Calls on 25 May 2019
16. Having listened to all the call recordings on 25 May 2019, we agree with the Trust that the first call made by Mr A at 2.12am was incorrectly categorised as a Category three call (120 minutes).
17. Based on the information provided by Mr A during the first call, that Mr B was unresponsive and later not breathing, and the Trust’s interpretation of this in its CAD notes (“caller saying friend not breathing”), our paramedic adviser says the first call should have been categorised as a Category one call (seven minutes).
18. If the first call had been correctly categorised, we consider that the call assessor should have provided Mr A with CPR instructions when they called him back so he could have at least attempted CPR on Mr B earlier.
19. Therefore, we consider these to be failings by the Trust and contrary to the new ambulance standards guidance from 2017 regarding 999 call categorisations. We note from the Trust’s Serious Incident Report (SIR) that it has already acknowledged that the first call was incorrectly categorised and the call assessor who dealt with it was subject to supervision and retraining, which we consider to be appropriate remedial action.
20. Mrs C is concerned that the call assessor did not believe the information provided by Mr A and failed to convey accurate information to the supervisor. She is also concerned that the call was not escalated to the Duty Manager.
21. There is insufficient evidence for us to say that the call assessor did not believe the information provided by Mr A. Clearly, the call assessor had difficulty obtaining the location information they needed from him during a very difficult call, that was eventually escalated to the supervisor. At times, we agree with the SIR that the call assessor’s tone was flippant or dismissive, and that they may have doubted Mr A. However, this is not enough for us to conclude with any certainty that they did not believe Mr A.
22. We agree with the SIR that handover of the first call to the supervisor was insufficient. The call assessor did not tell the supervisor that Mr B was unresponsive, which they should have done based on what Mr A said during the first call. Therefore, the supervisor did not have an accurate picture of the seriousness of the call. This is linked to the failure to categorise the first call correctly. If accurate information had been provided, then the call may have been given a higher priority.
23. We consider this issue to be a failing by the Trust and is contrary to its own protocols for Call Assessors and Call Taking Supervisor/Assistant Supervisor. We note from the SIR that these omissions have been acknowledged by the Trust and we would expect the call assessor handover issues to have been addressed by the supervision and retraining remedial action cited earlier.
24. The SIR states there was no escalation to the Duty Manager at any time to make them aware of the situation, and of the difficulties in obtaining a location. We note that this type of escalation (by the supervisor) could have happened, and they were considering it but, as we have said, the supervisor did not have an accurate picture of the seriousness of the call based on the information provided by the call assessor. Furthermore, the supervisor said in the SIR that they focussed on locating Mr B and Mr A and wanted to narrow the area down before dispatching an ambulance. Even if the supervisor had escalated to the Duty Manager, they would have had the same options and decision to make. In our view, this is a reasonable explanation as to why the supervisor did not escalate the call to the Duty Manager.
25. If the first 999 call had been correctly categorised and escalated with accurate information, it could have potentially opened up other options such as sending an ambulance to the vicinity, liaising with the police to see if they had received any dropped calls from the area, or checking historic calls from the mobile number to try and ascertain a home address for the caller. It may then have been possible to establish if the caller was near that address.
26. The Trust could still have mobilised an ambulance to the area after the first call and then redirected it as further location information came onto the system. Unfortunately, this did not happen because the original call was incorrectly categorised as a Category three and therefore this meant there was much less urgency to dispatch an ambulance. If the call had been correctly coded as a Category one, it is likely an ambulance would have been dispatched to the vicinity even if Mr A’s precise location had not yet been established. We consider this to be another failing linked to the incorrect categorisation of the first call. At Mr B’s inquest, it was confirmed that the Trust has put new processes in place to ensure ambulances are dispatched to the ‘vicinity’ if location is not confirmed, which is appropriate remedial action.
