London Ambulance Service NHS Trust

4. Mr F complains about the actions taken by London Ambulance Service (the Trust) following a 999 call in relation to his grandfather, Mr L, on 12 March 2025. Specifically, he complains:

• the Trust incorrectly categorised the 999 call • the crew did not adequately assess his grandfather on arrival at the scene • the crew delayed giving his grandfather care • the crew did not provide cardiopulmonary resuscitation (CPR) or other lifesaving medical interventions in line with clinical protocols • the Trust did not download the defibrillator data before it was overwritten.

5. As a result of these failings, Mr F says his grandfather was not given the opportunity to receive any lifesaving treatment. He has been left wondering if the outcome could have been different if the Trust had provided different care. He and his family are heartbroken by his grandfather’s death.

6. Mr F wants the Trust to acknowledge its failings and make service improvements.

7. Mr L’s wife called 999 at 12.07pm on 12 March 2025, as he had begun to feel unwell. She stated he was experiencing some chest pain, was clammy and had gone to lie down. Following its assessment, the Trust categorised this call as a category two. We give further details about call categorisation in paragraphs 25 to 26.

8. At 12.16pm the Trust assigned an ambulance. It arrived on scene at 12.26pm. At 12.37pm, the Trust sadly pronounced Mr L as deceased.

13. 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.

The categorisation of the 999 call

14. In his complaint to us, Mr F said the Trust incorrectly categorised his grandfather’s, Mr L’s symptoms, as a category two, when Mrs L called 999 at 12.07pm on 12 March 2025. Mr F believes the emergency call handler should have categorised the call as a category one. He said his grandfather was asking for heartburn medication, coughing up phlegm (thick mucus) and stating he had chest pain which would have been indicative of a heart attack. Mr F said this should have warranted a category one response.

15. The Trust said at the time Mr L’s wife placed the call, she reported Mr L was conscious and breathing. The call handler proceeded with routine structured assessment questioning and triaged the call using the chest pain protocol from the medical priority dispatch system (MPDS). The call received the high-risk determinant code 10D4, which is a category two response. The Trust concluded the call was determined at the appropriate level of priority.

16. We have found the Trust correctly categorised the call as category two.

17. When a member of the public calls 999 and asks for the ambulance service they are transferred to the Emergency Operations Centre for the relevant local service. The staff who answer the calls ask a structured set of questions as guided by the system they use to assess the priority of calls. Our adviser explained that, at the time of this incident, London Ambulance Service used MPDS.

18. MPDS is a structured emergency medical dispatch system which follows scripted pathways to determine patient priority according to the answers given by the caller. The categorisation would reflect what is reported during the call in answer to the questions, not what may later be clinically diagnosed. Ambulance service call handlers are not clinicians so cannot diagnose people over the telephone.

19. MPDS converts a caller’s answers into a determinant code. Each code has three parts, the protocol number (the chief complaint that has been identified), the determinant level (A-E) and a sub-determinant digit which describes the specific finding under the assigned protocol. The determinant level operates under a tier system, starting with the lowest priority situations requiring a non-urgent response (A) to the most time critical, life-threatening situations which require immediate action (E).

20. In Mr L’s case, the call handler identified the chief complaint was non-traumatic chest pain/chest discomfort. The determinant code 10D4 was generated following the assessment of Mr L’s symptoms using the questions set by MPDS. 10D4 is the code for chest pain not related to a traumatic injury, where an urgent response is required. This meant a category two response was allocated.

21. Upon reviewing the 999 call recording, we noted the information Mrs L provided during the call and the questions the call handler asked. When asked if Mr L was breathing and awake, Mrs L confirmed he was. She explained he had a cold, was coughing up phlegm, and complained of chest pain, which he thought was caused by injuring himself while coughing.

22. Mrs L reported that Mr L was breathing and responding normally but stated he was sweating and "a bit clammy" when she touched his face. She also mentioned that Mr L appeared red in colour, although her partial sight made it difficult for her to see clearly. She confirmed he had not vomited, was not nauseated, and had no history of heart problems. The only medication Mr L had taken was for his cough.

23. At this point, the call handler reassured Mrs L that help was on its way and advised her to stay on the line. Before ending the call, the call handler told Mrs L to call back immediately if Mr L’s condition worsened.

24. Our paramedic advised us, the call handler categorised the call using the appropriate diagnostic system. At the time of the 999 call, Mrs L reported Mr L to be awake, breathing and responding normally. Because of this, the call did not meet the criteria for a category one response.

25. According to NHS England’s ARP, a category one response is reserved for the most serious and life-threatening situations. This is the highest response level a Trust can assign to a 999 call. These will involve time critical incidents which require immediate intervention. A cardiac arrest, an airway obstruction and someone unconscious with abnormal or noisy breathing, are some examples of incidents that will receive a category one response.

