12. NHS 111 is a non-emergency telephone service available to the public for urgent health care assessment and advice. NHS 111 provides assistance and advice in line with the Department of Health national guidelines using a process called NHS Pathways (NHSP). NHSP is an electronic patient assessment triage tool used by the NHS 111 call handler to determine the most suitable level of care appropriate to the presenting symptoms of the patient calling the service.
13. NHSP uses a series of algorithms, or pathways, to guide the call handler to the correct advice based on the responses they receive from the patient to the set questions. 111 call handlers are not clinically trained, however the NHSP allows them to provide advice to the caller. The 111 call handler asked questions which were unrelated to Mrs A’s condition, inappropriate and misleading
14. Mr A says the 111 call handler asked questions which were unrelated to his wife’s condition, inappropriate and misleading. Mr A says there was a clear missed opportunity by NHS 111 at this time to ensure that his wife received the treatment she needed. He says this view is supported by comments made by Mrs A’s GP.
15. The recording confirms that Mrs A received a call back from NHS 111 on 5 April. The 111 call handler asked Mrs A the reason for the call, and she said she had been suffering with ‘a very, very stiff neck’ right at the back of her head. She said that she had felt unwell the day before, had been vomiting and had nothing to eat.
16. Mrs A then provided a full account of her recent experience and her symptoms. She said that on 3 April she had completed household activities, gardening and had exercised on her spin bike. She advised the call handler that after approximately 30 minutes exercise on her spin bike her neck felt funny. Mrs A said she was not sure whether she had strained a muscle in her back or neck. Mrs A said that due to the pain she was experiencing she couldn’t eat anything, she had a shower and went to bed as she didn’t feel right.
17. Mrs A said her symptoms continued the next day and she said again that she had started to vomit. She said her vomiting started at 1.30pm and continued until 7.30pm. She said she had not eaten any food and her neck stiffness and pain had become worse. She said it was her neck that was the problem, it was annoying and debilitating her.
18. The 111 call handler confirmed Mrs A’s details, and that she was not at home alone. The call handler said she was going to ask a series of questions, some of which may not seem relevant, but they would help the call handler complete a thorough assessment and get Mrs A the appropriate help. The 111 call handler then asked the following series of questions:
· Have you been bleeding heavily in last 2 hours? Mrs A answered no.
· Is the skin on your chest normal temperature? Mrs A answered yes.
· Is your main concern your neck or the vomiting? Mrs A said it was her neck. She had not vomited since first thing that morning.
· Have you had a head injury last four weeks? Mrs A answered no.
· Have you become increasingly breathless? Mrs A answered no.
· Have you had any toothache or dental pain? Mrs A answered no.
· Have you stopped doing all of your usual activities? Mrs A said she was not sure.
· Can you do some or most of your usual activities? Mrs A said she was not doing her usual yoga. She said she was not sure if she could do what she usually does as she hadn’t tried.
· Do you have any new lumps or swelling on your head, face or neck? Mrs A answered no.
· Do you have an aching pain in your chest, the same time as your neck pain? Mrs A answered no.
· Do you have an aching pain in your neck, throat or jaw when exercising, when excited or upset? Mrs A answered no.
· Do you have a severe headache that started suddenly like being hit with brick? Mrs A answered no. She said she had a ‘terrible ache in the back of head and in her neck’.
· Do you have a headache that started suddenly, like a clap of thunder or like you have been hit with a brick? A sudden, severe headache? Mrs A answered no. She said it was more like stiffness and tightness with pain down both sides of her neck.
· Is the pain just in your neck? Mrs A answered yes.
· Do you have any numbness or weakness in your legs? Mrs A answered no.
· Have you felt hot or feverish in the last 12 hours? Mrs A answered no.
· Is the pain in one side of your neck? Mrs A answered no. She said it was in both sides of her neck. She explained that it felt like a ‘stress pain’.
· Have you experienced any new loss of vision? Mrs A answered no.
· Have you experienced any unusual confusion? Mrs A answered no.
· Is your scalp sore when you touch it? Mrs A answered no, but it did feel tender.
· Do you have pain in your cheek or jaw when chewing? Mrs A answered no.
· Is the skin of the affected area hot or inflamed? Mrs A answered no.
