London Ambulance Service NHS Trust

4. Miss R complains London Ambulance Service NHS Trust delayed sending her an ambulance on 23 July 2025. She had a suspected ectopic pregnancy, severe pain, had fainted twice, injured her head and was unable to get off the floor.

5. As a result of the Trust’s claimed failings, Miss R says: • she was in continued agony whilst waiting for emergency help to arrive at her house • she lost four litres of blood, leading to her having multiple blood transfusions • she has been through a very traumatic experience, and she believes her presentation was life-threatening.

6. By bringing this complaint to us, Miss R would like: • an investigation into why the 999 operator triaged her call as not urgent enough to warrant sending an ambulance • the Trust to recognise that a suspected ruptured ectopic pregnancy is a severe, life-threatening emergency • our recommendation of an appropriate financial redress.

7. At 10.24am on 23 July 2025, Miss R called 111 as she was unable to move with severe abdominal pain and a suspected ectopic pregnancy. The Trust put her in a queue for a callback from a clinician in the clinical assessment service.

8. Miss R called 999 at 11.20am. She said she had a suspected ectopic pregnancy, was in severe pain and burning up, and fainted every time she stood up. The Trust triaged her call as ‘category three’ (non-urgent) and did not dispatch an ambulance to her home address. The call handler advised her to call 111 for further support.

9. At 11.40am the 111 service called Miss R to check on her condition. She advised she had hit her head when passing out. She was in pain and extremely worried. Unfortunately, a clinician was not available at that time to assess her symptoms so Miss R remained in the queue for a clinician callback.

10. A clinician from the 111 service called Miss R at 12pm and then again at 12.12pm as Miss R missed the first call.

11. The clinician assessing Miss R initially asked if she would be able to make her way to hospital in a taxi if they sent one to her. Miss R said she could not stand up. The clinician therefore arranged an ambulance for her.

12. The Trust sent her an ambulance at 12.46pm and it arrived on scene at 12.57pm.

13. When Miss R arrived at the hospital, staff diagnosed her with a ruptured ectopic pregnancy. The hospital admitted Miss R for an emergency fallopian tube removal, and provided several blood transfusions as she had lost four litres of blood.

17. 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 found any indications that something has gone wrong.

18. When a member of the public calls 111 or 999, the call is answered by a non-clinical call handler. Call handlers ask a pre-set series of questions provided through the system they are using to triage calls. The Trust’s 111 service uses a system called NHS Pathways, whereas the 999 service use the Advanced Medical Priority Dispatch System (AMPDS). NHS Pathways and AMPDS work in a similar way to identify the type of response required and which calls are of the highest clinical priority.

19. The call handler will ask a series of pre-set questions depending on the problem the caller describes. Based on the caller’s answers, the call handler will select the most accurate corresponding option on NHS Pathways or AMPDS, and this will generate different questions. It is important to note call handlers are not clinicians, so they will not use clinical judgment. They will purely select the closest answer to what the caller said.

20. The call handler may ask clarifying questions in case of ambiguity, to get the most accurate response possible. The answers to these questions then generate an NHS Pathways or AMPDS code, which outlines the chief complaint. The NHS Pathways/AMPDS code is then matched to an ambulance priority response. This is agreed nationally as part of Ambulance Response Programme.

21. The Ambulance Response Programme sets out four categories of ambulance response. Category one is for immediately life-threatening conditions such as when someone is not breathing or their heart has stopped. Category two is for serious emergency conditions which require urgent assessment and/or treatment such as stroke or heart attack. Category three is for urgent problems which may require treatment or transport to hospital. Category four is for non-urgent problems.

22. When Miss R called 111 at 10.24am, she explained she had a suspected ectopic pregnancy and was experiencing abdominal pain, dizziness, and had fainted. NHS Pathways identified the most appropriate course of action was to speak to a clinician. The Trust put Miss R’s call into a queue for a clinician to call her back, with a priority level of two. The Trust aims to call 90% of priority two patients within one hour.

23. From what we have seen, we are satisfied the Trust appropriately used NHS Pathways to identify Miss R needed a call back from a clinician.

24. Before 111 could call Miss R back, she called 999 at 11.20am. Miss R confirmed she was breathing and awake. She told the call handler she was around seven weeks pregnant with a possible ectopic pregnancy. She said she was in severe abdominal pain. She confirmed she did not have any significant bleeding or any health conditions which make pregnancy high risk.

