The length of time it took the Trust to answer Mrs B’s 999 call
13. In her complaint to us, Mrs B said the Trust took 27 minutes to answer her 999 call.
14. In its complaint process, the Trust said British Telecom (BT) is the operator who initially answers 999 calls and then transfers them to the appropriate emergency service. The Trust said BT received and transferred Mrs B’s call to the Trust at 5.48pm. The Trust said it then took seven minutes before its EOC answered at 5.55pm.
15. The Trust said it was facing high levels of demand at the time. Between 5pm and 6pm that day, callers waited on average three to 11 minutes before the Trust had a call handler available to answer a call.
16. We found the Trust acted in line with relevant guidelines and took the actions it should have to try and answer 999 calls like Mrs B’s as soon as possible.
17. First, we saw a conflict between Mrs B’s and the Trust’s account about how long the Trust took to answer her call. Therefore, we considered the other available evidence to try and reconcile this conflict.
18. We reviewed the correspondence between BT and the Trust during the Trust’s complaint process. We saw the Trust told BT what Mrs B said about how long she waited. The Trust asked BT, as the phone operator, to identify whether there was a delay like the one she alleged.
19. After reviewing its records, BT confirmed Mrs B called 999 at 5.48pm. BT transferred her call to the Trust’s ‘primary’ and then ‘alternative’ line, but the Trust did not respond on either association. Then, at 5.55pm, BT tried transferring her call to the Trust’s ‘secondary’ line. On this attempt, BT said the Trust’s EOC answered.
20. As this information comes from the phone operator after review of its records from the time, we consider this is compelling evidence about when Mrs B called 999 and when BT transferred her call to the Trust.
21. On this basis, we consider the evidence shows Mrs B called 999 at 5.48pm. The Trust’s call logs confirm it connected her call to the call handler she spoke to at 5.55pm. Therefore, this shows it took seven minutes for the Trust to answer her call from the point BT first transferred it.
22. Below, we went on to consider whether the Trust did what it should have to try and answer her call as quickly as possible. Having done so, we saw the Trust acted in line with guidelines to take the actions it should have to try and answer her call.
23. Section three of the Ambulance Quality Indicators does not set out how long staff should take to answer a call from the point BT connect the call to an EOC. It simply says BT should connect the call and staff in the EOC should take it. Our adviser said there are no reportable targets about how quickly EOC staff should answer such calls.
24. We saw the Trust said it was experiencing a high level of demand on its service, and this meant it could not answer Mrs B’s call right away. Therefore, our adviser said staff should have taken measures in line with the Trust’s Safety Plan to try and answer calls as quickly as the Trust’s resources allowed.
25. On this basis, we considered whether staff took the actions they should have from the Trust’s Safety Plan to try and manage this demand.
26. To begin with, it is important to give an overview of the Trust’s Safety Plan. It sets out various levels of pressure or demand the Trust may face on its service. These are as follows:
• (level) green and yellow – business as usual – the Trust is servicing demand within normal limits, and it is facing no specific pressure points • orange – moderate pressure - demand pressures are leading to an increasing number of incidents waiting for the Trust to allocate resources to • red – severe pressure – the level of demand on the Trust’s service far exceeds its available resources and the number of incidents waiting for the Trust to allocate resources to increases • purple – extreme pressure – the level of demand on the Trust’s service far exceeds what it expects even with every front-line resource it has available dealing with demand.
27. Section four of the Trust’s Safety Plan sets out when staff can declare a certain level of pressure. This is normally when demand exceeds certain thresholds. For example, when demand means it takes the Trust more than 120 seconds on average to answer 999 calls, the Trust’s Safety Plan says this indicates extreme pressure on its call handling service. Staff can then declare the Trust is operating at level purple.
28. Section five of the Trust’s Safety Plan sets out actions staff can consider implementing to manage demand at each level. At each level, the Trust’s Safety Plan splits demand management actions into different areas of operational delivery. These operational areas (and actions) include:
• ‘call handling’ actions, which the Trust can take to prioritise and respond to the most urgent 999 calls when the EOC’s capacity to take these calls is stretched • ‘dispatch’ actions (how the Trust deploys ambulances when its ability to send ambulances to patients is stretched) • ‘Emergency Clinical Assessment Unit (ECAS) and Urgent Clinical Assessment Unit (UCAS)’ actions (how the Trust deploys clinicians working in its EOC so it can prioritise and respond to the sickest patients) • ‘other’ actions the Trust can take to help it prioritise and respond to the sickest patients.
