South Central Ambulance Service NHS Foundation Trust

7. Miss M complains the Trust incorrectly categorised her father, Mr M’s 111 call on 29 December 2020. She says the call was categorised as a category 3 when it should have been a category 2 call.

8. Miss M tells us this means it took too long for an ambulance to attend to her father. She has told us he was suffering from a gastrointestinal (GI) haemorrhage, and he sadly died while the paramedics were with him.

9. Miss M says if the ambulance had been dispatched sooner her father would have been treated before he deteriorated and he may have survived. She tells us how distressing it is to know her father suffered and died without receiving the correct care. She has told us she suffers from anxiety as a result of the Trust’s actions which has meant she can no longer work for the NHS.

10. Miss M would like an apology, service improvements, a financial remedy and to know whether her father would have survived if the ambulance had been dispatched sooner as the outcome of her complaint.

11. At 7.19pm on 29 December, Miss M called 111 after her father reported vomiting blood and being weak on his legs. 111 placed the call in the queue for a clinician call back.

12. As Miss M was not with her father, a 111 clinician called her on a conference call with Mr M’s ex-partner, Ms K who was with him. This call was at 7.26pm. Ms K reported he had shortness of breath when moving, he was conscious but confused and had been vomiting blood, described as coffee ground. Ms K also reported blood in his urine and ‘black and tarry’ stools. The 111 clinician requested a category 3 ambulance response.

13. Ms K called 999 at 9.58pm, to see how long they would have to wait for an ambulance. The Trust told her it was very busy and that if nothing had changed or worsened, they would have to continue to wait for an ambulance.

14. Ms K made a further call to 999 at 10.32pm to say Mr M’s condition had deteriorated. She passed the phone to Mr M’s neighbour who reported Mr M had just been sick again and it was ‘very dark.’ The neighbour reported his condition had worsened and that he was not lucid. The call was re-triaged to a category 2.

15. An ambulance was dispatched at 10.51pm, and at 11.05pm Ms K made another call to say Mr M had deteriorated further. Eleven minutes later at 11.16pm the first ambulance crew arrived. The ambulance crew assessed Mr M. He was short of breath, pale, confused and disorientated. They listened to his chest and reported he had a ‘profound wheeze’. At 11.29pm the ambulance crew administered salbutamol. This is used to relieve wheezing.

16. Mr M then suffered from a seizure.

17. At 11.59pm the ambulance crew requested back up as Mr M had gone into peri-arrest. The crew started cardiopulmonary resuscitation (CPR), this included assistance from the Helicopter Emergency Medical Service and a team leader paramedic. Peri-arrest is the period before or after a full cardiac arrest.

18. Sadly at 12.54am on 30 December Mr M died. The cause of death was large upper GI haemorrhage.

Call categorisation

22. NHSE ARP guidance says category 2 calls are those classed as an emergency for a potentially serious condition that may require a rapid assessment, urgent treatment and/or urgent transport. For example, a person may have had a heart attack or stroke or be suffering from sepsis or major burns.

23. Category 3 calls are those classed as an urgent problem (but not immediately life-threatening) that needs treatment to relieve suffering, and transport. In some instances, patients are treated in their own homes.

24. We sought clinical advice from a paramedic adviser to help us reach a view on what category response the Trust should have assigned to Mr M. Our adviser said from listening to the call recordings they thought there was an opportunity to ask further questions during the nurse clinical call at 7.26pm. Our adviser said given Mr M’s presentation and history they would have expected the clinical call back to have led to a category 2 response. This is because he had a ‘potentially serious condition… which required urgent transport.’

25. JRCALC guidance on GI bleeding says if a patient has haematemesis (vomiting blood), haemodynamic compromise (insufficient blood flow in the body) or a decreased level of consciousness they should transfer the patient urgently to the nearest appropriate hospital.

26. We have seen evidence Mr M was vomiting blood and was showing signs of confusion during the clinical call back. This would indicate he required urgent transport to hospital and a category 2 ambulance response and should have been recognised in the nurse clinical call at 7.26pm.

27. We find the Trust’s categorisation of the 7.26pm call was incorrect. We find this to be a failing.

Impact

28. Miss M says if the ambulance had been dispatched sooner her father would have been treated before he deteriorated, and he may have survived.

29. We looked to see if we can reach a view on what would have likely happened if the Trust had correctly categorised the call. Our paramedic adviser said based on the Trust’s response times on 29 December, had the Trust arranged a category 2 response following the 7.26pm call, it is likely an ambulance would have been with Mr M by 8.30pm. This is because the Trust records show the longest wait at this time for a category 2 response was one hour.