· Is the skin red? Mrs A answered no.
· Do you have any new blisters or painful lines or areas? Mrs A answered no.
She said she had a red patch of skin at bottom of her coccyx which started approximately a week earlier.
· Have you received any care from a cancer specialist in the last year? Mrs A answered no.
· In the last month have you had any night sweats, felt generally unwell, suffered unexpected weight loss, lack of appetite, felt tired all the time or had any severe, increasing pain? Mrs A answered no. She said she had been fine until the last few days.
19. The 111 call handler then asked Mrs A if she had suffered any new pain and stiffness in both her shoulders with pain travelling from her neck into both shoulders? Mrs A said this was correct, she had pain going down both sides of her neck into her shoulders. She said it is not ‘what you would call pain, but stiffness’.
20. The 111 call handler said based on what she had told her, Mrs A should contact her GP practice tomorrow, or at least within three days. She should take paracetamol or ibuprofen to help with the pain and gently move her neck to help with the stiffness. The 111 call handler advised Mrs A not to wear a collar and to call back with any concerns or if her symptoms got worse. The 111 call handler confirmed Mrs A understood the advice they had provided and ended the call.
21. Our adviser said the questions asked by the 111 call handler were consistent with the Face, Neck Pain or swelling pathway within NHSP and they did not stray from the NHSP protocol at any point. Our adviser said that if any of the questions had been answered differently then additional questions may have been prompted by NHSP and asked by the call handler, meaning alternative advice may then have been provided. However, based on the responses the call handler received, the advice they provided is consistent with the pathway within NHSP, in particular the Face and Neck Pain or Swelling pathway.
22. We carefully considered this advice, the information provided by Mr A, and the recording. We found the 111 call handler followed the prompts from NHSP and the pathway in place for triaging neck pain and stiffness, when asking Mrs A the questions about her symptoms. As we have said, NHSP is an electronic patient assessment triage tool used by the NHS 111 call handler to determine the most appropriate advice to provide and the call handlers themselves are not clinically trained. The role of the 111 call handler is to follow the prompts provided by NHSP and the pathway it sets based on the answers they receive.
23. We found no evidence to indicate the questions asked by the 111 call handler were not relevant to the symptoms being reported by Mrs A, or that they were inappropriate, or misleading. We can understand why Mr A thinks some of the questions asked were irrelevant to his wife, the 111 call handler said this may be the case at the beginning of the call, yet it is clear these questions were to rule out other causes of her symptoms. From the evidence we have seen, the questions asked were the questions generated by NHSP following the answers provided by Mrs A. For this reason, we have decided to not uphold this point of the complaint.
The 111 call handler failed to ask Mrs A whether she had any other medical conditions such as blood pressure, diabetes, or heart issues
24. When considering this point, it is important we understand the role and remit of 111 and the expectations of the 111 call handler. As we have said above, NHSP is an electronic patient assessment triage tool used by the NHS 111 call handler to determine the most suitable level of care. 111 call handlers are not clinically trained and must follow the direction, prompts, and pathways set out by NHSP when providing advice to the caller.
25. Our adviser said it is not within the 111 call handler’s remit to ask any supplementary questions regarding a patient’s medical history, or medications, unless presented within these triage questions whilst following the NHSP. Our adviser said it would not be appropriate for the 111 call handler to stray from the questions prompted by NHSP as they are not medically trained professionals. The NHSP is based on years of research and testing to ensure it is a robust system. If individual non-medically trained call handlers stray from the NHSP this would increase the risk of inappropriate advice being provided.
26. We carefully considered this advice, the information provided by Mr A to support his complaint, and evidence provided in the recording. We have found no evidence to indicate the 111 call handler should have strayed from the questions prompted by NHSP to ask Mrs A whether she had any other medical conditions such as high/low blood pressure, diabetes, or heart issues. For this reason, we have decided to not uphold this point of complaint.
The 111 call handler failed to acknowledge that Mrs A had been suffering severe vomiting and headache prior to her call
27. The recording confirms that the 111 call handler asked Mrs A about her symptoms and Mrs A gave a detailed account of the symptoms she had experienced during the previous three days. As we have set out earlier in our report, the 111 call handler asked Mrs A specific questions to establish whether she was suffering headaches and specific questions about her vomiting and neck stiffness.