29. The demand management actions mostly aim to free up resources to help the Trust prioritise and respond to the sickest patients. Each individual demand management action listed in the Trust’s Safety Plan sets out what impact the Trust expects the action to have.
30. The Trust’s Safety Plan recommends, before declaring higher levels of pressure, staff consider demand management actions from the level of pressure below. For example, to declare moderate pressure (level orange), staff should have considered implementing the demand management actions recommended at level yellow first.
31. Sections one and two of the Trust’s Safety Plan say staff use this policy to help maintain clinical safety. It is not a rigid set of rules, but a set of guiding principles. The actions staff take should be the minimum needed to manage demand and prevent harm to patients. This is because the action the Trust takes can impact on other NHS services.
32. Staff do not have to implement all demand management actions listed in the Trust’s Safety Plan. They should consider implementing actions based on the cause of the pressure they see. For example, if the Trust experiences a surge in 999 calls, this may require certain ‘call handling’ actions. Staff may not need to take any ‘dispatch’ actions in how they deploy ambulances.
33. Section three of the Trust’s Safety Plan says staff must keep a record on the Trust’s systems about the level of demand/pressure and decisions they take in declaring changes on this. They should also document actions they have taken to manage demand.
34. We saw the management reports the Trust sent us around the time Mrs B called 999 show staff had declared extreme pressure on its service (level purple). On average, it took 177 seconds for staff in the Trust’s EOC to answer incoming calls because of the number of calls the Trust was receiving.
35. As we highlighted in paragraph 27, this is an indicator from the Trust’s Safety Plan of extreme pressure on its call handling operation. This passed the threshold of 120 seconds in which, on average, it took staff to answer 999 calls.
36. Because the Trust declared the highest level of pressure, staff could have decided to implement all the demand management actions listed in the Trust’s Safety Plan. However, as this pressure was in its call handling operation, the Trust needed to focus its actions in this area.
37. The Trust’s management reports referred to separate pages (safety plan pages) on its system where staff documented decisions about the level of demand the Trust was facing. The management reports said these pages contained information about what safety actions staff were taking at the time to try and manage this demand.
38. Noting, as we set out in paragraph 33, staff should keep records like this, we asked the Trust to send us these pages. However, the Trust told us, in updating its system records later and saving these updates, staff saved over the safety plan pages. Due to this error in overwriting these pages, the Trust confirmed the information within the safety plan pages is no longer available.
39. This means we cannot confirm what demand management actions staff considered and whether they aligned with the Trust’s Safety Plan from its safety plan pages themselves. As pieces of important evidence are not available, we looked elsewhere to form a view.
40. The Trust’s management reports said the safety plan pages contained details on the level of demand on its service and the safety actions staff had put in place to manage this. So, although the pages with this information are no longer available, reference to them suggests staff considered actions from the Trust’s Safety Plan and implemented them based on the level of demand.
41. Also, within the management reports, our adviser saw reference to demand management actions staff implemented to manage the high volume of incoming 999 calls. Our adviser said these actions aligned with actions within the Trust’s Safety Plan. Our adviser saw the Trust’s managers noted they:
• stopped training and deployed staff in training sessions to answer 999 calls • made proactive plans to recover 999 call handling through redeploying staff from other EOC functions to take 999 calls, including staff from the Trust’s clinical hub.
42. We note these are all actions the Trust’s Safety Plan recommends, either at level red or purple, to increase the resources it has available to handle 999 calls. These actions increase the number of staff handling these calls.
43. Our adviser said, with the documentation available, there was less evidence than they would expect to see about what demand management actions the Trust was taking to try and respond to 999 calls. However, this did not mean staff did not consider or implement them. The lack of documentation meant our adviser could not evidence all the Trust’s actions and how or whether they aligned with the recommendations in the Trust’s Safety Plan.
44. Having reviewed the advice and the documentation available, we can see evidence managers considered and implemented some demand management actions from the Trust’s Safety Plan. The measures we saw all sought to aid how the Trust responded to 999 calls at a time it was receiving a high volume of these calls. The documentation shows staff identified this as the main cause of pressure on its service.
45. Given the reference to managers having further safety plan measures in place (in the now unavailable safety plan pages), we think it is likely they considered more measures to address the problem they identified in responding to 999 calls.
46. This is in line with the Trust’s Safety Plan, which says staff should consider implementing relevant actions based on the cause of the problem they have identified. However, this does not mean staff must implement all demand management actions.
