An independent provider in the Cumberland area

The Trust 4. Mrs K complains about the Trust’s actions in relation to her husband’s care in late January 2025. She is unhappy: • when she spoke to a 111 clinician, they told her a doctor would ‘call’ without clarifying this would not be a physical visit • after she called 999, it took more than three hours for an ambulance to attend • the crew did not assess Mr K sufficiently or consider if it was safe to leave him at home • the crew decided not to transport her husband to hospital and incorrectly advised they could not administer a drip in the ambulance.

5. Mrs K says she had to struggle to get her husband to hospital herself and he injured himself in the process. She is concerned the Trust’s actions contributed to her husband’s deterioration as his hospital treatment was delayed for almost eight hours. She has been left questioning if this was a factor in his death a month later. The bereavement has had a lasting impact on her and her family.

6. Mrs K wants the Trust to acknowledge its failings, apologise and improve its service. She would also like us to consider making a financial recommendation.

the out of hours service 7. Mrs K complains about the actions of the out of hours service in relation to her husband, Mr K’s, care in late January 2025. She is unhappy the doctor did not call 999 to arrange an ambulance and said she should do this herself.

8. Mrs K says this meant there was a delay and confusion when the ambulance crew attended. She is concerned the out of hours service’s actions contributed to her husband’s deterioration as his hospital treatment was delayed for almost eight hours. She has been left questioning if this was a factor in his death a month later. The bereavement has had a lasting impact on her and her family.

9. Mrs K wants the out of hours service to acknowledge its failings, apologise and improve its service. She would also like us to consider making a financial recommendation.

10. We include this brief background to put the complaint into context. It is not intended to reflect all of the detail Mrs K has provided about her experience.

11. Mr K was in his seventies at the time of the events. Mrs K called 111 late in the evening. She was referred to the out of hours service and had an out of hours call with a doctor.

12. The out of hours service doctor completed a telephone assessment and advised Mrs K to ring 999 for an ambulance. She did so around 2.30am the next morning. Around three hours later, she called to check when the ambulance was going to arrive. The crew got to her home shortly before 6am.

13. We recognise there is a dispute about the discussion Mr and Mrs K had with the ambulance crew. Ultimately, Mrs K drove Mr K to hospital.

14. Sadly, approximately one month after this, Mr K passed away.

The Trust

Contact before the ambulance arrived

18. 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 seen an indication that something went wrong, as reflected in the Trust’s response.

19. The Trust acknowledged a clinician said an out of hours doctor might “call” and that was interpreted by Mrs K as ‘visit’, rather than ‘phone’. It apologised for any confusion.

20. The Handbook to the NHS Constitution says patients can expect to be treated at the right time and according to their clinical priority. Emergency ambulance calls in England are prioritised under the NHS England Ambulance Response Programme. This framework separates calls into categories according to clinical urgency.

21. There are four call categories for an ambulance response. Category 2 is used for emergency calls requiring rapid assessment and/or urgent transport. Category 3 is used for urgent calls where treatment, clinical assessment or transport is required, but the presentation is not immediately life-threatening.

22. The first 999 call was made at 2.32am after the out-of-hours doctor advised Mrs K to request an ambulance. This call generated a Category 3 ambulance response. Dark bowel motions can represent blood loss, and Mr K was not asked whether he had suddenly become confused or was more confused than usual.

23. The Trust said this meant the response entered for potential blood loss may have been inaccurate and that the answers to these questions could have resulted in a category 2 ambulance response. We asked our paramedic adviser about the Trust’s response times.

24. Mrs K made a further call at 5.27am. The ambulance did not arrive until 5.53am, a total interval of approximately 3 hours and 21 minutes from first 999 contact to ambulance arrival. Our adviser said the operational pressure the Trust was under helps explain why an incorrectly categorised lower-priority call could remain unanswered for a prolonged period.

25. The later call resulted in a category 2 response and this happened in line with the relevant timeframes. The ambulance arrived approximately 26 minutes after the call started. That is within the national response standard, 90% of calls to be responded to in 40 minutes.

After the ambulance attended

26. 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 seen no indication that something went wrong in relation to this part of the complaint.

