East Midlands Ambulance Service NHS Trust

The Practice 9. Mrs P complains on 12 April 2022, the Practice prescribed her father, Mr C, morphine which was inappropriate considering his age and medical history. She also complains when her father saw a GP on 14 April, he: • failed to identify or act upon signs of infection or possible sepsis.

• should have arranged for Mr C to be admitted to hospital instead of incorrectly advising he could return home and return to the Practice in five days’ time.

• prescribed naproxen which was inappropriate, considering Mr C’s age and medical history, with a stomach liner that was not an appropriate caution for a drug that can affect the heart and kidneys.

EMAS and the Trust 10. Mrs P complains of a six-hour delay between the ambulance arriving at hospital at 7.01pm on 16 April, and her father being handed over to emergency department (ED) staff at 12.50am on 17 April. Specifically, Mrs P questions whether it was EMAS’ and/or the Trust’s responsibility and failure to have booked her father in when the ambulance arrived.

The Trust 11. Mrs P complains the Trust did not give her father appropriate treatment for his infection, organ failure and/or possible sepsis until after 7am on 17 April. She complains he was not given adequate pain relief when receiving end-of-life care.

12. Mrs P also complains about the way the Trust handled her complaint, specifically the considerable time it took, the lack of updates she received, the loss of audio and any documentation from the first meeting, and the inadequate recommendations set out in the substantive response. She complains the Trust made criticisms of the other organisations involved yet it failed to accommodate a coordinated response and/or meeting with those organisations to allow for their input.

Claimed injustice 13. Mrs P says the Practice’s failure to act on signs of infection and arrange admission delayed hospital treatment, which may have changed the outcome. She says the morphine and naproxen may have directly caused her father’s death.

14. Mrs P says if EMAS did fail in its responsibility to book her father in, this left ED staff unaware of his arrival and in turn he was not given the senior doctor review that should take place every 30 minutes when patients are held on the rear of ambulances, as per national guidance. She says the Trust failed in its responsibility to book her father in, it subsequently failed to provide the senior doctor review that should take place.

15. Mrs P considers this, and further medication delays once her father was in the ED, left his infection, organ failure and/or possible sepsis without appropriate treatment, to deteriorate considerably. Mrs P also says her father was left in pain at the end of his life.

16. Mrs P thinks these failings caused her father to die prematurely, if not avoidably, on 18 April 2022. She has been caused significant upset and distress by these events and remains devastated by the sudden and unexpected loss of her father. Mrs P has needed to seek bereavement counselling and she continues to struggle to process her considerable grief. Mrs P describes the Trust’s handling of her complaint as inhumane, having only compounded her distress at the most difficult time, and leaving her with conflicting information and without any closure or ability to move forward.

Outcomes 17. To resolve her complaint, Mrs P would like the Practice, EMAS and the Trust to acknowledge their respective failings and apologise to her for their impact. She seeks improvements, for lessons to be learned and action taken to ensure these events do not happen to anyone else in future. Mrs P also seeks a financial payment in recognition of the impact caused by these failures.

18. Mr C was 84 years old at the time of these events. The Practice received his regular blood monitoring results on 8 April, which showed abnormalities. At a consultation on 11 April Mr C reported weight loss, feeling unwell, having no energy, a reduced appetite, with low back and testicular pain. An appointment was made for Mr C to attend the Practice and have repeat bloods taken on 14 April.

19. On 12 April Mr C spoke with a GP by phone, explaining he had called an ambulance overnight for back spasms and he could not move without severe pain. It is noted Mr C needed Entonox (nitrous oxide, known as ‘gas and air’) from paramedics to manage his pain sufficiently to sit up in bed. Paramedics offered hospital admission, noting Mr C declined.

20. The GP prescribed oral morphine (an opioid analgesic, a ‘painkiller’). The GP called for an update later that day, noting Mr C reported taking two doses of morphine which had lessened but had not resolved his pain. The plan remained for him to attend the Practice on 14 April.

21. On 13 April records note Mrs P rang. We accept she says this conversation took place with her brother. Records note the Practice was advised Mr C would not be able to attend his appointment the next day due to his reduced mobility from increasing back pain, reporting morphine was only ‘dulling’ this. The GP notes offering to arrange hospital admission, noting Mr C declined. He requested a home visit the next day, and the GP agreed.