25. Miss R’s records show AMPDS generated the correct code for a call relating to someone who is less than 22 weeks pregnant and has abdominal pain with no significant bleeding. The AMPDS code was correctly matched to a category three ambulance response.

26. Our adviser explained that even when at risk of ectopic pregnancy and/or having abdominal cramping and pains when less than six months’ pregnant, AMDPS will not categorise a patient at high risk of complications, unless the patient is completely unconscious or currently losing lots of blood.

27. It is also important to note AMPDS system does not triage calls based on presenting conditions. Its categorisation criteria are based solely on clinical risk.

28. Miss R’s records show the 999 call handler re-triaged her using the ‘unconscious/fainting’ pathway. This led to the call handler asking some different questions as directed by AMDPS. The answers Miss R gave led to a different AMDPS code, relating to someone who is alert but with abnormal breathing. This code was also matched to a category three ambulance response.

29. From what we have seen, we are satisfied the Trust used AMDPS properly to triage Miss R’s call and decide on the correct clinical priority of a category three ambulance response. Our adviser said there was no evidence in either Ms R’s calls that she should have been higher than a category three ambulance response or priority two clinical callback.

30. Under normal circumstances when classifying a call as category three, an ambulance will attend within two hours of receiving a call. The Trust’s response to Miss R explains that on 23 July 2025 it had escalated its own Clinical Safety Plan (CSP) to ‘blue category – extreme pressure’. This meant it was experiencing very high levels of demand and had to prioritise patients with immediately life-threatening conditions over patients who needed a category three or four response.

31. Ambulance Trusts have an approved Clinical Safety Plan in place, setting out clear criteria according to which they will safeguard and ensure they can respond to the most critically ill patients. For example, those who are not breathing or are not conscious will be prioritised for an ambulance, even when there is extreme pressure on the 999 service. This may include setting criteria in which 999 calls undergo a further clinical assessment to determine the most clinically appropriate response.

32. We can see the Trust followed the Clinical Safety Plan in the handling of Miss R’s 999 call. As the Trust was operating at level blue, the Trust could not send an ambulance to Miss R because she was assessed as category three. We recognise this will have been very distressing for Miss R. The Trust needed to prioritise ambulances for patients who were at greater clinical risk and assessed as categories one and two. The Trust followed the Clinical Safety Plan by advising Miss R to call 111 for further assessment and potential non-emergency transport.

33. We note from available call logs a 111 call handler called Miss R back 20 minutes later, at 11:40am. Miss R informed them her health was further deteriorating, having now fainted twice, hit her head on the toilet floor, now unable to move and still in severe abdominal pain. The operator assured her they would consult with a clinician and would ask them to call her again shortly to reassess her.

34. It is evident from call logs timed 12 noon and 12:12pm, a clinician did attempt and then manage to speak to Miss R. After a further clinical review of all Miss R’s symptoms, they initially asked if she could make her way to hospital in a taxi. Miss R explained she could not get up, so the clinician arranged for an ambulance to be sent as a category two priority. Clinicians have authority to upgrade the priority of calls when necessary.

35. The Ambulance Response Programme says that for category two ambulances, the target average response time is 18 minutes, with 90% of responses being within 40 minutes. The ambulance arrived at her home at 12:57pm, 31 minutes after the clinician upgraded Miss R’s call to a category two ambulance response. We understand this will have felt like a long time for Miss R to wait when she was in pain and very unwell.

36. As we have identified no indications of failings, we are of the view the actions the Trust took were in line with relevant standards, when considering the extreme pressure it was under on 23 July 2025.

37. We are very sorry to learn of the details of Miss R’s complaint. We recognise how distressed and worried she was when she requested help from the Trust. We also understand why she believes a faster response time would have been appropriate under the circumstances.

38. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it. We would like to thank Miss R for bringing her concerns to our attention and we hope we have provided her with assurance about the Trust’s services on the day of the events.

1. We are very sorry to read about Miss R’s experience with the London Ambulance Service NHS Trust (the Trust) in July 2025 and recognise the painful physical and psychological challenges she faced. We acknowledge the importance of her concerns about the 999 service and ambulance dispatch timings.

2. We have carefully considered all available evidence. Having done so, we have decided to take no further action. This is because we do not see any indication of failings in the complaints raised about the Trust’s care provided to Miss R.

3. We understand this was an upsetting time for Miss R. Our decision fully took into consideration the distressing circumstances around the events. We have explained the reasons for our decision below.