47. Weighing all this up, we consider it is more likely than not that staff considered implementing the demand management actions they should have from the Trust’s Safety Plan. This means, on the balance of probabilities, we consider staff followed the principles set out in the Trust’s Safety Plan, and they took the actions they should have to try and answer 999 calls like Mrs B’s.
48. While we did not see failings in the Trust acting to answer Mrs B’s call, we saw staff did not keep all the documentation they should have (the safety plan pages).
49. Where an organisation’s record keeping impacts on our ability to determine what happened, even if this is not within our scope of investigation, we can highlight this. In this instance, we have needed to reach a view about what happened on the balance of probability rather than confirming this from records the Trust should have kept.
50. Therefore, the Trust may wish to consider taking action to learn from this to ensure it maintains such records in the future. However, as the Trust’s record keeping is outside the scope of investigation we agreed, we cannot make any formal recommendation on this.
51. We recognise it must have been distressing for Mrs B to wait to get through to one of the Trust’s call handlers.
52. We hope our review of these events helps to clarify what happened. We also hope it explains actions the Trust were taking to try and answer 999 calls like hers.
How the Trust categorised Mrs B’s 999 call
53. In her complaint to us, Mrs B said she is concerned the call hander she spoke to at the Trust categorised her call as a category two priority rather than category one.
54. We found the call handler acted in line with guidelines when categorising her call as a category two priority.
55. Section two in the Ambulance Quality Indicators says 999 call handlers should use a nationally recognised triage tool to categorise a call into the four categories set out in the Ambulance Response Programme. These categories are as follows:
• category one (calls from people with immediately life-threatening illnesses or injuries) • category two (emergency calls) • category three (urgent calls) • category four (less urgent calls).
56. The Trust used the Medical Priority Dispatch System (MPDS). Our adviser said this is a nationally recognised triage tool around half the ambulance services in England use.
57. The Ambulance Response Programme and the AACE Guidance explain what patient presentations fit into the above categories.
58. These guidelines say category one incidents include immediately life-threatening conditions like cardiac arrest and severe allergic reactions. These patients need immediate live-saving interventions like resuscitation. Category two incidents include emergencies like burns, strokes, and heart attacks.
59. Our adviser said the Trust’s call handler used MPDS to establish Mr B was breathing, he was conscious, and he had chest pains. They said this evidence supported their decision to categorise Mrs B’s call as category two.
60. Mr B’s presentation matched the category two features from the guidelines we set out above. He did not need immediate live-saving interventions like resuscitation to address an issue like loss of breathing.
61. Also, when the Trust’s paramedics saw Mr B later, they diagnosed a heart attack. This further supports the category the Trust’s call handler assigned. Therefore, the Trust acted in line with guidelines assigning a response category.
62. We also cannot see the Trust’s call handler breached any standards regarding how long it took them to decide how they categorised Mrs B’s call after answering it.
63. The Trust’s call logs show they assigned her call a category two priority two minutes and 49 seconds after answering. This was at 5.58pm.
64. The Ambulance Standards say, prior to the publication of these guidelines in 2017, call handlers were allowed 60 seconds from answering a call to sending out a vehicle. NHS England found ambulance services felt this was not long enough and staff often sent the wrong response, which led to wasted time and resources.
65. On this basis, NHS England said staff should get more time to assess 999 calls to ensure patients get the right response the first time. It did not set a maximum time to achieve this. However, the introductory section of the Ambulance Response Review says the national average is two minutes.
66. Our adviser said this is not a reportable target for ambulance services, and they saw no breach of any target here. We also note this is an average, and some calls will take longer to process than others.
67. We listened to Mrs B’s 999 call and noted the call handler awaited her responses to their questions to correctly categorise the call. As this was in line with what our adviser expected to see, we did not see a delay even though it took a little longer than the nationally reported average time.
68. We recognise Mrs B wanted the Trust to prioritise her husband because he needed care. This must have been a very difficult time for her.
69. We hope we have clearly explained our findings. We hope this helps assure Mrs B the Trust assigned a call category for her husband in line with guidelines.
How long it took for the Trust’s paramedics to get to Mr B
70. In her complaint to us, Mrs B complained it took 59 minutes from the point the Trust allocated an ambulance to paramedics arriving at her flat.
71. She noted when paramedics arrived at the building her flat was in, they struggled to access it. She felt paramedics should have done more to get the information they needed to gain access. Had they done so, they could have got to her husband faster.