22. Mr C did go to the Practice on 14 April, though was unable to attend in the morning for the blood test. The GP advised Mr C of his abnormal blood results and that it was possible he had myeloma (a type of blood cancer). Discussion of hospital admission or home took place. Mr C returned home, with a plan for an appointment and blood tests at the first opportunity after the Bank Holiday weekend, on 19 April. The GP prescribed naproxen (an NSAID, a non-steroidal anti-inflammatory drug, a different type of painkiller).

23. On 16 April Mrs P called NHS 111, receiving a call back from a GP. Records note Mrs P reported her father was very sleepy and refusing food and drink. The GP advised he could visit but said this would unlikely change the medical management, which was to admit Mr C to hospital. Records note Mrs P would call for an ambulance, and she called 999 at 5.46pm.

24. EMAS sent a double crewed ambulance, which arrived with Mr C and Mrs P at 5.56pm. It left the home at 6.43pm, arriving at the Trust at 7.01pm. Mr C remained in the back of the ambulance, parked outside of the hospital building. The ambulance crew handed over to another EMAS crew at 8.30pm and remained outside with Mr C.

25. Records note Mr C was moved into the ED at 12.49am on 17 April and he was later admitted. By the afternoon of 17 April, clinicians concluded that Mr C would sadly not benefit from any escalated care. A ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) order was put in place, and Mr C was placed onto an end-of-life care pathway. Mr C sadly died on the morning of 18 April.

26. Mrs P raised her complaints, receiving separate responses from the Practice, EMAS and the Trust. Remaining unhappy with the responses received, she asked us to investigate.

The Practice

Morphine 31. GMC guidance says doctors should provide effective treatments, prescribing drugs with adequate knowledge of the patient’s health and when satisfied these serve the patient’s needs. NICE CKS guidance on analgesia recommends a stepwise approach to managing mild to moderate pain. It sets out five steps, with step one to give paracetamol only and step five to add a weak opioid (such as morphine) to paracetamol and/or an NSAID (such as naproxen).

32. Mr C was reporting testicular pain and severe back pain of unknown cause. By the time morphine was prescribed, he reported co-codamol (which includes paracetamol) having no effect and needing Entonox from paramedics to manage his pain sufficiently, even to just sit up in bed.

33. We consider morphine was prescribed appropriately on 12 April, in line with GMC guidance and NICE CKS guidance on analgesia, in best attempts to help relieve Mr C’s severe pain in the short-term. We highlight that drug recommendations within NICE CKS guidance on analgesia are for mild to moderate pain. Mr C’s pain was severe, making this prescription even more reasonable.

34. We do not find Mr C’s age or anything in his medical history a contraindication (a reason to withhold or not give a certain treatment as it could be harmful to the patient) to morphine. Our GP adviser explains all medications are prescribed with cautions. BNF guidance on morphine cautions the use of all opioids in the elderly by recommended a reduced dose. The dose prescribed was low, in line with BNF guidance on morphine, taking account of Mr C’s age. We do not find any evidence of service failure here.

Naproxen 35. Records note when the GP called on the afternoon of 12 April to check on Mr C, he reported the morphine had lessened but had not removed his pain. On 13 April Mrs P says it was her brother who called, to advise the morphine was only ‘dulling’ his father’s increasing back pain. The GP offered hospital admission, and it is noted Mr C declined and wished for the continued plan to be seen face-to-face the next day.

36. Records of the appointment on 14 April note Mr C reported the morphine did not help his pain. The GP was appropriately worried about the cause of Mr C’s severe back pain and noted informing him of the possibility he may have myeloma. Our GP adviser confirms this was in keeping with the clinical findings. Records note discussion was again had over hospital admission or returning to the Practice, and a plan was made for Mr C’s return within days for monitoring and follow-up.

37. Naproxen was appropriately prescribed in line with GMC guidance and NICE CKS guidance on analgesia. Step five of the latter recommends introducing NSAIDs such as naproxen, for mild to moderate pain. We consider this even more reasonable, considering Mr C’s pain was severe, untouched by co-codamol and only dulled, if that, by morphine.

38. The dose prescribed was low, also in line with BNF guidance on naproxen, and for a short duration. A different oral analgesic had already been prescribed and tried without adequate effect. There were no contraindications, no potentially hazardous drug interactions, and Mr C was not already using an NSAID. These are all considerations listed within NICE CKS guidance on NSAIDs, which we can see the GP followed.

39. The GP co-prescribed lansoprazole for gastroprotection. We can assure Mrs P this was an appropriate caution for naproxen, and prescribed appropriately, in line with NICE CKS guidance on NSAIDs.

