4. Mrs S complains the Trust’s 111 service did not correctly handle a call it received from her son, Mr S, on 5 January 2021 and this contributed to his death on 6 January.
5. She says her family is devastated by the loss and their upset and distress has been compounded by the poor service he received from the Trust’s 111 service.
6. Mrs S wants the Trust to acknowledge its mistakes, apologise for them and improve its service.
7. Mr S tested positive for COVID-19 on 26 December 2020 and called the Trust’s 111 service on 5 January 2021 when his symptoms worsened.
8. Mr S told the Coronavirus Service Adviser (CVSA) that he had developed a severe headache over the past two days and paracetamol was not working.
9. Following discussion with the CVSA, Mr S was told he could either receive a call-back for further assessment or complete on online assessment form. These options would further review his symptoms and signpost him either to seek treatment, and where to go to receive it, or provide advice around how to further manage his symptoms at home. Mr S decided to complete an online assessment form.
10. Mr S deteriorated the next day and was taken to hospital by ambulance where he sadly died.
14. Mrs S tells us the CVSA did not sufficiently question her son around the severe headache he reported. She says her son sounded uncertain when answering questions and the onus appears to have been placed on him to decide whether he wanted a call back or whether he wanted to complete an online assessment. Mrs S says her son’s severe headache should have been enough for him to be passed to a clinician.
15. The Trust’s 111 service says at the time of Mr S’s call, NHS111 services nationwide were experiencing unprecedented levels of demand due to the COVID-19 pandemic.
16. It says the NHS111 service devised a system which would ‘swiftly identify and manage those patients with immediate and potentially life-threatening symptoms.’ If life threatening symptoms were ruled out during the initial assessment with a CVSA, the patient would undergo a more detailed assessment (either by callback or online form).
17. Essentially, the CVSA’s role at the time was to ‘signpost callers quickly and effectively’ to the most appropriate services who could deal with their enquiry. It says its CVSA acted correctly on 5 January by ruling out emergency symptoms and by offering Mr S further assessment options.
18. Due to the standdown of pandemic emergency measures and the ongoing COVID-19 enquiry, the guidance for CVSA’s and the processes they followed is unavailable. Instead, we have carefully considered whether the Trust’s 111 service acted in line with Our Principles.
19. Our Principles say public bodies should treat people sensitively, deal with people in a co-ordinated way and refer them to other sources of help if required.
20. At the time of Mr S’s call in January 2021 additional triage processes were in place to relieve the pressure upon emergency services. By adding additional triage processes it was felt this would allow rapid assessment of anyone presenting with life threatening COVID-19 symptoms and would also allow services to prioritise care more effectively.
21. Having read the call transcript and listened to Mr S’s 5 January 2021 call, we can see Mr S appears to have been considered at the additional triage stage described above.
22. We carefully considered what the CVSA and Mr S said during the call. We can see the CVSA asked the appropriate questions to determine Mr S’s priority and he responded in the negative to those questions (i.e. no disability, not living alone, symptoms did not disrupt daily activities, and oxygen levels did not appear to be an issue).
23. Our 111 adviser says Mr S did not therefore appear to present with life threatening COVID-19 symptoms which required urgent action.
24. As a result, Mr S’s condition was not considered life threatening, and he was offered further assessment to better understand what help he may need.
25. We recognise Mrs S has been through a great deal and has continuing concerns that her son was asked to either receive a call-back or complete an online assessment, rather than being transferred directly to a clinician. We also appreciate Mrs S says her son was trying to be helpful and not be a burden upon emergency services, which is why he decided to complete the online assessment.
26. We do not dispute Mr S was unwell, but the evidence we have seen would indicate his condition was not life-threatening at the time of the call and did not therefore need to be transferred to a clinician. The CVSA appears to have correctly offered a follow-up call or asked Mr S to complete an online assessment alongside providing safety netting advice in case his symptoms worsened. In response, we can see Mr S chose to complete an online assessment.
27. We understand NHS England have since reviewed its data and cannot see it received an online assessment from Mr S in January 2021. It therefore appears he never completed one, and, as a result, no further action was taken by the Trust’s 111 service at the time. There is no way for us to know, even on balance of probabilities, what would have happened had Mr S completed an online assessment and submitted it.
28. Having carefully considered all the available evidence, we are satisfied the Trust’s 111 service acted correctly in line with Our Principles. We have therefore decided to take no further action in Mrs S’s complaint.
29. We are mindful these events were extremely traumatic, and Mrs S and her family continue to be affected by their experience. We hope our statement provides some reassurance around the action taken by the Trust’s 111 service on 5 January 2021.
1. We have carefully considered Mrs S’s complaint about the Trust’s 111 service. We recognise how concerned she is about the care her son, Mr S, received and we offer our condolences for her sad loss.
2. We know our primary investigation cannot change what happened or take away her, or her family’s pain. We sincerely hope our decision statement addresses the concerns she has about what happened and provides some reassurance around the service Mr S received.
3. We have seen no indication something went wrong with the service Mr S received and have therefore decided to take no further action. We have set out our reasoning in this decision statement.