26. A category two response will be allocated to potentially serious conditions, which require urgent assessment, on-scene intervention and/or transport to hospital. Examples of category two incidents include a heart attack, stroke, major burns or major blood loss and someone unconscious with normal breathing.

27. We recognise Mr L’s symptoms were concerning to his family. The records do not indicate Mrs L reported immediately life-threatening symptoms (such as collapse, abnormal or absent breathing, seizure activity, or ongoing unconsciousness) which would have increased the priority to a higher category. From what we have seen, we are satisfied the Trust used the MPDS properly to triage Mrs L’s call.

28. Our paramedic adviser explained the call handler did not attempt to convert the 999 call to a first party call. This means they did not ask to speak with Mr L or clarify if Mrs L was with him during the call. In their review of the call, the Trust acknowledged the call handler could have asked to speak with Mr L and confirm Mrs L’s proximity to him. This may have resulted in Mrs L giving different responses to the questions asked by the call handler if she went into the same room and realised his condition had changed from when she started the call.

29. We are unable to say what would have happened if the call handler had asked these further questions. Whilst additional clarification may have resulted in different information being provided by Mrs L, we cannot say this would have changed the outcome of the call categorisation. This is because we do not know what answers she would have given. Our paramedic advised us there is no requirement for a call handler to ask to speak directly to a patient or confirm a caller is with a patient. We have not seen any guidance specifying that this step is mandatory.

30. Following our clinical standard, when we are considering complaints about clinical care and treatment, we consider whether there has been “good clinical care and treatment”. We aim to establish what would have been good clinical care and treatment in the situation complained about, and to decide whether the care and treatment complained about fell short of that.

31. Considering all this evidence and advice, we found the call handler correctly categorised the 999 call based on the information Mrs L provided to them. The call handler asked specific questions as directed by the MPDS. This generated a correct category two response and is entirely consistent with guidelines. As there is no standard that says 999 call handlers should ask to speak to the patient, or if the caller is with the patient, we cannot say it was a failing that the call handler did not do this. As such, we saw no indication of a failing regarding this issue.

32. It is understandable Mr F may feel his grandfather should have been given a higher priority earlier and this would have resulted in getting an ambulance sooner. Based on the information available to the service, this was only possible if it was reported to the call handler Mr L was exhibiting symptoms that require a category one response such as abnormal breathing or unconsciousness.

33. We understand Mr F’s concerns that the call handler did not prioritise his grandfather’s symptoms correctly, given he sadly died shortly after the 999 call was made. We appreciate how distressing this has been for Mr F and his family. We are truly sorry for their loss and the upset this situation has caused. We hope we have assured Mr F the Trust appropriately categorised the 999 call and followed correct the process as directed by the system.

The crew’s assessment on scene, the delay giving care and the decision not to do CPR

34. Mr F complains the crew did not adequately assess his grandfather on scene. He further complains they delayed starting treatment by first doing an ECG, which may have led to them missing a chance for effective resuscitation. He also complains the crew decided not to perform CPR or any lifesaving interventions.

35. The Trust explained that on arrival to scene the ambulance crew were met by a neighbour who said that Mr L had died and been unresponsive with no pulse for 30 minutes. The crew then went upstairs and completed a visual assessment. They noted Mr L was grey in colour, had vomited and urinated and looked like he had been in bed for some time.

36. After the visual assessment, the crew applied an ECG and found Mr L’s heart rhythm was asystole. This meant his heart had stopped beating and it had no detectable electrical activity. The crew noted he was not breathing, had no detectable pulses, and he had fixed and dilated pupils (his pupils failed to respond to light). In view of this, the crew concluded that Mr L had died.

37. JRCALC guidelines states in patients with cardiopulmonary arrest (where their heart is not beating and they are not breathing) ambulance staff must attempt resuscitation whenever there is a chance of survival. The guidance notes it is possible to identify patients in whom there is absolutely no chance of survival and where resuscitation would be both futile and distressing for relatives, friends and the healthcare personnel.

38. JRCALC guidelines specify that resuscitation would be futile if the following criteria are met: • 15 minutes since the onset of collapse • no bystander CPR prior to arrival of the ambulance • the absence of any exclusion factors (drowning, hypothermia, poisoning, overdose, or pregnancy) • asystole (flat line) for >30 seconds on the ECG monitor screen.

39. At the heart of this complaint is that the crew did not consider Mr L had any chance of survival and therefore they decided not to perform CPR or give any lifesaving measures. Mr F strongly believes the crew should have attempted resuscitation.