40. We know Mrs P is also concerned about the appropriateness of naproxen, considering it can affect the kidneys. BNF guidance on naproxen does caution that NSAIDs may impair renal (kidney) function. Mr C’s blood results from 8 April note his eGFR was 48. The estimated glomerular filtration rate or eGFR is a calculation of how well person’s kidneys are filtering out waste. An eGFR of 60 or more is considered normal, lower than 60 suggests the kidneys are not working properly, and lower than 15 is a marker of kidney failure.

41. Our GP adviser explains Mr C’s eGFR was lower than normal, yet not so low to mean naproxen was contraindicated. It was prescribed with caution and given with a known, planned follow-up in a short period ahead to enable monitoring whilst supporting the plan for Mr C to return home. This was all in line with the above guidance.

42. Mr C remained in considerable pain, and we think the GP prescribed naproxen alongside lansoprazole accordingly, in line with guidance, and in best attempts to help his pain whilst he remained at home. We do not find any evidence of service failure here.

Infection and sepsis 43. GMC guidance advises doctors to adequately assess patients’ conditions, taking account of their history, their views and values, and to examine the patient where necessary. Records of the face-to-face appointment on 14 April assure us GMC guidance was followed.

44. Records note Mr C reported waking 10 days’ previously with severe low back pain, with some slight constipation and no urinary symptoms. The GP recorded an examination, finding Mr C in pain with a tender lumbar spine, a soft and non-tender abdomen, yet with a clear chest, normal heart sounds and a normal pulse rate.

45. His abnormal blood results from 8 April were known at that time. One of those abnormalities was his C-reactive protein level or CRP, a marker in the blood indicating inflammation/infection. Mr C’s CRP was 198, which is very high. CRP can be raised due to inflammation when people have pain, and Mr C’s pain was severe. Increased CRP levels are also an indication of inflammation caused by active myeloma.

46. From the history reported by Mr C and findings on examination, there was no clinical indication of infection or sepsis at the appointment on 14 April. The GP was appropriately worried about the cause of Mr C’s severe back pain and noted informing him of the possibility of the working diagnoses. Our GP adviser confirms this was in keeping with the clinical findings and we do not find any evidence apparent infection or sepsis was missed. We do not find any evidence of service failure here.

Advice for home 47. Mrs P says the GP advised against hospital admission on 14 April owing to the Bank Holiday weekend and likely long waiting times, and as this was the GP’s suggestion, her father agreed. The GP says he explained the options for hospital or home in detail and Mr C was clear he did not want hospital admission.

48. We cannot resolve the difference in this recollection of the discussion. All agree that discussion about hospital and home took place, and we find this noted in the records.

49. By 14 April, Mr C was fully informed of the circumstances. The GP explained the possible diagnoses on that date. Concerns about his abnormal blood results and ongoing severe pain had also been shared with Mr C by a different GP on 13 April.

50. Discussion about hospital admission was recorded on 13 April as well, with it noted that Mr C declined. We also find any entry of the paramedics’ attendance to Mr C at home on 12 April noting they offered hospital admission and Mr C declined.

51. These records are made by different individuals and show a consistent picture of Mr C’s wishes, aligning with the impression that despite knowing the possibility of a significant diagnosis, Mr C declined admission. His recorded preference for home on 14 April was in keeping with his prior recorded wishes, whether this was at his own suggestion or in agreement with the GP’s suggestion.

52. In line with the Mental Capacity Act, Mr C was rightly assumed to have capacity, and there is no evidence to suggest otherwise. His choice, as was his right, was respected on 14 April and those earlier occasions when he chose to stay at home.

53. GMC guidance advises doctors to refer a patient when needed. It also advises doctors to take account of the patient’s views and values. We are assured the evidence shows various Practice staff explained the options to Mr C and offered to refer him into secondary (hospital) care, whilst also appropriately acting in line with his views, wishes and fully informed preference to remain at home.

54. Due to this, the GP appropriately arranged a follow-up appointment for the soonest possibility after the Bank Holiday weekend. He provided appropriate safety netting, advising Mr C to attend the ED should he choose or should he worsen, giving a print-out of his recent blood results and consultations to take to hospital should that circumstance arrive before the arranged appointment. This was good clinical practice.

55. We hope to assure Mrs P we do not find any clinical urgency for Mr C to have been admitted at the 14 April appointment, nor any need for the GP to have insisted upon this or acted any differently. We do not find any evidence to suggest Mr C returning home was inappropriate and we do not find any evidence of service failure here.

