South Central Ambulance Service NHS Foundation Trust

4. Mr A complains the Trust did not correctly categorise his call request for an ambulance for his mother, on 3 April 2024. He says the Trust did not consider all relevant factors such as his mother’s previous medical conditions and her age in its assessments.

5. Mrs C died on 4 April 2024. Mr A believes had the Trust completed an appropriate assessment it would have recognised his mother required immediate medical attention. He says then an ambulance would have arrived sooner, and his mother’s death may have been prevented, or the family would had had the opportunity to understand what was happening. He says this has caused him distress.

6. As an outcome to his complaint Mr A is seeking service improvements and financial compensation.

7. Mrs C was in her eighties at the time of her death. She had a history of atrial fibrillation (an irregular heartbeat), chronic kidney disease, hypertension (high blood pressure), and a previous stroke. She also had an underactive thyroid (a condition where the thyroid gland does not make enough hormones).

8. Mrs C became unwell on 3 April 2024. Mr A called for an ambulance several times. The ambulance arrived around 2am on 4 April 2024, when Mrs C had already sadly died.

12. Mr A says from around 5pm he was telephoning the Trust for assistance. He believes had the Trust conducted a robust assessment which included his mother’s previous medical history and presenting symptoms, it would have realised she required immediate medical attention.

13. In its complaint response, the Trust said it conducted an audit of Mr A’s calls and its clinician’s assessment of Mrs C’s presenting symptoms. It said its assessment did not comply with its internal processes. Specifically, it said Mrs C’s assessment was not robust and there may have been a missed opportunity to categorise the calls correctly for a more urgent ambulance response.

14. The Trust acknowledged its call centre staff did not comply with its internal processes during two wellbeing check phone calls to Mrs C at 10.25pm and around 2am. It said its staff failed to adequately assess her level of consciousness during these calls. The Trust further stated had it categorised Mr A’s initial call correctly, the earliest an ambulance would have arrived is around 7pm.

15. The Trust apologised, acknowledged its errors, and said it had implemented service improvements and reflection.

16. The ARP is a national framework for Ambulance response times across the UK. It sets out four categories of calls to manage ambulance response times for different patient needs. It also implemented pre-triage questions and clinical assessments to identify those patients requiring an urgent response.

17. It defines a category one response as immediately life-threatening, for example where a patient is going into cardiac arrest. It defines a category two response as serious conditions such as suspected cardiac chest pain or significant respiratory distress. A category three response is for urgent calls such as abdominal pain. Category four calls are less urgent and include symptoms of diarrhoea, vomiting, and back pain.

18. NHS pathways is a clinical tool used for assessing, triaging and directing people to urgent or emergency care services. It is a symptom based approach, broadly divided into three modules.

19. Mr A’s first call to the Trust via 111 (a service in the UK that provides urgent medical advice and assistance) was at 5.15pm. He described his mother having been unwell for two to three weeks. She was feeling tired with swollen legs and hands.

20. We note a health adviser (HA) answered this call. Our paramedic adviser explains HAs are not clinically trained. Their role is to ask a series of pre-set questions that determine a priority. The first set of questions a HA will ask ensures all immediate life threats and immediate concerns are considered and ruled out prior to deciding about priority. If the HA is unable to assess the answers to these questions fully, they would need to request clinical advice or transfer the call for further clinical assessment.

21. We understand during this call, the HA was unable to decide a priority rating. They appropriately asked a clinician to assess Mrs C’s symptoms.

22. The second call from the Trust’s clinician to Mr A was at 5.44pm. The purpose of this call was for the Trust to complete a clinical triage of Mrs C’s symptoms. The Trust documented this as a category three response.

23. Our paramedic adviser says this call was not appropriate because the clinician did not fully explore Mrs C’s levels of consciousness. Mr A describes his mother as ‘slumped in her chair’. The clinician should have asked further probing questions to determine if she could be roused.

