East Midlands Ambulance Service NHS Trust

3. Mr E complains about aspects of the care and treatment his mother, Ms R, received from East Midlands Ambulance Service NHS Trust (EMAS) and University Hospitals of Leicester NHS Trust (the Trust).

4. Mr E complains there was a two-hour delay before an ambulance from EMAS attended to assess his mother on 1 August 2024. Mr E believes this was because EMAS wrongly categorised Ms R when he thought she was suffering from a heart attack.

5. Mr E also complains the Trust: • delayed starting emergency treatment once his mother was at hospital on 2 August • did not make sure intravenous (IV – given directly into a vein) furosemide was being administered correctly on 10 and 11 August.

6. Mr E believes that the initial delay in an ambulance attending, meant Ms R’s condition deteriorated due to not getting immediate professional medical help. He believes this caused or contributed to her death. He also believes the delay in the Trust starting emergency treatment once Ms R was in hospital, caused or contributed to her death. Mr E also believes the error administering furosemide caused a much lower urine output, which doctors used as justification to withdraw proactive treatment. He believes this caused or contributed to her dying when she may not have done if the Trust continued providing treatment. Mr E has told us this also caused him distress and emotional suffering.

7. Mr E would like an apology from EMAS and the Trust. He would also like both organisations to make service improvements. He would also like a financial remedy of at least £100,000.

8. On the evening of 1 August 2024 Mr E called for an ambulance as his mother, Ms R, was suffering from chest pain and had used her Nitrolingual pump spray. You would use a Nitrolingual pump spray to treat and prevent episodes of sudden chest pain.

9. Before calling the ambulance, Mr E had checked his mother’s blood pressure and noticed it was low.

10. On the initial call, Mr E asked for an ambulance to come quickly as he believed his mother was having a heart attack. However, EMAS told him the ambulance could take up to two hours to attend.

11. Around two hours later an ambulance arrived and after assessing Ms R they advised Mr E they would be taking his mother to hospital.

12. The Trust admitted Ms R at 00:50am on 2 August. Unfortunately, she had to sit in a chair initially, before being given a bed. The Trust diagnosed the chest pain was caused by a heart attack.

13. In the following days Ms R had low blood pressure and was often nauseous. She also had increased infection markers. Staff then diagnosed that Ms R was also suffering from a chest infection.

14. During her admission Ms R developed fluid overload due to her underlying heart failure. The heart attack and infection increased this overload. As a result, the Trust added furosemide to her treatment.

15. On 11 August the Trust assessed Ms R and believed she was not responding to treatment. Given her serious condition, the medical assessment of the Trust was that it would stop medical treatment and move to a palliative approach.

16. The nursing team informed the treating consultant that there had been an error with a furosemide infusion that had not been running for around 12 hours, due to the cannula not working effectively.

17. Staff completed a Datix incident report at the time of the error. Staff use the Datix system to report any unexpected event that caused or had the potential to cause harm, loss, or damage. This would include clinical Incidents, medication errors, and near-misses.

18. When the Trust made the decision to move to palliative care it told Mr E of its decision. He told the consultant that he disagreed with this decision, and we understand this was a distressing time.

19. Sadly, Ms R passed away shortly after.

22. The HSCA says we cannot investigate a complaint where a person has the option to take legal action, unless we consider it is not reasonable for them to do so. We do not base our decision on how successful legal action would be. Rather, we consider whether legal action is a reasonable option for someone to pursue.

23. We conversed with Mr E to understand his circumstances, his complaint and the outcome he seeks. Mr E told us that he would like an apology, service improvements and financial compensation of £100,000 or more. He also believes the care and treatment Ms R received, caused or contributed to her death.

24. Given this and the financial compensation he is seeking, Mr E could pursue legal action, specifically through a clinical negligence claim.

25. In Mr E’s communication with us, he also repeatedly said that he considers what happened to be negligence. We cannot reach a view on negligence. This is something that can be done through a clinical negligence claim.

26. We are generally not able to provide the same levels of financial remedy that a court can. Whilst we can make some recommendations for financial remedy, we would not be able to achieve the amount Mr E is seeking. This is because Mr E is seeking an amount that far exceeds the figures we typically recommend.

27. Mr E told us that he has not approached a solicitor or taken any actions to get any independent legal advice, to see if a solicitor could consider his case under a clinical negligence claim.

28. Mr E has not told us of any barriers to seeking legal advice. He told us he approached us thinking that was the correct route to take. We have explained to him that as he believes there has been negligence and he feels financial compensation should be paid, the best route to achieve this may be to take legal action.

29. Mr E has the option of seeking free legal advice and could seek legal representation under a conditional fee arrangement, commonly known as a ‘no-win-no-fee’ basis. This would not incur any upfront costs to him. As this is the case, there should be no financial barrier to Mr E taking his own legal action.

30. There is a three-year time limit for most clinical negligence claims. Mr E is still within this three-year time limit for his complaint, and therefore still has the option to take legal action.

31. Mr E has told us he would also like an apology and service improvements from EMAS and the Trust.While legal action would not necessarily lead to an apology and service improvements if/when a judge decides on any medical negligence matters, a byproduct may be that Mr E would receive the apologies he wants.

32. Any successful clinical negligence claim could also lead to the service improvements Mr E would like to see. If following the conclusion of any legal action Mr E does not feel he achieved the apology or service improvements he wants, it would still be open to him to approach us again at that point.

33. We have considered the relevant factors and the HSCA. Mr E is still in time to pursue legal action. The legal route is better suited as it may lead to the financial outcome he seeks.

34. We are unaware of any barriers to prevent him from pursuing or at the least exploring the option of legal action currently, and in line with the HSCA, we think it is reasonable that he does so. We have therefore decided not to consider the complaint further for this reason.

35. We recognise how important this complaint is to Mr E and we thank him for bringing it to us for our consideration.

1. We were very sorry to learn of Mr E’s complaint and the concerns he raised about his mother’s care. We recognise it was a worrying time for him.

2. We have decided not to consider Mr E’s complaint further because we consider he could take legal action to achieve the outcome he seeks.