EMAS and the Trust

Booking in 56. The Minimum Care Standards apply here. Standard 1 says: ‘all patients should be booked in immediately on arrival, regardless of handover delays’. We find this is reflected in the Trust’s local policy.

57. Both our paramedic adviser and our ED adviser explain the usual process of booking a patient in. They explain once the ambulance arrives outside the hospital building, one member of the crew will stay with the patient and the other will go into the ED to find the nurse in charge (NIC). That ambulance crew member will provide a verbal handover of the patient to the NIC who then has the necessary information to enter into the hospital’s electronic record system, completing the process of booking the patient in.

58. Once booked in, the patient will appear on the ED screen for the NIC to monitor, to manage the allocation of beds and the clinical management of this patient alongside any others outside waiting in ambulances. The ambulance crew member will return to the ambulance to stay with and monitor the patient.

59. The responsibility for the booking in process is therefore shared. It was EMAS’ responsibility to go into the ED and provide a verbal handover of Mr C, and the Trust’s responsibility to complete the electronic record keeping on receipt of that information. Completion of both parts of this process ensures the patient is ‘booked in’.

60. EMAS records confirm the ambulance transporting Mr C arrived outside hospital premises at 7.01pm on 16 April. EMAS records tell us Mr C remained in the ambulance, documenting his physical handover to a nurse in the ED at 1am on 18 April. The earliest Trust record we find documents Mr C arriving at 12.49am on 17 April, aligning with EMAS records of his physical handover into the ED at 1am.

61. We would not expect to find evidence of the ambulance crew member entering the ED, or of the discussion between them and the NIC. These are not actions we would expect to be documented. We would instead expect the booking in process to occur as it should, and for the entry into the electronic record system to evidence the handover having taken place.

62. As part of our investigation, we asked EMAS and the Trust for any screenshots of the arrivals screen, viewing screen, or terrafix system, all of which are referred to in their complaint responses. Both EMAS and the Trust explained these screenshots are not routinely saved at the time and cannot now be sourced from their systems.

63. We are left without evidence to show Mr C was booked into hospital when he arrived. The records made available to us show he was booked in almost six hours after his arrival by ambulance. This fell far below national guidance and the Trust’s local policy. From the evidence made available to us, we cannot know whether EMAS, the Trust, or both, failed in their respective responsibilities to complete the booking in process. We identify this as a failing of both EMAS and the Trust.

64. We have carefully considered the impact of this failing by looking further at the Minimum Care Standards. Alongside Standard 1 about the promptness of booking in, this national guidance contains clear instruction for what should happen when a patient remains held outside hospital in an ambulance. We relay the Minimum Care Standards in full below:

65. ‘All patients should be booked in immediately on arrival regardless of handover delays.

66. Every patient should have an initial assessment by a competent Trust clinician within 15 minutes of arrival regardless of whether they are in the department or waiting outside it.

67. The initial assessment must ALWAYS be performed next to the patient, NEVER by phone or via a handover.

68. After the initial assessment, further assessments by a competent Trust clinician should be performed after any deterioration and at least every 30 minutes. This will enable the receiving department’s clinical leaders to consciously balance risk and maintain patient safety.

69. If a patient’s condition deteriorates, the ambulance crew should escalate this immediately to the department they are waiting at AND to their own service. The receiving Trust is directly responsible for the care and safety of this deteriorating patient.

70. Patients held in ambulances should have regular observations (and NEWS2) performed by the ambulance crew every 30 minutes as a minimum.

71. Ambulance crews should document any and all actions, clinical interventions & communication performed by either themselves or by the acute provider until they leave.

72. If a patient is delayed in the back of an ambulance they should be physically reviewed by a Hospital Trust senior decision maker no later than 30 minutes of arrival and this should be documented in the patient’s hospital notes.’

73. Standards 2, 3, 4 and 8 are the responsibility of the Trust. We do not find any Trust documentation for Mr C prior to 12.49am on 17 April. We do have EMAS records covering the period Mr C remained in the ambulance and find nothing recorded to suggest he received any intervention from the Trust.

74. Mrs P is concerned that the failure to have booked her father in left him without the clinical reviews he should have received, and we agree. There is no evidence to show the Trust acted in line with its responsibilities under these standards, to provide the assessments or reviews it should have. We identify these as further Trust failings.

