An independent provider in the Ashford area

3. Mr U complains about the care his sister, Miss U, received from the Organisation on 27 April 2024. He says the call handler did not use the correct pathway when dealing with Miss U’s 111 call.

4. Mr U says if the Organisation had followed the correct pathway, it would have arranged an ambulance sooner. He believes the outcome could have been different. He also says an earlier ambulance could have led to his sister being in hospital, meaning the family would have had a chance to be with her before she died. He told us both of these things have caused significant distress to him and the family, it has also left the family having no faith in the 111 service.

5. Mr U wants the Organisation to make improvements to its service and to pay a financial remedy.

6. 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.

7. Miss U called the NHS 111 service at 6.01pm on 27 April 2024. The HA (health adviser) arranged for the out of hours (OOH) GP to call Miss U. The OOH receptionist called Miss U at 6.35pm and arranged an appointment for her at 8pm the same day. Miss U sadly died on the way to the appointment.

8. When Mr U subsequently complained, the Organisation acknowledged the HA did not handle the call correctly. It concluded that, even if the call had been handled correctly, it cannot be certain what the outcome would have been. It did however accept the possibility that an ambulance might have been dispatched and, if it had, the outcome may have been different.

111 call 12. Mr U says the call handler did not use the correct pathway when dealing with Miss U’s 111 call.

13. There is only one triage system used to triage 111 calls which is NHS England’s NHS Pathways system. The system is an interlinked series of algorithms, or pathways, that link clinical questions and care advice, leading to clinical endpoints. The outcome is not picked by the call handler, the answers inputted by the call handler prompt the system to generate an outcome.

14. The Organisation has already acknowledged that the HA who dealt with Miss U’s 111 call did not use the supporting information within the Pathways triage tool. They did not request direct clinical support for this call when they should have and instead referenced clinical advice they obtained during a previous call.

15. It said this influenced how the HA asked some of the additional triage questions and potentially affected the outcome.

16. We agree with the Organisation, that the HA should have sought clinical advice from a clinician when Miss U could not identify, out of several symptoms she was experiencing, her main concern.

17. We have considered the impact of the HA not seeking clinical advice during the 111 call and whether this could have generated a different outcome from the call, such as an ambulance response.

18. The Organisation’s view, when Mr U complained, was that an ambulance might have been sent (if the call had been handled properly) and, if it had, the outcome might have been different. The Organisation’s response did say, however, that it was not possible to be certain what the outcome of the telephone call would have been.

19. The Organisation’s view that an ambulance might have been sent is based on speculation and, in our view, cannot be determined with any degree of certainty for the reasons we explain below.

20. It is impossible for us to determine what would have happened if the call had been handled correctly. The clinical advice outcome may have been to ask Miss U additional questions. We do not know what the questions would have been, nor do we know what answers she would have given. Our adviser explained that the outcome of the triage is facilitated by Miss U’s answers.

21. This is made even more difficult as there are contradictions with the information Miss U gave to the HA during the call that would have needed further clarification. For example, when the HA asked Miss U to feel the skin on her chest to check her temperature, she said it was cold. However, later in the call Miss U told the HA she did have a temperature.

22. Our adviser said it should be noted, during the call, Miss U did not have classic heart attack symptoms and there is no mention at all of chest pains. They said this makes it harder to recognise as a heart attack over the telephone.

23. Our adviser confirmed ‘mottley skin’ alone would not have prompted an ambulance response.

24. Mr U’s belief is that if the call had been handled properly an ambulance would have been despatched. We understand his concern. There are multiple possible outcomes from a 111 call such as an ambulance dispatch, a GP appointment or a UTC appointment (urgent treatment centre). Ultimately, without knowing what would have happened if the HA had sought clinical advice, we do not think it is possible to say what outcome would have generated.

25. As we cannot say whether an ambulance would have been sent, even if the call had been handled correctly, we do not think it is appropriate for us to speculate on what would have happened if one had been.

26. We recognise Mr U is in a difficult situation with questions he would like answers to, about whether an ambulance should have been sent and whether the outcome would have been different if it had. The Organisation acknowledged before this complaint reached us that both of those outcomes were possibilities.

27. Considering the evidence we have seen, including the medical records and clinical advice we have obtained, we find the Organisation’s response was reasonable. We do not think we will be able to shed any more light than the Organisation has already on what would have happened had the call handling mistake not been made.

1. The Organisation has already acknowledged it did not act in line with the relevant guidance when handling Miss U’s 111 call. The Organisation has apologised to Mr U for the mistake, explained what it thinks the impact of the mistake was, identified and made service improvements to try to prevent the same thing happening again, and explained those improvements to the family.

2. We find the Organisation’s response to Mr U’s original complaint was reasonable and that the Organisation did all it could at that point to remedy matters. Therefore, we do not uphold the complaint.