Categorisation of call
15. Mrs O complains that the Trust incorrectly categorised the call. She feels that as her father was over 70, had a pacemaker, and was experiencing central chest pain, he should have been assessed as having a possible heart attack and categorised as category two.
16. Most ambulance services, including the Trust, use the AMPDS for triaging their emergency calls. The system is used by non-clinicians and uses several protocols, with scripted questions to determine the patient’s condition. Depending on the answer to the questions on each specific protocol a code will be given. This code is used nationally to determine the category of the incident.
17. In the initial 999 call, Mrs O reported that her father was experiencing central chest pain. On that basis the dispatcher correctly chose Protocol 10 ‘Chest Pain/Chest Discomfort (non-traumatic)’. We have seen that the questions that the dispatcher asked were the scripted questions for this protocol. From listening to the 999 call, we have seen that the dispatcher correctly recorded the answers Mrs O and Mr I provided.
18. Using the information provided, the AMPDS categorised the call as 10-C-3 which means chest pain, where the patient is over 35, but is breathing normally. This code is a Category three. Category three is for urgent calls.
19. It is understandable why Mrs O feels that the category should have been higher, as in hindsight, her father was having a heart attack and he did require immediate treatment. Unfortunately at the time of the call, Mr I’s symptoms did not trigger a higher category response. We appreciate that this is distressing for Mrs O.
20. We have seen no evidence that the call was triaged or categorised incorrectly. As such, we do not uphold this aspect of the complaint.
An ambulance should have been sent
21. Mrs O complains that the Trust should have sent an ambulance to her father instead of them having to take him to hospital themselves.
22. In its initial complaint response, the Trust said there were no ambulances available to send to Mr I, following the initial call, as it was experiencing a high volume of calls. When a search was made at 3:30pm an ambulance was showing available from the nearby area with an estimated time of arrival of 22 minutes. It said there is no evidence documented to suggest whether or not this resource was considered, or a request made to allocate this resource to Mr I.
23. However, in its second complaint response, the Trust clarified this by saying if the resource had been requested and allocated to Mr I, it would almost certainly have been diverted to a higher priority call, so it would not have arrived with Mr I.
24. NHS England’s ‘New ambulance standards’ sets out that at least 9 out of 10 Category three calls should be responded to within 120 minutes (two hours). As Mrs O took her father to hospital herself around 55 minutes after the initial call, it is unclear whether or not the Trust would have sent an ambulance to Mr I within this target.
25. The ambulance standards explain that the categories are prioritised for ambulance dispatch with the Category one incidents receiving the highest priority. Emergency calls are further prioritised within each of the categories in chronological order. Resources on the way to incidents will be considered for diversion to incidents of a higher priority that have no resources allocated to them.
26. At the time of the call, we have seen that the Trust was receiving a large number of calls and it did not have the resources to meet the demand. As such, the Trust appropriately put in place its demand management plan (DMP).
27. DMP’s have several levels which are triggered by either the number of waiting calls or the number of incidents by category that have not been allocated a resource. Each level has several actions that attempt to mitigate the impact to the service and patients. At the time of the call the service was operating at DMP level one.
28. We have seen that the Trust implemented DMP level one at 2pm. This was due to 67 unallocated Category three incidents, the trigger for implementation of DMP level one is greater than 60 Category three incidents awaiting allocation of resources.
29. Therefore, we have seen evidence that, unfortunately, at the time of the call, the Trust was extremely busy and could not allocate an ambulance to Mr I sooner than 3:30pm.
30. As the Trust has already acknowledged, we consider that the nearby ambulance should have been allocated to Mr I at 3:30pm. However, our paramedic adviser said, given the demand at the time, and that higher category calls were waiting to be allocated, it is extremely likely that given the 22-minute journey, that the ambulance would have been diverted to a higher priority call and would not have arrived with Mr I.
31. We have seen no evidence that there were any further ambulances that could have been allocated to Mr I before the family decided to cancel the ambulance and take him to hospital themselves.
32. We appreciate why Mrs O feels that an ambulance should have been sent sooner, and we accept that it would have been desirable if one could have been. We also appreciate that the wait for the ambulance would have been very stressful for the family, and it must have been a difficult decision deciding whether to take him to hospital themselves.
33. We have seen no evidence that an ambulance should have gotten to Mr I before it was cancelled. As such, we do not uphold this aspect of the complaint.
Information given by the call handler
34. Mrs O says the call handler should have given accurate information about the likely timescale for an ambulance arriving. She says the call handler told her the ambulance was on its way and to wait outside. She says if they had known it was not on its way, they would have taken her father to hospital sooner.
35. In its complaint response, the Trust acknowledged that the call handler should have advised that the Trust was busy and would aim to be with Mr I within the next two hours, or as soon as they had an ambulance available. It said the call handler should have explored the possibility of Mr I making his own way to hospital.
