18. When we look at whether there is a failing in the service provided, we consider what should have happened in line with relevant law, policy, guidance, standards, and our clinical adviser’s professional reasoning. We then consider what did happen, from all information and clinical records received, and if this was different to what should happen. If it was, we consider if it fell so far short of what should have happened, to be a failing.
19. If there was a failing, we then consider what injustice this may have caused. If it caused an injustice which has had a negative impact, our next step is to consider what actions the Trust has already taken to put things right. If we consider the Trust has not done enough, we may make recommendations for it to take further action.
20. We will now consider Mrs A’s complaint.
Staff asked unnecessary questions meaning a call-back within six hours was requested
21. Our adviser explained the NHS pathways system is a commercial clinical tool, accessing the full details and structure of the call handling process. Our SMG says an adviser may give their professional reasoning when giving their independent advice.
22. The NHS pathway system includes of three modules: zero, one and two.
23. Module zero is completed by a layperson (non-clinical) health advisor (HA) and is designed to prompt and identify immediate life-threatening signs and symptoms leading to automatic emergency ambulance dispatch.
24. Module one is also completed by a HA and has a more in depth ‘body map’ assessment of a patients’ non-immediate life-threatening signs and symptoms.
25. Module two is designed to be completed by qualified/registered clinician and is a more targeted assessment tool that allows for clinical judgement to be made.
26. Upon completing a module one assessment, the NHS software will use all factors to decide the most clinically safe and appropriate pathway. This may include emergency/non-emergency ambulance response, minor injury/urgent care centre appointment/referrals or, as in this case, remote telephone consultations with a qualified clinician. Pathways will also suggest the most appropriate timeframe for action, again based on clinical need and patient safety.
27. Mrs A says Mrs T contacted NHS 111 on 8 January 2021 for help and advice as she was feeling unwell having been diagnosed with COVID-19 on 5 January.
28. She says staff asked unnecessary questions about her mother’s usual daily activities like if she could check her phone, look at a book, watch television, and get a drink of water. Staff also asked if she was responding and reacting normally to other people and if someone was to telephone her, would she be able to say hello and not stare blankly into space.
29. In its response, the Trust said it found the call may not have been safe and appropriate due to the unnecessary questioning around whether Mrs T could complete some or all her normal daily activities. The Trust admitted a failing in this call, which led to it being passed to the out of hours service for contact within a six-hour period.
30. The Trust also explained that had the first response been selected without the further questioning, Mrs T would still have been referred to the out of hours service, but it would likely have been for a faster call-back.
31. The NHS pathways system was used when Mrs T called NHS 111, which would have started at module zero before moving onto module one. As HA’s are non-clinical staff, they are required to ask only what is suggested to them onscreen by the pathways system, and not reword questions or advice unless the caller is having difficulty understanding. This is so questions have the correct meaning, are easily understood and match up with what the HA sees on the screen.
32. From seeking clinical advice on this matter, it is our view protocols were not followed as Mrs T was asked unnecessary and extra questions. When Mrs T explained she ‘didn’t feel at all herself’, this suggested significant worry which is one of the criteria for not being able to complete daily activities. As such, the HA selected the wrong response. The right response would have meant a two-hour instead of six-hour call-back was requested.
33. However, because fatigue was the main symptom Mrs T had during her call to NHS 111, our adviser explained it would not have been right to put her on a COVID-19 pathway.
34. Triage tools, such as the NHS pathways system, are based on a caller’s description of their symptoms and the severity. Our adviser explained COVID-19 was the cause for Mrs T’s symptoms but was not the symptom itself, this was fatigue. Based on the symptoms and their severity which Mrs T explained during her call, she most likely would have been put on the same care pathway, a clinician call-back, and not a COVID-19 pathway. We have seen no failings here as the correct pathway was for a clinician call-back.
35. Next, we went on to consider the time taken for the call-back. From her records, we can see Mrs T’s initial call to NHS 111 on 8 January was completed at 6.34pm. She received a call-back from a clinician at 8.24pm. This meant a total time of one hour and fifty minutes between both calls, which was within a two-hour period.
36. As such, we do not consider there to be any injustice to Mrs T because the call-back took too long. We also cannot say that she may not have sadly died, as her condition did not change within the time of her getting a call-back. While she was incorrectly placed on a six-hour call-back period, she was called within two hours.
37. We also realise it has been difficult for Mrs T’s family to learn that she was incorrectly put on a six-hour period for a clinician call-back. This is an injustice which has caused upset and distress. We have considered what the Trust has done to put things right later in this report.
Staff should have arranged for an ambulance
38. The NHS pathway systems clinical tool is also relevant here. However, the guidance for this is included within the system and we cannot get or access this without a product licence. Therefore, in line with our SMG, our adviser has provided their professional reasoning to help in our decision making.
39. Mrs A explains Mrs T was suffering from COVID-19 and was unable to do simple tasks like hold a hairbrush and was struggling to walk to her kitchen to get a drink. She thinks staff should have arranged an ambulance based on their triage and the symptoms described. However, no ambulance was arranged, and instead, she was prescribed antibiotics.
40. In its response, the Trust says Mrs T did not tell NHS 111 about her breathlessness symptoms. Therefore, her reported symptoms at the time of this call did not need an ambulance response.
41. The Trust also explained ambulance referrals can made in many assessment pathways. These may be placed into lower positions or requirements within a pathway but can be increased by clinicians if they feel it is needed.
42. The need for an ambulance and its urgency is usually reached when life threatening symptoms are present such as severe breathing difficulties, chest pain suggesting cardiac arrest, severe bleeding, fitting, possible stroke, an unconscious patient, and some mental health symptoms amongst other possible situations.
43. We have carefully considered Mrs T’s records and the information she gave during her calls. During the call on 8 January, she did not identify or disclose any immediately life-threatening signs or symptoms. She denied any shortness of breath multiple times to both the HA during module one triage and the clinician during her call-back.
44. From our clinical advice, had staff identified any life-threatening or potentially life-threatening symptoms during the module one triage or the clinician call-back, these would have been escalated by NHS pathways system or the clinician, and an ambulance would have been arranged. Mrs T may have needed an ambulance at a later date, however, it was not needed at this time.
45. As such, we have seen no reason for the Trust to arrange an ambulance, and our decision is the Trust did not do anything wrong.