19. Mrs D had experienced an uncommon type of stroke called a subarachnoid haemorrhage. It may be helpful at this point to provide an explanation about what this is.
20. There are two types of strokes: ischaemic strokes, which are more common and caused by a blockage in an artery in the brain (such as a blood clot), and haemorrhagic strokes, which are caused by rupture of an artery leading to bleeding in the brain. Ischaemic strokes caused by blood clots account for 85% of strokes. Haemorrhagic strokes are less common.
21. A subarachnoid haemorrhage is a haemorrhagic stroke caused by a weakness in the wall of one of the arteries which supplies the brain, causing a berry aneurysm (a bulge in a main artery which resembles a berry on a tree). When the berry aneurysm ruptures, this forces blood through the arachnoid mesh, a layer of membrane which covers the brain. This causes bleeding into the subarachnoid space around the brain. The function of the subarachnoid space, which lies under the subarachnoid mesh, is to allow cerebrospinal fluid (CSF), a clear fluid which protects the brain, to move around the brain.
22. Diagnosis of a subarachnoid haemorrhage can only be done through a CT scan of the head. If confirmed, a CT angiogram (a CT scan with dye injected into the arteries of the brain) is done to identify if there is a weakness in one of the arteries.
23. The first treatment after subarachnoid haemorrhage involves medication to minimise the inflammation caused by blood in the subarachnoid space. Some patients develop obstruction to the normal drainage pathways for CSF, which causes the fluid to build up and increase the pressure within the skull (hydrocephalus). This may need surgical treatment through insertion of a drainage tube into the fluid cavities in the brain to drain the excess fluid (external ventricular drain – EVD).
24. Around one in five patients dies in hospital from a subarachnoid haemorrhage, and this number is higher in patients where the bleeding extends into fluid cavities in the centre of the brain, as sadly happened with Mrs D.
South Western Ambulance Service NHS Trust (SWAST)
The lack of urgency in taking his wife to hospital
25. Mr D says he felt there was a lack of urgency by ambulance crew in taking his wife to hospital. We looked at what happened once the ambulance crew arrived at their home on 26 April.
26. The ambulance healthcare records show paramedics assessed Mrs D for signs of stroke using the FAST (Face, Arms, Speech, Time) test. Mrs D was recorded as FAST positive, with facial droop at 7.26pm which had resolved by 7.40pm. The ambulance crew transported Mrs D to hospital 46 minutes after arriving at her home. SWAST said in its response to the complaint this is a normal timeframe and is the average time an ambulance crew spends on the scene before transporting a patient to hospital.
27. Our paramedic adviser says JRCALC guidelines do not give expected timeframes for assessing and treating patients, although it does state patients with time critical presentations (which include acute stroke symptoms) need timely transport to hospital. JRCALC medical emergency guidelines say a primary survey must be done as soon as possible, including assessing airway, breathing, circulation, levels of consciousness and baseline observations. These were all done within five minutes of the crew arriving.
28. JRCALC stroke guidelines says patients presenting with stroke symptoms are time critical and should have a FAST (face, arms, speech, time) test in a pre-hospital environment. The guidelines add if stroke symptoms resolve within 24 hours of onset, this should be considered a Transient Ischaemic Attack (TIA, also commonly called a ‘mini-stroke’) but the patient should still be transported to hospital for investigation, which should be done according to NICE stroke guidelines (NG128) within 24 hours. As previously mentioned, the FAST test was done as part of the ambulance crew’s assessment of Mrs D.
29. Our paramedic adviser says the time spent between ambulance staff arriving at the home and transporting Mrs D under normal driving conditions to hospital was acceptable. Her stroke symptoms had resolved at that time, she was alert and her observations were stable and so her condition was not time-critical.
30. We think the ambulance crew acted in line with JRCALC and NICE guidelines in the time taken to transport Mrs D to hospital. We have not seen evidence they acted with a lack of urgency in taking Mrs D to hospital. This is not to say we dismiss Mr D’s concerns, as understandably this would have been a very worrying time for him.
The failure to recognise his wife’s symptoms as due to a brain haemorrhage rather than a more common stroke
31. Mr D says the ambulance crew failed to recognise his wife had had a brain haemorrhage, rather than a more common ischaemic stroke. Our explanations in paragraphs 19 to 24 explain a brain haemorrhage is an uncommon type of stroke.
