South Central Ambulance Service NHS Foundation Trust

4. Miss G complains when attending to her father, Mr G, at home on 24 July 2024, the Trust’s care and treatment decisions prevented him from going to hospital.

5. Very sadly, Mr G died at home on 26 July 2024. Miss G says this was a missed opportunity to have saved her father’s life, that if he had received hospital-based care he may be alive today. She says these events have seriously impacted her emotional and mental health, and she has struggled to grieve.

6. To resolve her complaint, Miss G would like the Trust to acknowledge its failings and to apologise for the impact. She seeks service improvements, for learning to take place to reduce the chance of these failings happening again. Miss G also seeks a financial payment in recognition of the injustice caused by these failings.

7. On 22 July 2024, Mr G went to the emergency department reporting abdominal pain and vomiting. The Trust said Mr G received antibiotics for a possible infection and self-discharged because of concerns about his dogs at home.

8. On 24 July Miss G called 999 with her father present and speaking. An assessment was completed and an ambulance crew attended. They gave Mr G intravenous (IV) fluids at home and documented advising him to go to hospital if his pain got worse and antibiotics had not cleared up any possible infection. Mr G signed the patient declaration part of the record, confirming the information recorded was explained to him, that he understood the advice given and agreed with the pathway of care.

9. The next day, Miss G called 999 explaining she wasn’t with her dad but said he had ‘been poorly’. She said he was found that morning having fallen with ‘vomit everywhere’ and was quite confused, having gone to hospital recently with ‘an infection of his tummy’. Miss G told the call handler her father was ‘reluctant to go into hospital’ and ‘he talked everyone around’, explaining ‘everybody I’ve gotten in to check on him, he’s like no I’m not going in’.

10. Miss G explained her cousin was with Mr G and she gave the call handler his number. The call handler called the cousin who passed the phone to Mr G. An assessment was completed from which the call hander advised Mr G to contact his GP in the next 24 hours. Mr G said he would do that and safety netting advice was given (information on what to do if things changed or worsened).

11. Also on 25 July, someone called 999 stating they were a friend of Mr G but wanted to remain anonymous. They raised concerns about Mr G’s welfare and asked for a check at home. The caller explained an ambulance crew had attended the day before and said Mr G had ‘refused to go to hospital’, that he ‘doesn’t want anyone to go round’ and ‘doesn’t want to go to hospital’. The caller explained Mr G was home alone and had ‘gone downhill’ and so the call handler advised they would arrange an ambulance.

12. An ambulance crew attended that evening. They documented that Mr G opened the door but remained standing in the doorway and was surprised to see the crew as he was not expecting them. They noted Mr G said he was fine, didn’t need help, and he refused to have any observations or assessments. Mr G signed the patient declaration part of the record, confirming that despite the advice given he had declined assessment, treatment or transport to hospital.

13. On 26 July Mr G’s ex-wife found him collapsed and not breathing at his home. Very sadly, despite attempts at giving life-saving measures, when the ambulance crew attended Mr G was declared deceased on scene.

17. Miss G’s complaint to us, is that the ambulance crew’s care and treatment decisions on 24 July prevented her father from going to hospital. We do not see that anything the ambulance crew did on this date meant Mr G was prevented from going to hospital, that hospital wasn’t an option for him to have advocated for, or that he was told he couldn’t go to hospital.

18. Evidence from the audio recordings of calls made by Miss G and the anonymous caller the following day contain several statements that Mr G was ‘reluctant’ and ‘didn’t want to go’ to hospital. From what was said on these calls, it appears this was despite the ambulance crew having attended the day before, and Miss G and others trying to suggest and encourage Mr G to do so.

19. In addition, when an ambulance crew returned to Mr G’s home on the evening of 25 July, they noted Mr G ‘refused’ any help or transport, and on both 24 and 25 July Mr G signed the patient declaration part of the record confirming he understood and agreed with the content of the recorded entries. This all supports our view that there is nothing to indicate the ambulance crew prevented Mr G from going to hospital on 24 July.

20. We do however think that the ambulance crew should have considered transferring Mr G to hospital and documented their thinking on this, having more explicit conversations with Mr G about this possibility.

21. The crew documented Mr G’s observations several times. Each time observations are measured they are given a number to provide a total, called the National Early Warning Score (NEWS). The higher the NEWS, the greater the indication of deterioration in adult patients. NEWS guidance sets out the level of response required, depending on the score.

22. When his observations were first taken Mr G’s NEWS was a 3, which the guidance explains does not indicate any immediate concern nor requires additional or alternative action. However, when these observations were repeated Mr G’s NEWS had risen to 5 because of his low blood pressure and raised breathing rate. Our adviser explains over the following observations taken, Mr G’s blood pressure returned to a reasonable level although borderline low, and his breathing rate remained raised.

23. JRCALC guidelines say health practitioners should suspect sepsis in patients who have a NEWS of 5 or greater. It explains that NEWS does not diagnose sepsis but identifies sick patients who need urgent senior clinical review and interventions. Our adviser emphasises that the evidence does not suggest Mr G was showing apparent sepsis, but the raised NEWS was a warning sign and meant hospital transfer was indicated.

