this call, in that the call handler, should have asked further questions about Miss T’s chest pain. This would have enabled a full assessment of Miss T’s presenting symptoms, but it is unlikely to have changed the categorisation.

29. Mrs I’s second call to the Trust was documented appropriately as a category two response. This is in line with ARP guidelines and we have seen no evidence the Trust should have considered escalating it to a category one response at this point.

30. During Mrs I’s third and final call to the Trust, we note Miss T had collapsed and was not breathing regularly or responding. Mrs I was informed to perform CPR. The Trust escalated this call to a category one response.

31. Our paramedic adviser says this call was appropriately identified as a category one call as there was an immediate threat to life and it was appropriate to start CPR. Our adviser explains the transition of Miss T’s cardiac arrest appears to have incurred between the three calls made to the Trust, which is clinically possible in the context of acute myocardial infarction (heart attack).

32. The advice to commence CPR is in line with the Resuscitation guidelines which emphasise for any unresponsive person with an inconsistent breathing pattern, basic life support in the form of CPR should be given. It says in 999 situations, the ambulance call handler should provide guidance for CPR.

33. We are very sorry to hear about Mrs I’s complaint. This was an immensely distressing time for her, and we understand it continues to have a profound impact on her mental and physical wellbeing.

34. From the evidence we have seen no indication the Trust’s categorisation of Mrs I’s emergency calls were incorrect. Miss T’s presenting symptoms during the first two calls were consistent with a category two response and the third call was appropriately escalated to a category one response.

35. We hope our investigation goes some way in providing Mrs I and her family the answers they were looking for. We thank Mrs I for bringing this complaint to us.

1. We have carefully considered Mrs I’s complaint about South East Coast Ambulance Service NHS Foundation Trust (the Trust).

2. We have seen no indication the Trust’s categorisation of Mrs I’s calls for an ambulance on 2 November 2023, were incorrect. We fully explain the reasons for our decision in this statement.

3. We are deeply sorry to hear about Mrs I’s complaint. The events leading to her daughter, Miss T’s death were harrowing, and we are very sorry to hear this continues to cause Mrs I distress.