32. SWAST told us the ambulance crew identified Mrs D was FAST positive and her symptoms appeared to resolve before they left the home. This meant a TIA was the working diagnosis for the crew. SWAST said it is not possible for ambulance crew to identify whether a patient has an ischaemic or haemorrhagic stroke as this can only be identified through a CT scan, which would need to be done in hospital.
33. JRCALC stroke guidelines say stroke is common and may be due to either cerebral infarction (ischaemic stroke) or haemorrhage (bleeding), and it is not possible to distinguish between these two types of stroke clinically. Our paramedic adviser points out the NHS website says a brain scan should be done to find out if the stroke has been caused by a blocked artery (ischaemic stroke) or burst blood vessel (haemorrhagic stroke) and this would need to be done at hospital. Our paramedic adviser adds it was appropriate for SWAST to conclude Mrs D had suffered a TIA as their working diagnosis at the time, taking into account the information recorded in the ambulance healthcare records.
34. Our neurosurgeon adviser says it is not possible to identify clinically whether a patient has bleeding causing subarachnoid haemorrhage, or a bleed into the brain itself. Taking into account the evidence we have seen, we think it would not have been possible for the ambulance crew to identify whether Mrs D’s symptoms were due to a blocked artery or a burst blood vessel, as this could only be diagnosed in hospital through a CT scan.
35. We do not see evidence of any failings in the diagnosis reached by the ambulance crew. We can see how Mr D had concerns about this, given it was later found his wife had had a brain haemorrhage. We hope our explanations reassure Mr D this diagnosis could not have been reached until after his wife arrived at hospital.
The decision to take his wife to Royal Bournemouth Hospital rather than Southampton General Hospital
36. Mr D says his wife should have been taken directly to Southampton General Hospital, which has a specialist neurosurgical unit for treating brain haemorrhages. He says Royal Bournemouth Hospital does not have those facilities and this led to a significant delay in his wife being seen by clinical staff who had the training and facilities to treat brain haemorrhages.
37. SWAST told us patients experiencing a suspected stroke or TIA should be transferred to their nearest stroke unit, which in this case was Royal Bournemouth Hospital, which has a Hyper Acute Stroke Unit (HASU). As this was the nearest hospital with both an emergency department and a stroke unit, it said this was the appropriate place to transfer Mrs D to. It told us it acknowledges its response to Mr D’s complaint did not make clear to him there was no pathway available for ambulance crew to take patients directly to Southampton General Hospital. SWAST apologised for missing out this explanation in its response to Mr D’s complaint. It recognises this could have been helpful for Mr D at the time he made his complaint, and would have explained the decision of the crew to take Mrs D to Royal Bournemouth Hospital.
38. SWAST’s explanation is in line with JRCALC stroke guidelines, which say patients presenting with stroke symptoms should be transported to the nearest hospital with a HASU as quickly as possible. Our paramedic adviser confirmed the ambulance crew’s decision to take Mrs D to the Royal Bournemouth Hospital was correct, as it was the nearest hospital with a HASU.
39. Southampton Trust explained to Mr D, in response to his concerns, services to treat subarachnoid haemorrhages are centralised across the UK to ensure patients are treated by clinicians with a lot of experience in the condition. This means most patients will be admitted to their local district hospital, receive a diagnosis there and then be transferred to a University Hospital with neurosurgery services. It said in the Wessex area there are 12 district hospitals which transfer patients when appropriate to the neurosurgery services at Southampton Trust, and this set up for specialist neurosurgery services is similar across the country.
40. Our neurosurgeon adviser says neurosurgery units do not have capacity to take all patients with bleeding into or around their brain, and only take patients who are suitable for surgery. They say patients with strokes due to either blood clots or bleeding would not normally be taken straight to a hospital with on-site neurosurgical units.
41. From what we have seen, there was no pathway in place for Mrs D to be taken directly to Southampton General Hospital by ambulance. In our view the decision to take Mrs D to Royal Bournemouth hospital, which had an emergency department and a HASU, was the correct decision. We hope this explanation provides reassurance to Mr D that this was not an option to the ambulance crew.
42. We understand why Mr D felt his wife should have been taken directly to Southampton General Hospital. It is clear Mr D remains concerned being taken first to Royal Bournemouth Hospital led to a delay in his wife receiving appropriate treatment for her brain haemorrhage. We address this concern later in this report.