40. The ambulance crew described Mr L as presenting with signs he had already died when they attended to him. Following the crew’s observations, they conducted their assessment and determined that the Trust’s Policy for Verification of Fact of Death was satisfied. This states that it must be: • over 15 minutes since a confirmed cardiac arrest • no exclusions factors present (when resuscitation would always be attempted such as the patient is under 18 years old, a drowning, pregnancy) • no bystander CPR in progress or attempted before the ambulance crew arrival.

41. The Trust said Mr L met all the above criteria.

42. This situation is complicated because of discrepancies between what Mrs L said in the 999 call, what the neighbour said on arrival, and what the crew observed when they arrived at the bedside. This means it is unclear when Mr L became unresponsive and when his heart stopped beating.

43. During the 999 call at 12.07pm Mrs L said Mr L was breathing and awake. The call ended at 12.12pm. Mrs L provided us with a statement which said after the call ended she checked on Mr L and found him unresponsive. She then went to her neighbour’s house for help. She said as they made their way back to her house, the ambulance arrived. Mrs L mentions this sequence happened "very quickly," implying a much shorter window of time between the onset of her husband’s symptoms and the ambulance arriving. This would support the idea that sadly Mr L had become unresponsive before the ambulance crew’s arrival.

44. We do not have a statement from Mr and Mrs L’s neighbour.

45. Mr F’s mother, Mrs F, also provided us a statement. She said Mrs L called her at approximately 12.20pm. She said Mrs L sounded panicked and said Mr L was not well and she had called an ambulance. Mrs F said Mrs L told her that Mr L had been talking to her just before she called 999.

46. The crew both provided statements to the Trust. These statements both document that on arrival at 12.26pm, Mr and Mrs L’s neighbour said he had been unresponsive with no pulse for 30 minutes.

47. Where there is conflicting evidence or uncertainty about what happened, our service model guidance (SMG) says we should consider whether something is more likely to have happened, based on the simple balance of probability. Our review found conflicting evidence about the timeline of events, particularly between the neighbour’s account, Mrs L’s and Mrs F’s statement, and the ambulance crew’s documentation.

48. For example, the neighbour estimated that Mr L had been without a pulse for 30 minutes before the ambulance crew arrived at 12:26pm. This would have meant Mr L was without a pulse at around 11.56am. The 999 call was made at 12.07pm, when Mrs L reported Mr L was awake and responding normally. In this instance, we have been unable to determine precisely when Mr L went into cardiac arrest due to significant variations in accounts from the family, the neighbour, and the crew’s notes.

49. When considering if the crew took the right actions, we must base our decisions on the information they had at the time. Whilst the neighbour’s account that Mr L had been unresponsive for 30 minutes does not align with what Mrs L said in the 999 call 19 minutes earlier, it does indicate Mr L had been unresponsive with no pulse for a significant length of time.

50. On arrival the crew completed their visual assessment of Mr L and described him as presenting with signs he had already died. Crew A noted he was unresponsive in bed and Crew B observed he was grey in colour, had urinated, vomited and appeared to have been there for some time.

51. The records show the crew then assessed Mr L’s airways, breathing and circulation at 12.31pm. They noted his airway was partially obstructed with vomit, he was not breathing, and he had no pulse.

52. Given what the neighbour told the crew, and what the crew saw when they arrived at Mr L’s bedside and examined him, it was in line with JRCALC guidance to do an ECG rather than starting immediate CPR. Our adviser explained the neighbour’s account, and the findings of the visual assessment and initial examination all suggested Mr L had died and resuscitation would likely not be successful. The ECG confirmed Mr L’s heart was not in a shockable rhythm, and it was in line with guidance for the crew to confirm he had sadly died.

53. The Trust explained the crew’s assessment findings showed clear signs of a cardiac arrest that was not recent. It explained that even if the crew had started CPR, the chance of survival in this scenario was sadly very low.

54. The Trust also said there are factors in this case that made survival less likely.

55. Mrs L said Mr L was responding normally at the time the call was placed, at 12:07pm. This was 19 minutes before the crew arrived. We recognise Mr F does not believe the crew could accurately confirm it had been more than 15 minutes since Mr L was in confirmed cardiac arrest. A neighbour told the crew he had been unresponsive for around 30 minutes. From what we have seen, it is more likely than not that Mr L had passed the threshold for resuscitation.

56. Mrs F describes Mr L as “warm to the touch” when she arrived shortly after the ambulance. She also noted that she did not see any "medical equipment or paraphernalia".