27. The second 999 call made by Mr A at 2.48am was correctly categorised as a Category one call as it was stated that Mr B was in cardiac arrest. The ambulance arrived on scene approximately eight minutes after the call was received. Our paramedic adviser says the Electronic Patient Record (EPR) indicates that Mr B had suffered a cardiac arrest and was unresponsive when paramedics reached him. He was moved into the back of the ambulance as he was found in darkness at a remote location.
28. CPR was commenced by paramedics and Mr B was administered appropriate medication, including adrenaline, but he remained asystolic throughout. This means there was no recorded electrical or mechanical activity in his heart. His death was called in by the paramedics at the scene, and he was taken to the mortuary.
29. Overall, our paramedic adviser says the care provided to Mr B by paramedics, once the ambulance arrived, was appropriate and in accordance with Resuscitation Council UK, Adult advanced life support guidelines. Very sadly though, it was too late to save Mr B’s life.
Staff attitude
30. Mrs C is concerned about the attitudes of the call assessor and the supervisor during the first call, as some of their comments are inappropriate in tone and content. The SIR states that the manner displayed towards the caller was inappropriate in its tone and content. At one point, Mr A was told abruptly to be quiet and was asked in a doubtful manner if an ambulance was required. There was some bad language and comments by Trust staff about “needing to go to the toilet” and “here we go again” although this was during dial-out.
31. Our paramedic adviser has commented that the call assessor seemed exasperated by the difficulties in their communication with Mr A, whereas the supervisor seemed more supportive when they spoke with him.
32. We consider there was a failing in the way the call assessor spoke to Mr A. Specifically we agree with the Trust that some of the comments such as being told abruptly to be quiet, were inappropriate in their tone and content.
33. As regards other comments during dial-out, our paramedic adviser has added that in this type of environment and situation, there is often background noise and comments made by other staff. The bad language and other comments could not by heard by Mr A on the night as they occurred during dial-out. Mrs C has heard the full recordings of the calls and it is understandable that her perception of how the calls were handled has been negatively affected by some of what was said.
34. We note from the SIR that the Trust has already acknowledged this and has issued a notice to all staff reminding them about language and behaviour in the control room. This is alongside the supervision and retraining for the call assessor highlighted earlier. We do not have any concerns about the way the supervisor spoke to Mr A. Therefore, we consider that appropriate remedial action has been taken.
Summary of impact
35. As we have said, the first 999 call made by Mr A at 2.12am was incorrectly categorised by the Trust. This and a lack of information about their location caused a delay of over 40 minutes in an ambulance reaching Mr B.
36. Our paramedic adviser says there is a possibility that Mr B would have survived if an ambulance had reached him sooner, and appropriate treatment had been provided more promptly. However, we do not know if he had suffered a fatal heart attack by the time Mr A made the first 999 call. This is important, as both our advisers agree that Mr B would not have survived even in hospital if he suffered a fatal heart attack before the first call. This is supported by what the pathologist said at Mr B’s inquest.
37. It is difficult to make out everything that is said during the first call, but Mr A can be heard saying that Mr B was “just about breathing”. Our cardiologist adviser says it is clear Mr B had suffered some sort of event and subsequent information has established this was a heart attack, but we do not know precisely when his heart attack occurred. Unfortunately, it seems unlikely we will ever be able to establish the precise time of this event. Mr A was the only witness, but he told us he was unsure precisely what time Mr B had his heart attack as he (Mr B) was unconscious. We also note that Mr A is not a clinician and therefore taking account of these factors we cannot rely on his account of what time Mr B had his heart attack.
38. During the calls, Mr A can be heard calling Mr B’s name but there is no response from Mr B. Our cardiologist adviser says this indicates that Mr B was not conscious at this time, even if he was still breathing. It is unclear if Mr A was able to carry out any effective CPR on Mr B before the paramedics arrived. He told us that he did not attempt any CPR until he was told to by call handlers after his second call. If he had received CPR instructions earlier, Mr A says he could have started CPR after the first call, as he says Mr B was alive and breathing for at least 25 minutes after the first call. We have already said that Mr A should have been given CPR instructions during the first call and fact that he was not given this information is a failing linked to the incorrect categorisation of the first call.
