South East Coast Ambulance Service NHS Foundation Trust

3. Mr S complains that, when responding to a request for help for his mother Mrs S in September 2024, the Trust did not send the correct responders for the medical issues that were raised in the call, and did not take into account her medical history.

4. He says as a result of this his mother sadly died. He said this has caused him shock, torment and heavy depression. He says this resulted in him seeking doctors’ support and greatly relying on friends. He has had to support his family emotionally and financially.

5. The outcome he seeks is a financial remedy.

6. Mrs S became unwell and Mr S’s father called an ambulance.

7. Two ambulance crews attended and made the decision to transport Mrs S to hospital. There are different accounts about what happened. Mr S’s father says the ambulance crew let go of the carry chair, causing Mrs S to drop backwards, hitting her head on the floor. The statements from the two members of the ambulance crew carrying Mrs S say they noticed she was not breathing normally, and lowered her backwards to give treatment.

8. A further member of staff arrived and gave assistance with resuscitation. Sadly, despite trying to resuscitate Mrs S for 30 minutes, she sadly died.

12. We first looked at Mr S’s concerns that the Trust did not send the correct responders, and at the guidance provided about this. In 2017 NHS England implemented new ambulance standards across the country, to ensure the sickest patients got the fastest response. This Ambulance Response Programme (ARP) introduced a set of pre-triage questions, to identify those patients in need of the fastest response.

13. It is these the standards that were in place at the time of the call. There are four categories of call in the guidance, Category 1 being calls from or about people with life-threatening illnesses or injuries.

14. The Trust categorised the call as a Category 1. This is the highest category and is reserved for people with life threatening illnesses. The Trust then dispatched an ambulance crew comprising a paramedic and a trainee associate ambulance practitioner (TAAP), who were the first to arrive at the address four minutes after the call. A second crew arrived less than a minute later. This crew was made up of two TAAPs.

15. The Trust guidance, Dispatch Standard Operating Procedures (DSOP), says ‘The nearest available resource regardless of resource type will be assigned to every Category 1 call.’ It is not prescriptive about what resource this should be. This guidance also says ‘If the nearest resource to a Category 1 call is not a Double Crewed Ambulance (DCA), a DCA must be assigned immediately as a second resource.’

16. Our adviser told us the responders dispatched were the correct responders for the medical emergency that was described during the call – a patient that was not breathing. In this case we can see that the first crew was the nearest available resource, and was a DCA, and so the Trust acted in line with its DSOP. The Trust also dispatched a second crew and so there were four staff members attending to Mrs S.

17. There is no single national guidance that outlines a specific grade or number of ambulance staff for every Category 1 call. The guidance outlined in paragraph 12 requires that life-threatening emergencies receive the fastest available and most appropriate response. Our adviser explained that the exact resource dispatched is determined by an ambulance trust's clinical dispatch protocols and resource availability.

18. In this case the Trust acted in line with its own protocols, as outlined in paragraph 15. Our adviser told us these are similar to those they have seen from other trusts.

19. Our adviser also explained the paramedic was a registered clinician, and would be capable of responding, with their colleagues, to the medical emergency that presented itself.

20. We can see a Critical Care Paramedic (CCP) was called by the attending crew when Mrs S’s condition deteriorated. We have considered whether the Trust should have dispatched a CCP sooner.

21. CCP attendance is generally reserved for patients who are likely to benefit from enhanced critical care interventions that would be beyond the scope of a standard ambulance crew. Our adviser told us that up until the point at which Mrs S lost consciousness there is nothing to show the input of a CCP was needed.

22. The relevant guidance is the Trust’s Critical Care Desk Dispatch policy including Major Trauma. The policy has a flow chart that shows the categories of incident that would require the Trust to consider sending a CCP for immediate attendance, such as falls from height, and a patient being trapped under a vehicle. Mrs S did not meet the criteria of the incidents listed, from the information presented during the call.

23. When Mrs S’s condition deteriorated it was correct that the crew called for the assistance of a CCP, as this then met the criteria outlined in the CCD dispatch policy. This identifies ‘Cardiac arrest in special circumstances. Prolonged resuscitation’ or ‘Semi-conscious patients with respiratory compromise’ as issues that, following further consideration, may require a CCP to be tasked to attend.

24. Again, as outlined in paragraphs 17 and 18, there is no national guidance on this particular issue. The Trust acted in line with its own policy, and this is in line with the standards our adviser has seen in other trusts.

25. We looked at Mr S’s concern that the Trust did not take into account his mother’s medical history. The relevant guidance is that outlined in paragraph 12. When an ambulance call-handler sends out an ambulance, as outlined in the ARP, this is based on a set of pre-triage questions, and the immediate clinical need of the patient.

26. The ambulance call-handler does not take into account the medical history of the patient, just the information that is shared within the call. As outlined in paragraph 14 the Trust properly categorised this as the most serious category and acted in line with that. The team had the necessary skills to deal with the medical situation, and the paramedic was a clinician registered with the professional body.

27. To conclude, we know Mr S has been deeply affected by what happened. We hope we have properly explained why we have concluded that the Trust acted in line with guidance and why we have decided we do not need to take any further action.

1. We have carefully considered Mr S’s complaint. We did not see any indications of failings in the actions of the Trust. For this reason, we will not be taking further action.

2. We were sorry to hear about how much this experience affected Mr S. We hope our statement explains the reasons we have concluded there is no further action we need to take.