Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, and the priority they were allocated by the Trust, was reasonable and appropriate. The investigation also considered whether the advice provided by Trust staff during the calls was reasonable and appropriate. Finally, the investigation considered whether Mrs C was appropriately assessed and managed by the Health Board following her arrival at the Emergency Department of Morriston Hospital on 15 September.
The Ombudsman found that the emergency calls were correctly triaged and prioritised by the Trust’s emergency call handlers. However, a clinician on the Clinical Support Desk (“CSD” – a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category. If this had happened, an ambulance may have been allocated to Mrs C sooner. This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her. This complaint against the Trust was upheld.
The Ombudsman was concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after she shared the views of her Paramedic Adviser in April 2024. The Ombudsman considered that this raised serious concerns about the robustness of the Trust’s investigations of the complaints it receives, particularly as this was not the only case in which she had identified deficiencies in the Trust’s complaints investigation process.
In respect of the advice provided by the Trust’s staff, particularly the advice not to move Mrs C, the Ombudsman found that this was clinically appropriate because moving her could have worsened her injuries and caused her more pain. This complaint against the Trust was not upheld.
The Ombudsman found that Mrs C received appropriate care, investigations and treatment whilst she was in the ambulance outside the Emergency Department and after she was admitted to Morriston Hospital. Although there was a missed opportunity to have stopped the administration of nephrotoxic medication (medication that can damage the kidneys) at an earlier stage, there was no suggestion that this caused Mrs C harm or affected her outcome. This complaint against the Health Board was not upheld. However, the Health Board was invited to share this report with the relevant staff and consider how it could improve the training its clinicians receive in recognising and managing patients at high risk of acute kidney injury.
The Ombudsman made a number of recommendations, which the Trust accepted. These included: • An apology to Mr B, an explanation about the shortfalls in the investigation process and payments totalling £2,750 for the distress, loss of dignity and uncertainty caused and for Mr B having to pursue his complaint.
• To share the report with the Trust’s complaint investigation team to review the conduct of its investigation in line with the Duty of Candour and identify learning points to ensure that similar failings are not missed in the future.
• To share the report with the Trust’s Quality and Patient Safety Committee to consider my findings and include its learning from these recommendations in its Annual Report on the Duty of Candour.
• To share the report with all appropriate staff and remind them of the importance of fully reviewing information recorded in the Command & Dispatch system at the time of the call.