39. However, we note it is possible for a patient to be unconscious but still breathing. If Mr B was unconscious for a prolonged period (say 30-45 minutes), which seems likely from the available information, our cardiologist adviser says his chances of making a meaningful recovery were remote.
40. If Mr B was still breathing at the time of the first call, then this indicates he was still alive at that point. However, it is unclear for how long he was still breathing after the first call. He had sadly died by the time paramedics arrived. Our cardiologist adviser says given the difficulties locating Mr A and Mr B, it is unlikely an ambulance could have reached them in seven minutes even if the first call had been correctly categorised.
41. If an ambulance had arrived within this timeframe, our cardiologist adviser says Mr B’s chances of surviving an out of hospital cardiac arrest is at best 12%. This is in accordance with relevant clinical studies highlighted in the OHCAO registry. In Mr B’s case, we also have to take into account his use of drugs that evening, especially cocaine, and a pre-existing heart condition. Our cardiologist adviser says these factors likely further reduced his survival chances.
42. Given the lack of information provided by Mr A during the first call about their location, we also considered why they could not be located from mobile telephone data at the time. The SIR indicates that Mr A and Mr B could not be precisely located during the first call possibly due to the remoteness of their location, and a lack of mobile telephone masts in the area.
43. Our paramedic adviser says the first call had a confidence radius of only 1299 metres. This means it was more difficult to pinpoint Mr A’s location, likely due to the remoteness of the area and him not being close to mobile telephone masts. The second call had a confidence radius of three metres which indicates that it would be much easier to pinpoint Mr A’s location. By the time of the second call, it appears he had started to move around which could explain why the confidence radius is so much better.
44. Mr B sadly died in tragic and unexpected circumstances, and Mrs C believes he would have survived if the first call had been correctly categorised, and an ambulance had reached him sooner. However, this is not what we have found during our investigation of her complaint.
45. If paramedics had arrived within seven minutes of the first call, and started CPR on Mr B, there is a possibility that he could have survived especially if he had reached hospital. However, given the other significant factors that we have to take into account such as the remote location/lack of information, drug use, pre-existing heart condition, and apparent lack of effective immediate bystander CPR. Any suggestion that he would have survived is speculative. Therefore, on the balance of probabilities, there is insufficient evidence for us to say that Mr B would have survived if Mr A’s call had been correctly categorised, and an ambulance had reached him sooner.
46. We appreciate this leaves Mrs C with unanswered questions and some uncertainties about what happened on 25 May 2019. The outcome is no doubt unsatisfactory for her. We know it is emotionally distressing for Mrs C, but we are not in a position to precisely establish when Mr B had his heart attack, or fully verify everything that happened between the first call and when paramedics arrived. We hope that Mrs C will take some reassurance that many of our findings agree with those made at Mr B’s inquest.
47. We have found some failings by the Trust in terms of how it dealt with Mr A’s first call, and in the attitude of the call assessor, but the Trust has already addressed these failings by taking appropriate remedial action, as outlined in our report. The only outstanding issue is a written apology, which Mrs C is yet to receive from the Trust. This is dealt with below.
48. In this report, we have set out our views regarding Mrs C’s complaint about the Trust. We have thoroughly and impartially investigated the complaint and drawn views from careful consideration of the evidence. Based on the evidence we have seen it is our view that there were failings in how the first 999 call was handled and in the attitude of the call assessor. However, these failings have already been identified by the Trust and we consider that it has taken appropriate remedial action to address these matters. The only outstanding issue is a written apology for Mrs C which is covered by our recommendation. For this reason, it is our view to partly uphold Mrs C’s complaint. We have identified that these failings caused Mrs C some doubt, uncertainty and emotional distress.