The delay in handover of his wife from the ambulance to the hospital emergency department
43. Mr D is concerned there was a delay in handover of care of his wife between SWAST and UHD Trust, with poor communication between ambulance and hospital staff. Mrs D remained within the care of the ambulance crew for two hours and 46 minutes after arriving at UHD Trust.
44. Clinical records show the ambulance arrived at hospital at 8.20pm. The SWAST call log shows 20 minutes later, a delayed handover to hospital was registered and escalated to ambulance management. Our paramedic adviser pointed out this part of the handover process is the responsibility of the hospital to undertake within 15 minutes, not the ambulance provider. We look at this issue again in paragraphs 50 to 54 below.
45. The SWAST handover policy states a verbal handover should be completed with the triage nurse with the patient in the department. If there is no capacity in the hospital department, the patient can be maintained in the ambulance. If this happens, if the patient deteriorates or has a NEWS score (a scoring system based on baseline observations such as heart rate, temperature, blood pressure, with 0 meaning normal results) of over 4 this must be escalated to the emergency department triage nurse immediately.
46. Mrs D’s baseline observations were taken regularly while waiting in the ambulance, with a NEWS score between 1 and 2 and she remained alert while waiting for handover. Our paramedic adviser says this means Mrs D did not meet the threshold to escalate to the triage nurse as she was stable at the time. We can see Mrs D was managed appropriately by the ambulance crew after arrival at the hospital in line with SWAST’s handover policy.
47. NHS England’s Reducing Ambulance Handover standards say as soon as an ambulance arrives at hospital, the patient becomes the responsibility of the hospital. SWAST’s handover policy says ambulance crews should bring the patient into the hospital department unless told not to do so by the hospital ambulance liaison officer (HALO). The HALO’s role is to work with hospitals at times of high capacity to reduce handover times by co-ordinating with the hospital and ambulance staff.
48. SWAST apologised to Mr D for the length of time his wife had to wait in the ambulance. It said handovers between ambulance and hospital staff should be done within 15 minutes of arrival at the hospital, but it was currently experiencing unprecedented levels of delays in handover. It said on 26 April 2022 the average handover time for patients from its ambulances to Royal Bournemouth Hospital was one hour, with the longest handover time being three hours, 47 minutes.
49. SWAST said it had created a HALO role to communicate between ambulance crews and the nurse in charge of the Emergency Department. At the time of events it had already recognised the issue of delayed handovers and was undertaking a Patient Safety Incident Investigation (PSII). It issued its PSII report in July 2022. Specific issues looked at in this investigation included patient handover at the Emergency Department. The PSII report found SWAST was experiencing the highest levels of handover delays it had ever seen. Contributory factors included demand for emergency care exceeding Emergency Department capacity. The report set out a number of recommendations involving working with other local and national NHS organisations to improve the situation.
50. Our paramedic adviser says patients become the responsibility of the hospital at the time the ambulance arrives there, as set out in the NHS Standard Contract. They say the PSII report shows SWAST are working collaboratively with UHD Trust and other NHS organisations to reduce delays in handover. Our paramedic adviser adds delays in handover between ambulances and hospitals has been recognised by NHS England as a national system issue.
51. We have not seen evidence of failings on the part of SWAST due to the delayed handover or evidence of failings in communication. We have taken into account SWAST has recognised delayed handovers as a significant issue and is working to improve this.
52. Overall, we have not found evidence of failings in relation to the actions taken by SWAST. Mr D’s concerns are understandable, and we hope our explanations provide reassurance on the actions taken by the ambulance crew. We do not uphold Mr D’s complaint about SWAST.
University Hospitals of Dorset (UHD Trust)
The delay in handover of his wife from the ambulance to the hospital emergency department
53. After arriving at hospital Mrs D remained under care of the ambulance crew in the ambulance outside the emergency department for two hours and 46 minutes. Mr D has concerns there was poor communication between ambulance and hospital staff during this time.
54. NHS England’s Standard Contract for 2021/2022 sets out all handovers between ambulance and emergency departments must take place within 15 minutes (of arrival of the ambulance) with none waiting more than 30 minutes. Our ED adviser says this is becoming increasingly difficult due to emergency departments being overwhelmed.
55. Our ED adviser points out there is a discrepancy between the handover times recorded by the ambulance crew and the emergency department. The ambulance records show Mrs D moved to the emergency department at 11.01pm. The ED adviser explains the term ‘handover’ was used by SWAST and UHD Trust to describe slightly different processes. The emergency department used the term handover for when they received a clinical handover from the ambulance crew. The ambulance service used the term handover when the patient entered the emergency department and they were no longer required to provide direct care for the patient.