75. Standards 5, 6 and 7 are the responsibility of EMAS and we also identify these as further EMAS failings. Standard 6 refers to NEWS2, which is National Early Warning Score (NEWS) guidance. Under NEWS, a set of six physiological observations are measured and given a score. The greater the score, the more that one or several of those measured parameters varies from the normal range. NEWS is used to help improve the detection and response to clinical deterioration in adult patients.

76. EMAS records show 30-minute observations were taken in line with standard 6 by the first crew, however only three observations are documented after his care was handed over to the second crew from 8.30pm. Standard 6 was therefore not consistently met.

77. We do not find that standard 7 was met. EMAS records do contain contemporaneous, accurate and specifically detailed records of the NEWS observations taken and of information gathered when attending to Mr C at home. This included his past medical history, his back pain and many non-concerning features for example no dizziness, no shortness of breath, no confusion or abnormal gait. However, EMAS records only contain brief notation of the ambulance arriving at the Trust’s holding area and the later handover to the second crew.

78. The records do not contain any account of Mr C’s presentation for the nearly six-hour period in question. In EMAS’ response to the complaint, it says the crews recall Mr C frequently fell back to sleep in between observations, with him being alert and oriented when observations were taken. We would reasonably expect some factual comment documented to reflect these observations of Mr C’s condition at the time.

79. HCPC standards say paramedics: ‘must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to’. We do not find this nor standard 7 was adhered to.

80. We also find standard 5 was not followed. Mr C’s NEWS was 5 on the first three occasions recorded. At 7.38pm his NEWS was 6, and at 8.11pm it had risen to 7. Our Lead Clinician confirms this was a clinical indication of a deterioration and by the time his NEWS was 7, EMAS should have escalated this. There is no documentation to show EMAS escalated this to the ED or its own service, as per standard 5.

81. To summarise so far, we are left without evidence to show Mr C was booked into hospital when he arrived. We do not find either EMAS or the Trust acted in line with national guidance, to meet any of the eight Minimum Care Standards for which they both held responsibility. Whilst we can see Mr C was observed across this nearly six-hour period, he did not receive the clinical assessments, reviews or the number of observations he should have under guidance. We identify these as failings.

82. Mrs P is concerned this left her father’s signs of infection, organ failure and/or possible sepsis without the appropriate treatment. Our paramedic adviser, ED adviser, clinical adviser and Lead Clinician all confirm there were indications of infection and possible sepsis from the time of Mr C’s arrival outside hospital premises.

83. The ambulance arrived at 7.01pm, and observations taken at 7.03pm resulted in a NEWS of 5. This was due to Mr C’s low blood pressure and low oxygen saturations, two red flag indicators for sepsis. Minimum Care Standards say Mr C should have been booked in immediately and assessed by a Trust clinician within 15 minutes of his arrival. We know his NEWS at 7.38pm was also a 5 due to the same low parameters and therefore these indications would have been apparent at the assessment he should have had by 7.16pm.

84. Mr C’s blood pressure level was a high-risk criterion under the Sepsis Six, a pathway of clinical interventions recommended to take place promptly once sepsis is suspected. Additionally, during the complaints process the EMAS crew explained Mr C wanted to sleep and they observed an apparent deterioration in his functional ability. These are intermediate risk criteria under the Sepsis Six.

85. As recommended by The Sepsis Manual and NICE guidance on sepsis, this should have initiated the Sepsis Six. This recommends the appropriate treatment response as giving oxygen, intravenous (IV) antibiotics and fluids, taking bloods and close monitoring.

86. EMAS records show the ambulance crews gave Mr C oxygen and fluids and remained with him to provide close monitoring. This was appropriate treatment to his clinical presentation, in line with Sepsis Six, in line with the boundaries of the ambulance crews’ role. Paramedics and ambulance staff cannot give IV antibiotics or take bloods, as these are for clinical, Trust staff to have responsibility for.

87. We can see that whilst Mr C’s early NEWS did rise, his NEWS at 10.58pm was 1. At that time, his oxygen saturation and blood pressure levels returned to normal, showing a positive clinical response to the appropriate treatment given by EMAS. Importantly, Mr C’s temperature remained normal throughout. Our paramedic adviser explains this overarching picture did not suggest Mr C was in any way critical.

88. It remains the clinical aspects of the Sepsis Six were not initiated whilst Mr C remained in the ambulance, nor other aspects of care under Minimum Care Standards, as a direct result of the failings we identified earlier. We therefore agree with Mrs P’s concern, that her father did not receive the full extent of the treatment he should have for his presentation at that time. We will address this impact of this later, after considering the next circumstances in Mr C’s care journey.