24. Our paramedic adviser explains the Trust should have asked further questions regarding Mrs C’s colour, whether she was hypoglycaemic (had low blood glucose levels), and it should have considered stroke symptoms.

25. Our paramedic adviser explains had the Trust asked these additional probing questions, there is the potential it would have decided a category two response was appropriate.

26. From the evidence we have seen this call was not in line with module 0 of an NHS pathways assessment. The evidence shows the Trust did not do a full assessment of Mrs C’s level of consciousness. This may have impacted the categorisation of the call. We have considered the impact of any failings we have identified later in this report.

27. Mr A next called the Trust at 9.10pm requesting an update as to when the ambulance will arrive. The HA noted Mrs C’s symptoms had not worsened and there were no new symptoms. We note the Trust recognised in its investigations this call did not meet its own standard operating procedures. This was because the call handler should have offered a full triage.

28. Our paramedic adviser agrees the call handler should have offered a re-triage of Mrs C’s symptoms which could have potentially upgraded the category response. This call was also not in line with the Trust’s standard operating procedures (SOP).

29. Mr A telephoned the Trust again at 9.27pm to chase when the ambulance would arrive. The Trust offered to re-triage his mother during this call. We note Mr A declined because his mother was asleep and he did not want to disturb her.

30. Our paramedic adviser says the Trust managed this call appropriately in that it offered a re-triage.

31. The Trust telephoned Mr A for a welfare check at 10.29pm. It asked whether Mrs C was conscious and breathing, and that nothing had changed or worsened. Mr A advised his mother was asleep. A similar welfare check took place again at 1.58am. Staff asked Mr A if he could hear his mother breathing and he replied, ‘I think so.’

32. Our paramedic adviser says these two welfare checks were not appropriate because the Trust did not explore Mrs C’s level of consciousness, and this may have led to an upgraded category response.

33. During the second welfare check, the Trust missed an opportunity to reassess Mrs C’s breathing when her son could not confirm she was breathing normally. The Trust should have explored this further or, based on its clinical support desk procedures, escalated the case to a clinician for an additional clinical assessment. It is likely identifying Mrs C as unresponsive or breathing inadequately would have led to an upgraded emergency response.

34. The Trust did not conduct the two welfare calls in line with The Trust’s SOP and NHS pathways. It failed to carry out a full assessment of Mrs C’s level of consciousness, which likely affected the call’s categorisation.

35. Mr A’s final call to the Trust for an ambulance, was at 2.08am where he informed the call handler he was unable to wake his mother. He also confirmed she was cold and not breathing. The Trust documented this as a category one response which was appropriate and in line with ARP guidelines.

36. We note the Trust’s ambulance crew arrived within five minutes, and it commenced cardiopulmonary resuscitation (CPR - an emergency procedure used to maintain blood flow and oxygen to vital organs when the heart stops beating) on Mrs C.

37. The Trust terminated CPR shortly after because Mrs C had sadly died.

Impact

38. We note the initial 111 assessment resulted in the request for a category three ambulance response. The ARP states nine out of ten times, a response for a category three ambulance should arrive within 120 minutes.

39. The Trust received the call at 5.50pm, so an ambulance should have arrived before 7.50pm. However, the high demand on the service and limited resource availability at the time of this complaint must be considered when assessing whether the 120-minute target was achievable. We will consider this further below.

40. Our paramedic adviser further explains, had the Trust asked Mr A probing questions about the level of his mother’s consciousness in any of the subsequent calls, it may have escalated to a category two response.

41. This would have meant an ambulance could potentially have arrived as early as before 6.30pm. This is because the ARP states nine out of ten times a response for a category two ambulance should arrive within 40 minutes. Again, demand on the service, and resource availability would have to be considered as to whether that was achievable.

42. We understand from the Trust’s response, during the time of this complaint, patients with a category three response were waiting up to ten hours.