56. Our ED adviser adds patients can be seen and managed (by emergency department clinicians) in the back of an ambulance. They do not need to wait until they are inside the department to be assessed by emergency department staff.
57. We have seen evidence there was a delayed handover which is the responsibility of the hospital to manage, and as set out earlier, we have not seen evidence of failings on the part of SWAST. While UHD Trust acknowledged in its response to Mr D there was a lack of capacity in the department at the time and they had to queue patients, it says Mrs D waited in the ambulance for just over one hour before she was moved into the emergency department. From what we have seen, we do not think this is correct and we look at this further under the heading ‘UHD Trust’s response to the complaint’.
The initial misdiagnosis of his wife’s brain haemorrhage as a more common stroke, with a lack of urgency and failure to prioritise care
58. As explained earlier, a subarachnoid haemorrhage is an uncommon type of stroke caused by bleeding in the brain. Therefore, standards relating to patients with suspected stroke apply here.
59. UHD Trust uses the Manchester Triage System to prioritise patients arriving in its emergency department. The Manchester Triage System is a risk assessment tool commonly used in emergency departments in the UK and worldwide. There are five categories into which patients can be triaged, with 1 being the most urgent needing immediate medical review, 2 meaning very urgent with review within 10 minutes, 3 meaning urgent with review within one hour, 4 meaning standard with review within two hours, and 5 meaning nonurgent with review within four hours.
60. Mrs D was first seen by a doctor at 11.40pm, three hours and 20 minutes after she arrived and by a senior doctor at 00.18am on 27 April, almost four hours after her arrival. Our ED adviser says Mrs D’s presentation suggested a stroke caused by intracranial bleeding, with her history of facial droop and dysarthria (slurred speech), a sudden headache, vomiting and high blood pressure. They say she should have been triaged as 2 (very urgent) under the Manchester Triage System, meaning she should ideally have been seen by a doctor within 10 minutes. UHD Trust said Mrs D was triaged as 3, meaning she should have been reviewed by a doctor within 60 minutes.
61. Taking into account standards relating to triage and Mrs D’s presentation, we think she should have been triaged as 2 and prioritised more urgently, and been seen by a doctor, and a senior doctor, sooner.
62. NICE headache guidelines (CG150) say people with headache should be assessed and considered for further investigations and/or referral if they have sudden-onset headache reaching maximum intensity within five minutes or vomiting without other obvious cause.
63. Our ED adviser says Mrs D presented with classical symptoms of a subarachnoid haemorrhage. They say a patient presenting with a history of sudden headache with loss of consciousness at the time, vomiting, very high blood pressure and transient (short-lived) neurological findings should be considered at very high risk of a subarachnoid haemorrhage and should get a CT scan as soon as possible. They add it is good practice to record the intensity of headaches and this was not done in the emergency department, but should have been done. The ambulance healthcare records note the headache was severe, and so Mrs D should have been managed urgently.
64. We think the emergency department clinicians should have considered the possibility of a brain haemorrhage as soon as they saw Mrs D and prioritised her care more urgently. We think she should have seen a senior doctor within 10 minutes. Mrs D waited three hours and 20 minutes to be reviewed by a doctor and a further 38 minutes to see a senior doctor. We find there was a failure to prioritise Mrs D appropriately. We consider the impact of this failing further on in this report.
Delays in carrying out tests, leading to a delay in the diagnosis of brain haemorrhage
65. Mrs D had a CT scan done at 1.06am on 27 April, four hours and 46 minutes after arrival at the emergency department.
66. NICE stroke and TIA guidelines (NG128) recommend patients with suspected stroke undergo assessment and diagnosis as quickly as possible. This includes arranging CT brain imaging for early assessment of people with suspected acute stroke. It adds a CT scan should be done immediately for people with specific symptoms including ‘severe headache at onset of stroke symptoms’.