The Trust

Treatment 89. When we look at what happened when Mr C was transferred into the ED at 12.49am, we find his clinical presentation at that time should have triggered the Trust initiating the Sepsis Six pathway.

90. NICE guidance on sepsis reflects the Sepsis Six. It says within an acute hospital setting, immediate senior clinical review should take place to assess the patient and consider alternative diagnoses to sepsis, a venous blood test should be taken, IV antibiotics given within an hour and discussion held with a consultant.

91. Records show the above actions were taken by the Trust yet were delayed. The initial triage took placed promptly at 12.53pm however lacked sufficient clinical information, with no observations, examination findings or assessments recorded. Bloods were taken at 2.51am. Mr C’s observations were noted at 3.20am and IV fluids given by the Trust at 3.45am.

92. Our ED adviser finds the first comprehensive clinical review of Mr C is documented at 6.30am. IV antibiotics are recorded as commencing at 7.25am. The first entry of a consultant’s assessment was at 8.10am and venous blood testing was first done at 10.25am. Records show significant delay in what should be a prompt and timely response, which we identify as a failing.

Impact 93. We have very carefully considered the impact of the failings, which left Mr C without the full extent of the treatment for his clinical presentation, including red flag indicators for sepsis. We know Mrs P is most concerned that this may have caused her father to die prematurely, if not avoidably, on the morning of 18 April.

94. We cannot imagine how difficult this time must have been for Mrs P and we recognise the significance of her ongoing distress, as she continues to question whether her father may not have died when he did. We know her loss is considerable, no matter our decision. We hope to provide her with the assurance that on the balance of probabilities, we do not think the very sad outcome would have been different, even if not for the delay in the full extent of Sepsis Six treatment.

95. We looked back on the full period involved in this complaint and we find Mr C was very unwell even at the point the ambulance was called. This was sadly irrespective of any subsequent delays in his care and treatment.

96. Mr C’s blood results were abnormal when reported on 8 April. He remained unwell since before these results, reporting symptoms ongoing for at least six days’ prior, if not longer. From 8 April he reported almost daily worsening symptoms, having five contacts with the Practice and one with paramedics across a nine-day period, up to the time Mrs P called an ambulance reporting a considerable deterioration. Our clinical adviser explains this is indicative of a long-standing and potentially deep-seated underlying cause for such raised inflammation/infection markers.

97. This was not indicative of an acute or immediate cause. Whilst Mr C did demonstrate two red flag indicators for sepsis, our clinical adviser explains this was not a typical sepsis picture. If Mr C did have an infection, his much earlier blood results show it had been ongoing for some time. He did not present with any other typical signs of infection, for example his temperature and heart rate remained within normal levels throughout. This was not a typical, acute, overwhelming picture of sepsis, which is when the need for antibiotic provision can be more immediately needed.

98. Our clinical adviser says Mr C’s presentation appears more related to renal failure, and bloods taken soon after his admission confirm this diagnosis. We know this forms part of Mrs P’s concern. We know it will be difficult to read but do hope to assure Mrs P this was not something we found caused, or significantly contributed to, by the failings.

99. Our clinical adviser says those blood results in hospital show Mr C’s renal failure was severe, to such an extent it would not have suddenly developed in the time since he left home in the ambulance. The severity of his renal failure indicates this will have been developing for many days, if not longer.

100. The main omission in Mr C’s treatment was antibiotic provision in a timely manner. Whilst we find other aspects were delayed, we can see he did receive fluids and monitoring in the ambulance, and further fluids, monitoring and reviews from his arrival into the ED. Other aspects of care such as blood testing is recommended to influence future reviews and monitoring. The main omission in terms of direct treatment therefore hinged on a lack of timely antibiotic treatment.

101. We think antibiotics should have been given as early as 7.16pm on 16 April and they were given at 7.25am on 17 April. These were delayed by 12 hours. We know most sepsis guidance speaks about the immediacy of giving antibiotics. The BMJ article is no different, explaining the increased percentage risk of death from every hour of delay in antibiotic administration. However, this is in the context of a patient with septic shock. This was not the case for Mr C. Whilst he presented two indicators of sepsis, and the appropriate pathway for this should have been commenced, this was not clearly apparent sepsis.

102. Evidence suggests it is very likely Mr C’s unwell state in hospital and his subsequent death was the result of a much longer process than the time between him leaving home and arriving in hospital, or even between him leaving home and receiving delayed antibiotic treatment. If any of this was potentially reversible, it is our clinical adviser’s view Mr C would have required hospital treatment much earlier than 16 April.