30. The Trust has told us if this call had been triaged as a category 2 it is likely it would have been with Mr M at 8.36pm. Taking all the evidence into account we accept the latest arrival time was likely to have been 8.36pm.

31. JRCALC guidance says paramedics should assess the patient and take them to hospital. Our paramedic adviser said there would be no further care a paramedic could provide to treat the GI bleed. They said on average a paramedic assessment would take 30-40 minutes, and we calculated the transport to hospital would have taken around 30 minutes. On balance we think had a category 2 response been arranged, Mr M would have arrived at hospital by 9.40pm.

32. We also sought advice from our gastroenterology advisers. This is to help us understand more about Mr M’s condition, when he likely deteriorated, and what would have likely happened had the failings we identified not occurred.

33. We first looked to see if we could determine the cause of Mr M’s upper GI bleed. The post mortem noted Mr M had blood in his stomach and in his small and large intestine. Our gastroenterology advisers explained that as Mr M had ‘coffee ground’ vomit it is possible the blood came from the stomach or duodenum. This is because when blood is in the stomach, or duodenum it interacts with the acid in the stomach and turns it black.

34. They explained bleeding in the stomach or duodenum is most likely caused by a peptic ulcer. This is an open sore in the lining of the stomach of duodenum. However, the postmortem did not find evidence of a peptic ulcer.

35. Our gastroenterology advisers said it is also possible Mr M had varices in the lower oesophagus. Varices are expanded blood vessels in the oesophagus. These are a known complication of cirrhosis. This is scarring of the liver. The post mortem says Mr M’s liver was ‘pale and showed evidence of early micronodular cirrhosis’. Micronodular cirrhosis is a type of cirrhosis that forms small nodules on liver due to scarring.

36. Our gastroenterology advisers explained when a person has varices, they often vomit red blood. They also explained the postmortem did not note evidence of varices. However, it is possible for varices to become less visible after bleeding as the loss of blood results in the varices collapsing.

37. Taking into account the evidence we have seen, we do not think it is possible to say even on the balance of probabilities what caused Mr M’s upper GI bleed. This is because we have not seen evidence to suggest one diagnosis is more likely than the other.

38. We next looked at what would have happened had the ambulance arrived and taken Mr M to hospital when we said it should have at 9.40pm.

39. NICE guidance on upper GI bleeding says doctors should carry out an endoscopy immediately after initial treatment to stabilise the patient, it calls this initial treatment ‘resuscitation’. Endoscopy is a test to look inside the body. This would be to find the source of the bleeding and to treat it.

40. Our gastroenterology advisers explained to stabilise Mr M, the hospital would have assessed him in line with NICE guidance on acutely ill adults in hospital and the initial treatment would have been determined by his presentation at that time. Treatment could have included oxygen therapy, fluids, blood transfusions and medications.

41. We have looked to see if we can reach a view on the balance of probability whether the hospital would have been able to successfully treat Mr M before he deteriorated. Our gastroenterology advisers explained Mr M was very unwell and he would have needed to be stabilised before treatment was commenced. They explained that stabilisation would have been a challenge even if he had arrived at hospital at 9.40pm.

42. We have listened to the 111 and 999 calls to help us understand what Mr M’s condition was like throughout the evening. On the call at 7.26pm, Ms K said Mr M had been unwell since the day before. She explained he had been vomiting for a few days but was now bringing up blood which was described as ‘coffee ground’. When she spoke to the nurse Ms K said Mr M was unsteady on his feet and had been acting ‘a bit peculiar’ in the last couple of days.

43. We do not know from the available evidence whether he had been eating or drinking other fluids and it is therefore possible he was dehydrated which would have contributed to his deterioration.

44. We note at 10.32pm, Ms K said Mr M’s condition had become worse. Our gastroenterology advisers said it is possible Mr M was deteriorating throughout this period (7.26pm-10.32pm), but it would not have been visible to the family. We also note the ambulance records say Mr M had been vomiting red blood for two hours previously prior to the paramedic’s arrival. Our gastroenterology advisers explained this is an indication his condition had deteriorated further.

45. We have carefully looked at all the evidence available. We consider this supports the view that Mr M was deteriorating throughout the evening and had been unwell since the day before.

46. Our gastroenterology advisers explained Mr M had blood in his stools, and this could mean he had been bleeding for some time. We do not think based on the available evidence we can understand the full extent of Mr M’s deterioration throughout the evening. Our gastroenterology advisers also told us it is possible Mr M could have deteriorated further on the journey to hospital had an ambulance arrived soon enough to transport him there.

