We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs A be transported to hospital within two hours, and that this was not a request for an emergency 999 response. However, we found that, if a request to be transported goes beyond the agreed timescale, then ambulance service call handlers will carry out urgent welfare call backs to check whether the patient's condition has deteriorated. Where the call handler identifies that the patient's condition has worsened, they should upgrade the call to an emergency response and process it through the medical priority dispatch system. We found that during the first welfare call back Mrs A was reported to be struggling to breath and that during the second welfare call back she had reportedly stopped taking sips of water. We considered that there were failures to appropriately explore possible deteriorations in Mrs A's condition during the first and second welfare call backs. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to Mrs C that possible deterioration in Mrs A's condition were not appropriately explored during the first and second welfare call backs. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future: Where there is an indication of a patient's condition deteriorating this should be processed appropriately using the medical priority dispatch system.
Related reading
View Decision Report 201708212 as a PDF (12.71 KB) Updated: December 2, 2018