43. We asked the Trust for a breakdown on the timescales for its category two responses during this period. It explained it provides 999 emergency ambulance service across Berkshire, Buckinghamshire, Hampshire and Oxfordshire. The Trust said on 3 and 4 April 2024, it received 63 category two calls and Hampshire had a cluster of 167 category two calls. It says the average waiting time during that period for a category two response was around 34 to 39 minutes.

44. We have found the Trust’s categorisation of Mr A’s calls were not in line with module 0 of NHS pathways and ARP guidelines. There was a missed opportunity on several occasions to explore Mrs C’s level of consciousness. It is not possible for us to say confidently, had the failings not occurred, if it was more likely than not Mr A’s calls would have escalated to a category two response.

45. This is because we cannot know what the outcome of the assessments would have been if staff completed them correctly. Based on the category two waiting times during that period, the earliest an ambulance would potentially have arrived would have been around 6.30pm.

46. Mr A told us the Trust’s incorrect categorisation of his calls for an ambulance meant he did not have the opportunity to understand the severity of his mother’s condition. He believes had an ambulance arrived sooner, his mother’s death may have been avoided. He says his mother’s death was undignified and family members did not have the opportunity to be with her during her final hours.

47. We are very sorry to learn about the upset and distress these events caused Mr A. It is clear from our communication with him that this was a very difficult time for him.

48. We next considered if we can know the possible clinical impact of the failings we have identified.

49. We understand Mrs C was taking atorvastatin (a cholesterol tablet), bendroflumethiazide and Losartan (both blood pressure tablets), an iron tablet, a calcium and vitamin D tablet and levothyroxine (thyroid tablets). She was also taking apixaban (a blood thinner for her irregular heartbeat) and furosemide (a water tablet for swelling).

50. She last saw her GP in September 2023 for her annual health check. From her GP records, her health appeared stable at that point. However, three weeks before her death, she had deteriorated with swelling in her legs and hands and was struggling to get out of her chair.

51. From Mrs C’s postmortem report we note she had fluid in both pleural cavities (the space between the lungs and the chest wall). The lungs were also congested and swollen with fluid. Her heart showed moderate coronary artery disease (narrowing of the arteries supplying blood to the heart).

52. The left ventricle (the most important chamber of the heart in terms of pumping blood around the body) was thickened. There is a note of subendocardial pallor, which means paleness of the heart muscle, which may reflect a severe lack of oxygen going around the body.

53. We asked our consultant adviser what treatment options would have been available to Mrs C had the Trust’s ambulance crew taken her to hospital at either 6.30pm or 7.50pm on 3 April, and if she could have survived this period of illness.

54. Our consultant adviser explained Mrs C’s medical history of stroke, atrial fibrillation, and hypertension would suggest she had disease of her blood vessels. The swelling of her hands and her legs was suggestive of heart failure. This is where the heart is not pumping as well as it should, and fluid builds up in the body. This commonly causes patients to sleep in a chair (lying flat makes breathing difficult in this situation) and impairs their mobility because of the swelling.

55. Our consultant adviser said the postmortem findings are indicative Mrs C died from a combination of heart failure and pneumonia.

56. The adviser explained treatment for pneumonia would have included oxygen and intravenous (medication administered directly into a vein) fluids and antibiotics. Paramedics would be able to administer intravenous fluids and oxygen but would not administer intravenous antibiotics. This would be a treatment in hospital, and it would take some time to work in a patient with pneumonia.

57. Treatment for heart failure would include intravenous furosemide (or water medication) which would absorb the excess fluid building up in the body. Heart failure is more quickly treatable, in that the response to the furosemide in heart failure occurs swiftly.

58. Our consultant adviser noted, from Mrs C’s postmortem report she was frail, her heart was weak and under strain. For her to deteriorate so quickly at home shows her pneumonia was serious. The combination of heart failure and pneumonia is very serious and associated with a very significant risk of death in someone of Mrs C’s age and frailty. Had the Trust taken Mrs C to hospital sooner, our consultant adviser is of the view she still unfortunately, would not have survived.