103. The evidence suggests that this was more of a multi-organ failure picture than a picture of acute overwhelming sepsis. Antibiotics form only one part of the treatment for this, and do not require the same level of immediate urgency as in the case of apparent sepsis. The delay in their provision as we have identified here does not suggest that, sadly, this alone would have had any significant impact on the eventual clinical outcome.

104. In conclusion, we do not find Mr C’s renal, and later multi-organ failure, was explained solely by sepsis. On the balance of probabilities, we do not see that the 12-hour delay in him receiving the full extent of the treatment in the form of antibiotics caused or significantly contributed to his sad death.

105. We recognise our decision is likely to be upsetting for Mrs P to read. The failings we have identified leaves her with the knowledge that her father should have received care and treatment sooner, and she has been left not knowing the extent of the impact. We set recommendations to remedy the injustice.

Pain relief 106. Mr C was placed onto an end-of-life care pathway on the evening of 17 April. Records show he was given analgesia including paracetamol and oxycodone, which our nursing adviser confirms are appropriate to give a person for pain on end-of-life care.

107. NICE guidance on the last days of life says medication should be prescribed in anticipation of the possibility of symptoms such as agitation, distress or pain at the end-of-life stage. It says not all people in their last days experience pain, and where it is identified it should be managed promptly and effectively, matching the medicine to the severity of pain.

108. We find evidence showing NICE guidance on the last days of life was followed in Mr C’s case. We know Mrs P had need to approach staff through the night, reporting her father appeared in pain with altered breathing. Recorded evidence shows staff did not find that clinically Mr C was presenting in pain.

109. It is not uncommon for a person reaching the end of their life to experience terminal agitation. This is a term used to describe changes in their behaviour that can be distressing for loved ones to witness but are not necessarily indications the person is in distress.

110. Our nursing adviser did not find any evidence that Mr C had uncontrolled pain symptoms. We hope to assure Mrs P we find evidence to show the Trust gave Mr C analgesia appropriately at the end-of-life stage.

Complaint handling 111. NHS Complaint Standards explain how organisations should investigate complaints. They say organisations should respond at the earliest opportunity and give clear timeframes about how long any investigation is likely to take, providing regular updates throughout the process. NHS Complaint Regulations say the organisation investigating should send the response within six months of receiving the complaint.

112. Mrs P complained to the Trust on 19 April 2022. Three months passed before the Trust wrote to Mrs P on 21 July 2022 to explain it would proceed to investigate. It took a further six months to send its response in the form of a Case Note Review (CNR) report, on 26 January 2023. This was nine months after it had received her complaint.

113. The time taken by the Trust to respond breached expectations within NHS Complaint Regulations. Had the extended time been needed for good reason, we would expect the Trust to have advised Mrs P of this and kept her updated. We do not see any evidence this occurred, as it should under NHS Complaint Standards.

114. Mrs P complains the Trust lost the audio and any documentation from the first meeting she attended. Despite asking the Trust for its full complaint file, we were not given this audio or documentation. In the absence of evidence otherwise, we accept this has been lost. This does not demonstrate good practice in complaint handling.

115. Mrs P complains the Trust made criticisms of the other organisations involved yet it failed to accommodate a coordinated response and/or meeting with those organisations to allow for their input. We agree. We find both in the CNR and at the meeting, the Trust made comments criticising the actions of both the Practice and EMAS.

116. We find the CNR set a recommendation for EMAS, despite this being a Trust-authored document and without the Trust allowing EMAS any input prior to its issue. In evidence provided to us, we can see EMAS contacted the Trust to ask for a joint meeting, as Mrs P had informed it about the Trust’s criticisms. We see evidence EMAS chased up this request and cannot see the Trust responded. Without wishing to delay its own resolution of Mrs P’s complaint, EMAS was left to proceed independently.

117. At the Trust’s meeting, we see a member of its staff criticised the actions of the Practice, without having requested input from the Practice, nor known the context of that clinical decision-making prior to presenting this strong view of wrongdoing. We have addressed this here and found no evidence of failure. This left Mrs P with a new concern which led to her raising a complaint about the Practice at this much later time, only further exacerbating her distress. This matter has only now been resolved.

118. NHS Complaint Standards say organisations should work in partnership with other organisations in the interest of patients, including when responding to complaint issues. They say organisations should give fair and accountable responses. We cannot see this was followed, as the Trust did not allow for partnership working, reaching criticisms of and setting recommendations to other organisations outside of its remit, without demonstrating fairness in its lack of liaison with those organisations beforehand.