28. The 111 call handler asked Mrs A whether her main concern was her neck stiffness or her vomiting. Mrs A advised the 111 call handler that although she had been vomiting for an extended period the previous day, she had only vomited slightly that morning after taking her medication and she had not vomited in the last seven hours. Mrs A confirmed that the main concern was her neck which she described as a stiffness rather than a pain.
29. We acknowledge Mr A’s views. Having listened to the call and having considered the process in place for triaging calls to the 111 service we have not identified any evidence to indicate the 111 call handler failed to acknowledge Mrs A’s vomiting or her account of her head and neck symptoms. These symptoms are recorded and questioned by the 111 call handler. The main area of concern is reported by Mrs A to be her neck stiffness. As we have said previously 111 call handlers are not medically trained and their role is to follow the prompts provided by the NHSP.
30. We have seen no evidence to indicate the 111 call handler should have strayed from the prompted questions to further explore Mrs A’s symptoms of vomiting and headaches during this call. Her symptoms were recorded and explored by the 111 call handler in line with the NHSP protocol. For this reason, we have decided to not uphold this point of complaint.
The 111 call handler incorrectly advised Mrs A to take paracetamol for her headache and contact her GP in three days
31. Mr A says the call handler should have picked up on the obvious warning signs of a brain haemorrhage, which include vomiting and neck pain. He says it was wrong for the 111 call handler to advise his wife to take paracetamol for her headache and contact her GP in three days.
32. As we have stated above, the 111 call handler is not clinically trained. The recording indicates that Mrs A called 111 as she believed she had strained a muscle in her neck or back. Our adviser said the 111 call handler would not be expected to associate the symptoms of vomiting and neck stiffness/pain with a brain haemorrhage and they would not be adequately qualified to make this diagnosis. Our adviser said the relevant questions were asked and probed by the 111 call handler during the triage process and the advice they provided was consistent with NHSP’s instructions.
33. We carefully considered this advice, our understanding of the role and remit of the 111 call handler, the information provided by Mr A to support his complaint, and evidence provided in the call recording. We have seen no evidence of failings in the advice provided by the 111 call handler.
34. NHSP is not a system aimed at helping the 111 call handler to diagnose a patient’s condition, but a system aimed at helping them triage and refer a patient to the most suitable service and to provide interim advice until they can access that service. We found that the advice provided by the 111 call handler was generated by NHSP, and it was based on the information provided by Mrs A. For this reason, we have decided to not uphold this point of complaint.
The 111 call handler failed to recommend Mrs A be taken immediately to A&E at her local hospital
35. As we have said previously, 111 call handlers are not clinically trained and must follow the direction, prompts, and pathways set out by NHSP when providing advice to the caller. We found the relevant questions were asked and probed by the 111 call handler during the triage process, and the advice they provided was generated by NHSP as a result of the information obtained during the discussion with Mrs A.
36. We found no evidence of failings in the advice provided by the 111 call handler. We found no evidence to indicate the 111 call handler should have advised Mrs A to attend A&E at her local hospital as this outcome was not recommended by NHSP after all the information had been provided. For this reason, we have decided to not uphold this point of complaint.
37. Mr A says this was a missed opportunity to ensure his wife received the treatment she needed sooner. He says the poor assessment and advice from the call handler led to a delay in his wife receiving the care and treatment she needed for her brain haemorrhage earlier. He says if the call handler had made the correct enquiries, recognised the symptoms, and advised her to go to A&E at her local hospital at this time she may have received the treatment she needed sooner.
38. We acknowledge that Mrs A was later diagnosed with a brain haemorrhage, and we acknowledge that this is what has caused Mr A to question the advice provided by the 111 call handler on 5 April . We can appreciate why Mr A thinks different advice should have been given at this time and why he thinks more could have been done to prevent his wife’s sad death.
39. We have not seen any evidence to indicate failings on the part of the 111 call handler or that this call was a missed an opportunity to identify and diagnose Mrs A’s brain haemorrhage sooner given the information exchanged during the call. We hope our findings reassure Mr A that the 111 service acted appropriately and could not have been expected to diagnose his wife’s condition or refer her for treatment elsewhere based on the symptoms she was experiencing at this time.