59. We do not think the Trust’s failings in categorising Mr A’s emergency calls or the ambulance delay caused his mother’s death.

60. However, if the failings had not happened, this would have made a difference to Mr A. It would not have left him with uncertainty whether his mother could have got to hospital sooner. Therefore, the failings in the Trust’s categorisation of Mr A’s emergency calls caused him avoidable distress.

61. We set out our recommendations below.

1. Mr A complains about the service he received from South Central Ambulance Service NHS Foundation Trust (the Trust) during his emergency calls to it regarding his mother, Mrs C. We are very sorry to learn about the loss of his mother. We recognise the events leading to his mother’s death was an immensely distressing time for Mr A.

2. We have found failings in the Trust’s categorisation of Mr A’s calls for an ambulance on 3 and 4 April 2024. Whilst we have not linked these failings to his mother’s death, we think this caused Mr A distress.

3. We therefore partly uphold Mr A’s complaint. We recommend the Trust writes to Mr A confirming it has implemented the service improvements it had identified in its response to this complaint. We also recommend it pays Mr A £450 in recognition of the distress he experienced.

62. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

63. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

64. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

65. Through investigating Mr A’s complaint, we consider the Trust’s categorisation of his calls were not in line with NHS pathways and ARP guidelines. This means there was a missed opportunity to possibly escalate the response to a category two and a subsequent delay in when its ambulance crew could have attended to Mrs C. This caused Mr A avoidable distress.

What the organisation should do

66. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

67. By bringing this complaint to us Mr A would like service improvements and a financial remedy.

68. We first considered what action the Trust has taken in response to Mr A’s complaint.

69. In its response to this complaint the Trust acknowledged three calls did not meet its own compliance standards and it apologised. It explained it would review its welfare call policy in consultation with other ambulance services, aiming to either withdraw it or amend its criteria to better align with operational demands. It explained should welfare calls continue, the policy will include an additional check to ensure the call receiver is with the patient or can arrange to be so.

70. The Trust also addressed hospital handover delays, reviewing demand and resource levels to ensure sufficient staff and vehicles are available to meet patient needs, and tackling issues of under-resourcing.

71. The Trust assessed end-of-shift and meal break policies, ensuring crews are available for urgent category one responses during these periods while maintaining compliance with mandatory rest requirements. Feedback on calls that did not meet standards have been shared with individuals, along with opportunities for learning and reflection. The Trust said this complaint has been used as a tool for wider organisational improvement and learning to enhance service delivery.

72. The Trust has also shared an updated standard operating procedure which states whilst mandatory welfare checks are removed, some welfare calls will be made when clinically necessary, based on individual circumstances.

73. It is positive the Trust has taken learning from this complaint and has reflected on its service.

74. We have found the Trust’s service improvements are appropriate and in line with the NHS Complaints Standard Framework, which provides guidance on how organisations delivering NHS services in England should handle complaints.

75. We recognise Mr A also seeks a financial remedy for the loss of his mother. As set out above we have not linked the failings to Mrs C’s death and so we cannot make a recommendation for the loss of Mr A’s mother.

76. However, we have considered financial remedy for the distress Mr A experienced due to the failings we have seen in the Trust’s categorisation of his calls for an ambulance.

77. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

78. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice (SOI) scale.

79. Level two emotional injustices on our SOI scale includes distress, worry, annoyance and similar injustice which does not impact on the affected person’s ability to live a normal life, for a period of one to two weeks up to six months.

80. We consider Mr A’s injustice sits within level two on the scale. Following this review, we recommend the Trust:

• to send Mr A, a letter confirming it has implemented the service improvements it had identified in its response to his complaint • pay Mr A £450 in recognition of the distress he experienced.

• send us evidence it has done this within a month of our final report.

81. We recognise these events have been distressing for Mr A, following the loss of his mother. We thank Mr A for bringing his complaint to us.

82. This concludes our report.