119. Mrs P complains the recommendations set in the CNR are inadequate. The Trust sets a recommendation to EMAS for the failure to book Mr C in, without acknowledging its own role and the lack of evidence to show it acted appropriately. We consider this inadequate.

120. We see the Trust has acknowledged the need for earlier Sepsis Six treatment and set a recommendation for raising awareness of guidance. We do not consider this inadequate, yet do not find it addresses the systemic issues fully nor addresses the personal injustice to Mrs P.

121. We identify these as failings in complaint handling, and we can see how this led to avoidable distress for Mrs P during a time when she was grieving. As a result of these inadequacies, we can see how Mrs P has not been reassured by the responses given or the actions the Trust has taken in relation to what happened.

1. We shared our provisional views and considered all comments we received about its contents, before issuing this final decision.

2. We think the Practice’s decisions to prescribe morphine and naproxen with a stomach liner were appropriate. We find no evidence of apparent infection or possible sepsis at the GP appointment on 14 April nor any clinical need for the Practice to have arranged or insisted upon hospital admission at that time.

3. We do not find Mr C was booked into hospital as he should have been on 16 April. We identify this as a failing of both EMAS and the Trust. We identify further EMAS and Trust failings in the lack of adherence to national guidance, to which they each held responsibility, after the failure to book Mr C in.

4. We find this left Mr C without the full extent of the treatment he required in line with guidance, over a six-hour period. We also find the Trust delayed providing this treatment for a further six hours after Mr C was booked in.

5. We have carefully considered the impact of this against clinical evidence. On the balance of probabilities, we do not think the very sad outcome of Mr C’s death would have been any different, even if not for the delay in him receiving the full extent of treatment. It remains he was left without the treatment he should have received, and we identify this as a systemic injustice requiring remedy.

6. We think these failings have caused Mrs P a personal injustice, leaving her with the knowledge her father should have received treatment sooner, and with concerns about whether the impact was greater than we find it to have been. This requires remedy.

7. We find appropriate and adequate pain relief was given to Mr C under end-of-life care. We find a failing with the Trust’s handling of Mrs P’s complaint and consider this has only exacerbated her considerable distress, requiring remedy.

8. We have not upheld the complaint about the Practice. We have partly upheld the complaint about EMAS and the Trust, and we set recommendations to remedy the impact we identify.

EMAS

122. In considering our recommendations, we have referred to the NHS Complaint Standards. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

123. In line with this, we recommend that by 2 September 2024, EMAS should send Mrs P a letter to acknowledge the failings we have identified, and to apologise to her for the impact as set out in this report.

124. The NHS Complaint Standards say public organisations should look for continuous improvement and use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

125. In line with this, we recommend by 2 November 2024, EMAS should produce an action plan to describe what it has done or will do to improve this aspect of its care and treatment in future. The action plan should explain the learning taken from these issues, what it will do differently in future, who is responsible and how it will monitor this. EMAS should provide a copy of the action plan to Mrs P.

126. EMAS should send us evidence it has complied with our recommendations. It should also send an anonymised copy of our final report and the action plan to the Care Quality Commission (send to informationsharing@cqc.org.uk) and NHS Improvement (enquiries@improvement.nhs.uk).

The Trust

127. In considering our recommendations, we have referred to the NHS Complaint Standards. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

128. In line with this, we recommend that by 2 September 2024, the Trust should send Mrs P a letter to acknowledge the failings we have identified, and to apologise to her for the impact as set out in this report.

129. The NHS Complaint Standards say public organisations should look for continuous improvement and use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

130. In line with this, we recommend by 2 November 2024, the Trust should produce an action plan to describe what it has done or will do to improve this aspect of its care and treatment in future. The action plan should explain the learning taken from these issues, what it will do differently in future, who is responsible and how it will monitor this. The Trust should provide a copy of the action plan to Mrs P.

131. The NHS Complaint Standards say 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.

132. We consider this applies to the impact of avoidable distress caused to Mrs P because of the Trust’s poor complaint handling. 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, we recommend by 2 September 2024, the Trust should pay Mrs P £300 in recognition of the avoidable distress she experienced.

133. The Trust should send us evidence it has complied with our recommendations. It should also send an anonymised copy of our final report and the action plan to the Care Quality Commission (send to informationsharing@cqc.org.uk) and NHS Improvement (enquiries@improvement.nhs.uk).