47. We have found there is uncertainty around what Mr M’s condition would have been like had he arrived at hospital at 9.46pm. This is because we do not know the cause of the bleed, and we do not know enough about what his condition was like at 9.46pm. This gap in knowledge is because he was not reviewed sooner by paramedics at home, or at hospital in this period as he should have been. This uncertainty means we cannot reach a view on whether it is more likely than not that Mr M could have been successfully treated before he sadly died.

48. We consider the Trust’s failure to correctly categorise Mr M’s call creates avoidable uncertainty for Miss M about what may have been different if her father had arrived at hospital by 9.40pm, when he should have.

49. Miss M has told us she thinks her father may have survived had the failings not occurred. This has, understandably, been devastating. In our work we have not been able to say that Mr M would have survived. But we do not rule out the possibility that he could have. We consider Mr M was not given the best chance of survival and knowing her father missed an opportunity for treatment will undoubtedly be a source of ongoing distress to Miss M.

50. We were sorry to hear of Mr M’s death and acknowledge our findings will cause significant distress to Miss M. Miss M has told us how devastating she has found her father’s death and the impact this has had on her and her ability to work in the NHS. While we cannot change the sad outcome, we hope our recommendations ensure the same will not happen to another patient and their family in the future.

1. Miss M complains about the care South Central Ambulance Service NHS Foundation Trust (the Trust) provided to her father on the evening of 29 December 2020. Mr M very sadly died on 30 December. Miss M has told us of the distress and anxiety she has suffered since the death of her father. She has told us how this has affected her ability to work as she continues to grieve for him. We were very sorry to hear of Mr M’s death and offer our heartfelt condolences to Miss M.

2. We found the Trust incorrectly categorised Mr M’s 111 call as a category 3, where calls should be responded to in 120 minutes in at least nine out of ten cases. We find it should have used a category 2, where calls should be responded to in an average time of 18 minutes and within 40 minutes for 90% of calls. We have found this to be a failing.

3. We consider there is uncertainty around what Mr M’s condition would have been like had he arrived at hospital when we think he should have. We consider the Trust’s failure to correctly categorise Mr M’s call creates avoidable uncertainty for Miss M about what may have been different for her father.

4. In our work we have not been able to say Mr M would have survived. But we do not rule out the possibility that he could have. We consider Mr M was not given the best chance of survival and knowing her father missed an opportunity for treatment will undoubtedly be a source of ongoing distress to Miss M.

5. We uphold this complaint.

6. We ask the Trust to write to Miss M to acknowledge the failings, apologise and to outline what actions it has taken improve its services. We also ask it pays her £5,000 in acknowledgement of the deep distress caused to her knowing her father was not given the best chance of survival.

51. We have considered the actions the Trust has already taken as a result of Miss M’s complaint and the care her father received.

52. The Trust said when capacity allows, it uses clinical staff to deal with 111 calls to make sure they maintain their NHS Pathways skills and training. It said it engaged with the 111 service staff to make sure they are confident in referring to the 999 service if appropriate. The Trust has also said since this time, it has recruited a GP to the 111 service to help assess patients. It confirmed since Miss M’s complaint it has not identified any incidents with the same themes where with moderate harm or above was found.

53. It has also amended a standard operating procedure to strengthen the wording to make sure emergency call takers review the case details of the original call as well as asking questions around potentially life threatening symptoms if worsening symptoms are identified on the call.

54. The Trust’s serious incident (SI) report identified the clinician did not follow due process and did not ask correct questions to check if Mr M was suffering from life threatening emergency symptoms. The SI investigation identified clinicians are not supported with ongoing education or training in triaging calls.

55. The Trust has now shared with us training materials which have been used by staff to support clinicians when completing assessments of patients. The Trust has also confirmed that it has supported the specific clinician involved with individual learning and that it is confident with the training and that its system for patient assessments is robust.

56. We have considered whether the actions here are sufficient given the seriousness of our findings. We are now assured the Trust has taken Miss M’s complaint seriously and the work it has sone will ensure life threating symptoms are recognised so that calls are correctly categorised.

57. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. In line with this we ask the Trust to write to Miss M to acknowledge and apologise for the care provided to her father Mr M and the impact of this on her. It should do this within four weeks of the date of this report and share a copy with our office.

58. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, given we are now satisfied with the actions the Trust has completed we recommend it writes to Miss M to outline the work it has done since her father’s death to ensure clinicians recognise life threatening symptoms and triage calls correctly.

59. Our principles state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

60. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, our current thinking is the Trust should pay Miss M £5,000 in recognition of the distress and upset caused by these very sad events.