57. We recognise Mr L’s condition was observed differently by various parties.

58. Based on the available evidence and the information supplied to us by Mr F and his family, we have found it was in line with JRCALC guidelines for the crew to not start resuscitation or provide any other medical treatment to Mr L. We are satisfied the crew assessed Mr L appropriately and in a timely manner. The statements by the crew indicate the assessment met the guidelines for confirming death which included persistent asystole as recorded on the ECG, the absence of breathing, and absent circulation.

59. We note Mrs F said Mr L was still warm, this would not be inconsistent with sudden death occurring shortly before the crew’s arrival. Regarding the lack of visible medical equipment, the crew appeared to have prioritised immediate assessment of Mr L to ensure compliance with JRCALC guidelines. This would explain the absence of additional equipment or paraphernalia.

60. The Trust’s decision was fully consistent with the JRCALC and Trust guidelines. We have not seen any evidence of a departure from these protocols or that the crew’s actions amounted to an omission in care.

61. We recognise how difficult it must be for Mr F to come to terms with what happened and to feel assured that everything appropriate was done in Mr L’s case. We hope this explanation provides clarity about the crew’s approach and reassurance that their decision was consistent with clinical standards.

The Trust did not download the defibrillator data on the date of use

62. A defibrillator is a compact, portable device that can be used to monitor the heart’s electrical activity and deliver a shock if necessary. If it detects a pattern consistent with a cardiac arrest, the device will deliver a shock aimed at restarting the heart.

63. Mr F told us he had requested the defibrillator data from the Trust to show if Mr L had any cardiac rhythm to know if CPR was necessary and what time the defibrillator pads were put on his grandfather. Mr F said the device should have been put out of use until the Trust could have downloaded the data from it. The Trust confirmed the data was not downloaded from this device.

64. The Trust said the data had been overwritten and not available to download. This was likely due to the length of time that had passed between the incident date, the Trust’s attempt to retrieve it and the number of cases recorded on the device since the incident. The Trust said it does not routinely download data for cases where the patient is clearly deceased. It said the expectation would be to download the data where resuscitation has been attempted, and this was not the case for Mr L.

65. We have not seen any indications of failings in the Trust not downloading the data from the device.

66. Our paramedic adviser told us there is currently no specific national or Trust-level guidance requiring defibrillator data to be downloaded in all cases. They explained downloading the data is only necessary when CPR has been administered as part of a clinical record to document the resuscitation efforts and the interventions provided.

67. In Mr L’s case, no resuscitation was attempted and so there was no requirement to download or preserve the defibrillator data. This was in line with expected practice.

68. The Trust has shown it made efforts to retrieve the data from the device and review the cases available to download. We are satisfied that if it had been possible to access the data, the Trust would have provided this to Mr F.

69. Our review of the evidence supports this, as we found no indication to suggest otherwise. We have seen the echocardiogram (ECG) rhythm strip that was printed out on 12 March 2025. Our paramedic explained this showed Mr L had no cardiac rhythm and his heart did not have a shockable rhythm. We hope this reassures Mr F if the data was downloaded from the device when it was available, it would likely have showed the same.

70. We understand that Mr F believes the defibrillator data should have been downloaded immediately following the incident. After reviewing all the available evidence, we have not seen that the Trust did something seriously wrong in relation to this issue. The Trust took appropriate steps to locate the device used on 12 March 2025 and attempted to obtain the data from it to provide this to Mr F. We have not identified any guidance requiring the Trust to download data in these circumstances, or have we found any failings in the Trust’s decision-making around this issue. We will not be taking any further action.

71. We understand how deeply important it is to Mr F to feel assured that everything possible was done for his grandfather. We also appreciate how difficult it will have been to wonder if the defibrillator data may have provided more clarity on what happened. We recognise this would have been very distressing. We hope we have clearly explained how we reached our conclusion on this matter.

72. We would like to thank Mr F and his family for their patience whilst we considered his complaint to us, as well as for sharing their experience with us. We appreciate this decision will be disappointing to him. We are very sorry for their loss.

1. We have carefully considered Mr F’s complaint about London Ambulance Service NHS Trust. We recognise this has been an incredibly upsetting time for Mr F, and his family. We appreciate the importance of having his concerns addressed regarding the care and treatment provided to his grandfather, Mr L. We know Mr L’s sudden death had a huge impact on Mr F and his family, and we understand why they want to know if the Trust missed any opportunities to save his life.

2. We have seen no indication that anything went seriously wrong in any of the issues Mr F has raised. The evidence we have seen indicates the Trust categorised the 999 call appropriately, and that the crew acted in line with guidance on arrival at the scene and when they decided not to provide cardiopulmonary resuscitation or other lifesaving interventions to Mr L. We have also seen no evidence the Trust were required to download the defibrillator data after this event.

3. For these reasons, we do not see any indications the Trust did something wrong and therefore decided not to take any further action. We have explained our decision in detail below.