36. The Trust apologised that this information was not passed to Mrs O to enable her to have made an informed decision about whether to take her father to hospital herself, or wait for the ambulance.
37. The Trust’s DMP states that when level one is implemented (as it was here) the call handler should follow a script. For each Category three call, the call handler should explain ‘we are very busy and aim to be with you within the next two hours, or as soon as we have an ambulance available’. The DMP also states that, if appropriate, the call handler should explore the possibility of the patient making their own way to hospital.
38. We have listened to the 999 call, and the call handler did not include this information. The call handler did not provide any information as to the possible timeframe and told Mrs O ‘before the responder arrives, gather meds, unlock the door and if you can, have someone flag down ambulance crew. If he gets worse, call us back but all help has now been arranged for your Dad’.
39. As such, the call handler did not follow the DMP script. We consider this to be a failing.
40. Mrs O said that if the call handler had told her that the ambulance would not arrive quickly, she would have taken her father to hospital immediately herself.
41. We have seen that Mrs O did take her father to hospital herself at 3:54pm when it became apparent that an ambulance was not on its way. As such, on the balance of probabilities, we consider it likely that if Mrs O was told during the initial call that the ambulance could take two hours, she would have taken her father straight to hospital herself.
42. Therefore, we conclude that the Trust’s failure to provide the appropriate information to Mrs O led to a delay of around 50 minutes, where Mrs O was waiting for an ambulance for her father, when she could have taken him to hospital earlier.
43. Mrs O feels that if her father had been taken to hospital earlier then he would have received medical treatment earlier which may have prevented the damage to his heart and made his survival more likely.
44. Mrs O took Mr I to Hospital A, who later transferred him to Hospital B’s heart attack centre. The doctors in Hospital A diagnosed him as having an acute myocardial infarction (a heart attack) at 4:30pm. The Electrocardiogram (ECG - a test used to check the heart's rhythm and electrical activity) showed some of the heart muscle had died due to the obstruction of blood supply to the area.
45. The NHS England’s contract for cardiology states that primary angioplasty (stretching any narrowed areas of the coronary arteries using a balloon to improve blood flow to the heart) is the appropriate treatment for this type of heart attack. Hospital B started this at 7:35pm.
46. Therefore, if Mr I had arrived at hospital 50 minutes earlier, we consider it is likely that the primary angioplasty would have been started earlier.
47. The ‘Time is muscle’ study showed that delays in restoring blood flow, following a heart attack, are associated with worse outcomes, in terms of cardiac function, heart failure and mortality.
48. The European heart journal study found that mortality was lower in patients with a call for ambulance to treatment time of less than 90 minutes as compared to their counterparts with a time of more than 90 minutes. A particular high risk of death was observed in the group of patients with call for ambulance to treatment times ranging from 150 to 180 min, as one fifth of all patients in this group died after treatment.
49. Unfortunately, even if Mr I had been taken to hospital as soon as the family had made the initial call to the Trust, it is likely to have taken longer than 180 minutes for the primary angioplasty to have been started. This is because Mr I had to be assessed by Hospital A before being transferred to Hospital B.
50. As such, even if the family had taken Mr I to Hospital A straight after the initial 999 call, we cannot say, on the balance of probabilities, that Mr I’s sad death could have been avoided. This is because the studies all show that the chance of survival is lessened the longer a patient waits for treatment.
51. However, we can conclude that there was a missed opportunity to provide a better outcome to Mr I, as the study by De Luca et al showed that the risk of one year mortality is increased by 7.5% for each 30 minute delay. Although the delay caused by the failing was 50 minutes, we cannot say how long the delay in starting the primary angioplasty would have been because of all the other factors involved. This leaves an uncertainty to Mrs O and her family that things might have been different. This is a significant impact in its own right.
52. In its complaint responses, the Trust acknowledged and apologised for the failing we have found. However, it has not acknowledged or apologised for the impact of this failing on Mr I or the family. As such, we recommend that it apologises.
53. We have also seen that in response to the complaint, the Trust fed back learning points to the to the call handler at the time, via their supervisor, to ensure all learning points were actioned. The Trust said it has an audit performance procedure in place to manage its call handler’s performance based on feedback from complaints and specific/targeted audit reviews, as well as random reviews. The Trust told us that the call handler involved in this incident has not been on any performance plans recently and has not required any further action plans following this incident.
54. As such, we consider that the Trust has already taken appropriate action to learn from this complaint. The Trust has procedures in place to ensure, as much as possible, that this failing will not be repeated, and the call handler has not had any further issues. As such, we do not consider there is any further action we can recommend to ensure that the failing we have found will not be repeated.