Summary
C complained on behalf of their friend (A), a care home resident. A became unwell and was in a lot of pain. An Out of Hours GP suspected an internal bleed and arranged for an ambulance to be requested. A call was made to Scottish Ambulance Service (SAS) at 20:20, requesting a ‘one-hour response’ to hospital. The SAS call handler advised that the majority of responses were taking over four hours. An ambulance did not arrive until 02:21, by which time A’s condition had deteriorated and they were too ill to be moved. A was given medication and died in the care home. C complained about the delay in SAS providing an ambulance for A.
In their response to the complaint, SAS explained that they operate a priority-based system of dispatch to ensure that emergency ambulances are available to respond to the most serious and life-threatening cases in the first instance. They operate a welfare call back process when timed admission calls are unable to be met within the requested timeframe. Regular welfare calls were made to A’s care home, during which SAS apologised for the delay, checked on A’s condition, and gave worsening advice to call 999 if A’s condition deteriorated. SAS considered that the final welfare call, which was reviewed by a SAS clinician, was appropriately upgraded to an emergency response.
We took independent advice from a paramedic adviser. We acknowledged that some of the contributory factors which led to the delay in providing an ambulance for A were beyond SAS’s control. There were significant demands on their service and there were also delays in handovers at the receiving hospital. However, our investigation identified a missed opportunity to escalate the request for an ambulance following an earlier welfare call in which symptoms of faster breathing and agitation were reported, indicating a deterioration in A’s condition. Although it was not possible to say whether the outcome for A may have been different had an ambulance been provided sooner, this may have shortened the period of time during which A was in pain and distress. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to A for the unreasonable delay in providing an ambulance for A, and for the failings identified in our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: Clinician escalation/re-triage is mandatory when welfare calls report new or concerning symptoms, especially where serious underlying pathology is suspected.
Welfare scripts include condition-specific red-flag prompts to improve the detection of deterioration.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202410343 as a PDF (28.39 KB) Updated: January 21, 2026