24. Our adviser says from these documented observations, Mr G met the JRCALC criteria to have needed care and treatment either in hospital or via an appropriate community service capable of blood tests and home IV administration with the relevant medical oversight.

25. The ambulance crew did provide IV fluids to Mr G at home and remained present to provide medical oversight of this. They document doing so to help relieve Mr G’s symptoms of dehydration. Yet, our adviser explains that to better relieve dehydration, fluids should have been given over a longer period in a hospital-environment, which would also have allowed for investigations to potentially identify the cause.

26. In line with JRCALC guidance, the ambulance crew should have considered, and discussed with Mr G, transferring him to hospital. There is nothing documented to show any consideration of hospital transfer, or any significant or convincing attempt from the crew to get Mr G to agree to a hospital transfer, and we think this should have happened.

27. We find the Trust has already acknowledged these aspects of care and treatment we think were lacking. Within its response to Miss G’s complaint, the Trust has acknowledged that the NEWS of 5 should have made practitioners ‘think sepsis’. It also acknowledged that whilst treatment with IV fluids was correct management, it would have been better delivered at hospital over hours, when other tests could have been done.

28. We carefully considered whether we could link the impact Miss G claimed in paragraph five to these omissions in the service provided, and we did not consider we could make this link.

29. Even had the crew considered and discussed hospital transfer with Mr G in best attempts to gain his agreement, any transfer would have required his consent. It possible that Mr G may have declined transfer and opted to remain at home, just as he did on that day. There is no guarantee, even had the crew taken a stronger approach to discussing hospital-based care, that Mr G would have agreed. We also have evidence from call recordings of Mr G’s stated wishes that he did not want to go to hospital and evidence from the ambulance record on 25 July of his refusal of any help, even when an ambulance crew attended his home that evening.

30. It remains possible that Mr G may have agreed to a transfer. He would then have been taken to hospital where he would likely have received more fluid over a longer period and had the potential for further investigations into his overall condition. We cannot know what his hospital-based care would have looked like, what the outcomes or conclusions would have been or indeed how long he would have remained, but it is reasonable to consider at the least he could have received fluids in hospital on 24 July.

31. Yet, we know he did receive fluids at home, even in the absence of a stronger consideration for and discussion about going to hospital. Whilst a different approach in providing the correct treatment, the actions taken by the ambulance crew on 24 July still meant Mr G received the treatment he would have received in hospital that day. Mr G remaining at home did not deny him the correct treatment for the clinical findings at that time.

32. We know Miss G is very concerned about the matter of her father vomiting. She says the ambulance crew witnessed her father vomiting a red-brown liquid that clearly resembled blood, yet the crew claimed the colour was due to him drinking tea. In response to the complaint, the Trust said Mr G did not vomit in the crew’s presence, but they recall seeing vomit and having been informed he had tea, they considered it due to this whilst acknowledging there may have been some confirmation bias.

33. We do not doubt Miss G’s account and yet we are left with an opposing account from the Trust. When considering this point, we paid particular attention to what Miss G told us and looked to see if there was any independent evidence which we could use to support her account. We have been unable to identify any records or other supporting information that would allow us to challenge or criticise the information provided by the Trust.

34. We appreciate how disappointing this will be for Miss G. It is important that any decisions we make are supported in the evidence available to us and we must acknowledge where there is a lack of evidence to support a complaint, such as here.

35. Our adviser confirmed there is nothing in the evidence available to us to suggest Mr G was experiencing a bleed at the time of the ambulance crew’s attendance on 24 July. In addition, in the time that passed after this attendance, another ambulance crew was sent and help refused by Mr G.

36. We cannot say, even considering the balance of probabilities, that the outcome would have been any different even if the ambulance crew had more explicitly considered and discussed hospital transfer on that occasion. We must acknowledge the result could have been Mr G remaining at home, just as he did that day.

37. With too many unknowns about what might have happened and considering the time between this attendance and Mr G’s very sad death – which included a further ambulance attendance – it is not possible to agree that this was a missed opportunity to save Mr G’s life.

38. We were sorry to hear about how distressing this experience has been for Miss G, and to have learned about the ongoing impact this had on her. We hope we have explained in this statement the reasons we have decided not to take further action on her complaint.

1. We were very sorry to learn of Miss G’s concern, that her father may still be alive today if not for the ambulance crew preventing him from going to hospital on 24 July 2024.

2. We have considered the evidence carefully. We have seen no indication the ambulance crew prevented Mr G from receiving hospital care. We do think hospital transfer should have been considered and discussed more explicitly. Even then, we cannot say the outcome would have been any different. As we cannot link the injustice claimed, we have decided not to investigate further.

3. We recognise how important this complaint is to Miss G and understand how much she has been affected by what happened. We hope Miss G will be reassured by the information in this statement that there is no further action we need to take.