72. She said paramedics could have asked staff in the concierge lounge of a nearby building where to access her flat. She said paramedics or the Trust’s EOC could have called her. She would then have directed them or come outside to meet them.
73. In its complaint process, the Trust said the average response time for category two calls is 18 minutes. It aims to respond to 90% of these calls within 40 minutes.
74. The Trust said the ambulance it dispatched arrived on the scene at 6.29pm. Therefore, it met its target for responding to category two calls. This was because its ambulance arrived on the scene within 34 minutes of its EOC answering Mrs B’s 999 call.
75. It said its paramedics then struggled to find her flat because it was in a new building.
76. The Trust explained the actions paramedics took to try and find her flat. It said they drove around, asked members of the public, walked around the area, and used the mapping apps on their mobile phones to try and find it. As this did not work, they eventually found a concierge in a different building who directed them to the correct location.
77. The Trust added, according to the Trust’s Conveyance Policy, one of the first things paramedics should do is call its EOC if they are having difficulty locating an address. It acknowledged paramedics did not do this for 18 minutes after arriving on the scene.
78. We did not find service failings on this matter.
79. The introductory section of the Ambulance Response Review says, for category two calls, ambulances should aim to get to the scene within 40 minutes in 90% of these cases.
80. The Trust’s call logs and Mr B’s patient care records note the ambulance arrived on the scene at 6.29pm. As the Trust categorised Mrs B’s call as category two at 5.58pm, this shows the Trust’s ambulance arrived on the scene within the target timeframe.
81. Section seven in the Ambulance Quality Indicators says ‘the scene’ means within 200 metres of the patient.
82. We note Mrs B stayed on the phone with the member of staff who handled her 999 call until she confirmed the ambulance arrived. At the end of the call Mrs B told the call handler she could see the ambulance outside from the window of her flat.
83. Given the proximity of the ambulance as she described at the time, we consider this is compelling evidence the paramedics were within 200 metres of her flat at 6.29pm. Therefore, they arrived at the scene within the target timeframe set out in the Ambulance Response Review.
84. We appreciate Mrs B told us this did not mean paramedics were with her husband, and from this point, it took too long for them to get to him. We have considered the actions staff took to find Mr B once on the scene in more detail below.
85. Having done so, we did not find what happened fell so far below the standard we would expect to see, and that the actions staff took amounted to service failings.
86. Section 9.2 of the Trust’s Conveyance Policy sets out what paramedics should do when they arrive at the scene, but they cannot locate the patient.
87. They should contact the Trust’s EOC to confirm they cannot locate the patient and commence an area search. As a minimum, the area search means the crew exit their ambulance and physically search the area where the patient is thought to be (based on the information they received about the patient’s location). During the area search, the EOC should try and contact the person who made the 999 call to confirm the patient’s location.
88. Backing up what the Trust said in its complaint process, Mr B’s patient care records, and a call paramedics made to the EOC prior to finding him, show they commenced an area search when they arrived on the scene.
89. 18 minutes after starting their search, at 6.47pm, paramedics called the EOC to confirm they were struggling to find Mr B despite their search. They asked the EOC to call Mrs B for more information about her location while they continued their search.
90. The EOC then acted on this and spoke to Mrs B at 6.51pm. This call recording shows she told the call handler she could not leave her flat to meet paramedics. However, she gave some further information. She said her flat was in a new building opposite a pub on the other side of the road. EOC staff then relayed this information to the paramedics.
91. So, we saw the Trust’s paramedics started their area search before contacting the EOC. That said, our adviser said the paramedics followed all the actions set out in section 9.2 of the Trust’s Conveyance Policy, just not in the order they appear in the policy.
92. Having considered this evidence and advice, we think paramedics may have called the EOC earlier, and closer to the time they started their area search. Despite this delay, they were taking actions from the point they arrived on the scene to try and find Mr B. This is the main principle set out in the Trust’s Conveyance Policy.
93. On this basis, and because staff took all the actions they should, we did not see what happened fell so far short of what should have happened for us to consider it a failing.
94. We appreciate the additional time it took for paramedics to find Mr B was very distressing for him and Mrs B. We recognise Mrs B was very worried about her husband’s condition during this period.
95. We hope we have clearly explained our findings on this matter. We hope our review of the events helps to assure Mrs B the Trust’s paramedics were working hard to try and find her flat. We can see their efforts in their area search, which led them to the concierge, meant they got the information they needed to find her flat and reach Mr B.