27. Our adviser said if the crew advised that paramedics could not administer fluids at all, that would have been inaccurate. Paramedics can administer intravenous fluids when indicated under their scope of practice and relevant medicines guidance. We considered if Mr K needed saline at that time.

28. JRCALC guidance says saline can be administered if a patient has signs of poor blood perfusion and their systolic blood pressure is below 90.

29. The Trust’s records do not demonstrate that Mr K met these criteria at the time of ambulance assessment. His recorded blood pressures were 124/89 sitting and 145/110 standing. It appears he well perfused, not pale, not clammy, had normal blood pressure, and had no signs of active bleeding or shock. There was no indication to administer fluids to him.

30. The crew were under the impression Mr K had a lower gastrointestinal haemorrhage. They identified the Emergency Department as the appropriate pathway. They recorded that Mrs K was happy to convey Mr K by car and that Mr K had capacity.

31. Our adviser explained alternative transport can be used where the patient does not require ongoing ambulance clinical intervention, monitoring or treatment during transport, and is encouraged by Trusts where safe (especially in times of increased demand).

32. In this case, the documented observations and assessment support that Mr K was clinically stable at the time the crew were present. There was no recorded hypotension, reduced consciousness, respiratory distress, active collapse, or shock.

33. Our adviser noted it would have been better if the Trust had kept a fuller record of the discussion but from what we can see, the decision to allow Mrs K to transport Mr K is supported by the clinical observations recorded at the time.

34. We do not dispute Mrs K’s account about how difficult it was for her to get Mr K out of their home, into their car and to hospital. We do not underestimate the additional worry she experienced when Mr K sustained an injury in the process of this. As we have explained, we cannot say this was a result of a failing by the Trust.

35. Overall, we have identified a potential failing in the initial call categorisation which led to a delayed ambulance response. Based on the available evidence, we are unable to say whether an earlier ambulance response would have altered Mr K subsequent clinical course or death one month later.

The out of hours service

36. GMC Good Medical Practice says doctors must adequately assess a patient’s condition, promptly provide/arrange suitable advice, investigation or treatment where necessary, and refer to another suitably qualified practitioner if required.

37. Our GP adviser explained the information the doctor obtained from Mrs K was sufficient to suspect Mr K was bleeding in the gut. He had dark stool and felt very weak.

38. As reflected in the National Framework, it is the clinician's responsibility to contact the ambulance service where it is necessary. The clinician is able to convey the relevant information and findings in a way a lay person may be unable to.

39. The doctor did not act in line with this and asked Mrs K to call 999. the out of hours service has acknowledged this.

40. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Mrs K described.

41. We cannot say what clinical impact the doctor’s decision not to call had, but it is possible it delayed the ambulance service’s response. When Mrs K rang 999, it was initially handled as a category three call. Had the GP called the ambulance service, our GP adviser said it would have been responded to as a category two call.

42. We have already identified the ambulance crew’s decision not to transport Mr K to hospital was in line with guidance. We are therefore unable to conclude that the GP’s decision not to call had a significant impact on Mr K.

43. Our Principles say good complaint handling is not limited to providing an individual remedy to the complainant. Organisations should ensure that all feedback and lessons learnt from complaints contribute to service improvement.

44. As there is a sign something went wrong, we considered the action taken in response to the complaint. the out of hours service explained the doctor’s actions were not in line with its policy. It said it had shared individual learning with the doctor and carried out a case review. the out of hours service also sent a reminder to all of its clinicians about ensuring the clinician contacts the ambulance service.

45. We consider these actions reflect our Principles. There is nothing to suggest we need to investigate further or think about making formal recommendations for learning.

46. While we cannot change Mrs K’s experience, we would like to thank her for complaining. We hope our investigation has helped her. While we were unable to say things went wrong as she described, the learning from her complaint should help to improve services. We hope it is clear why we have decided not to investigate this complaint further.

1. We have carefully considered Mrs K’s complaint about the Trust and the out of hours service. We were sorry to hear her concerns about the care her husband, Mr K, received and her experience.

2. Both organisations have already acknowledged they could have acted differently. We have seen no indication that anything went seriously wrong beyond what they had identified.

3. As we will go on to explain, we have decided we cannot link the events complained about to Mr K’s later deterioration and death. This is why we are not investigating further.