67. NICE Stroke, Subarachnoid Haemorrhage and Headache guidelines (NG228) say urgent investigation to confirm a diagnosis of subarachnoid haemorrhage is required to reduce the risk of rebleeding from a ruptured aneurysm. It says when assessing a person who presents with unexplained acute severe headache, clinicians should have a high suspicion of subarachnoid haemorrhage and take a careful history to cover the rate of onset and time to peak intensity of the headache. It says a ‘thunderclap’ headache (a sudden severe headache, typically peaking in intensity within one to five minutes) is a red flag symptom of subarachnoid haemorrhage. Other signs and symptoms of subarachnoid haemorrhage may include nausea and vomiting, signs of altered brain function (for example reduced consciousness, or focal neurological deficit, such as those causing slurring of speech, facial droop and vision changes). The guidelines say people with suspected subarachnoid haemorrhage should be reviewed urgently in the emergency department by a senior clinician and referred for an urgent non-contrast CT head scan.
68. Our ED adviser says as a patient presenting with a history of sudden headache, loss of consciousness at the time, vomiting, very high blood pressure and transient neurological findings, Mrs D should have been considered at very high risk of subarachnoid haemorrhage and given an urgent CT scan as soon as possible. They noted the intensity of the headache was not recorded in the emergency department, it and should have been.
69. The guidelines do not specify a timeframe for when the CT scan should be done, just that it is urgent. Our ED adviser says it is good practice to identify the need for a CT scan early. We think the emergency department should have identified the need for a CT scan sooner and arranged this more urgently. Mrs D was placed into the routine queue for assessment in the emergency department. We find as a result this led to a missed opportunity to carry out a CT scan and diagnose the subarachnoid haemorrhage earlier.
70. Mrs D had a classic presentation of subarachnoid haemorrhage, and it is understandable Mr D had concerns about the time taken to diagnose his wife. We think Mrs D should have been more highly prioritised at triage, seen more urgently by a doctor and a senior doctor, and had a CT scan arranged sooner. We find these to be failings in Mrs D’s care.
Impact of clinical failings found – UHD Trust
71. Once the subarachnoid haemorrhage was identified, UHD Trust’s medical team took appropriate and prompt action to refer Mrs D to the regional neurosurgical team and followed the neurosurgery team’s advice for medication and further tests until her transfer to Southampton General Hospital. In this part we consider the impact of failings in care we identified before this diagnosis was made.
72. We find there were failings in triage and prioritisation of Mrs D and a delay in carrying out an urgent CT scan. In order to understand the impact of these failings, and whether they affected the progress of Mrs D’s condition or led to her death, we sought advice from a neurosurgeon adviser.
73. Our neurosurgeon adviser explained the first line of treatment after a subarachnoid haemorrhage is to give medicines to try to reduce the inflammation caused by blood in the subarachnoid space. We can see from the records appropriate advice was given to UHD Trust’s medical team by the neurosurgical team from Southampton General hospital and implemented by the doctors. Once the diagnosis was made, doctors acted appropriately in seeking advice from neurosurgery specialists and followed their recommendations until Mrs D was transferred to Southampton hospital. We think this process could have been started earlier which would have meant she could have received medication to treat the subarachnoid haemorrhage up to four hours earlier. However, we don’t think this affected the progress of Mrs D’s illness and explain this further below.
74. As explained by our neurosurgeon adviser, some patients develop obstruction to the normal drainage pathways for cerebrospinal fluid, leading to accumulation of this fluid, causing rising pressure within the skull (hydrocephalus). This may require surgical treatment with a drainage tube inserted into the fluid cavities in the brain, to drain the fluids externally (external ventricular drain – EVD). The aim of this treatment is to ‘block’ the aneurysm so that no further bleeding (rebleeding) can occur.
75. The healthcare records from Southampton General Hospital show Mrs D was initially treated with medications. Unfortunately her condition deteriorated at 7.50pm on 27 April with ‘worsening hydrocephalus’. Mrs D had surgery to insert an EVD at 6.45am on 28 April 2022, which successfully treated her hydrocephalus. A second operation was done at 5.40pm the same day to block the aneurysm from rebleeding. Mrs D’s aneurysm was treated within 48 hours of symptoms onset and there was no indication of further bleeding while she was waiting for treatment. The neurosurgeon adviser confirms there was no indication Mrs D would need surgery until her deterioration at 7.50pm on 27 April, and an EVD was not needed before then.
76. NICE Stroke, Subarachnoid Haemorrhage and Headache guidelines (NG228) say the risk of rebleeding (into or around the brain) after a subarachnoid haemorrhage is highest in the first 24 hours after symptoms start. Our neurosurgeon adviser explains after 24 hours the risk of rebleeding declines but does not go away, with the risk of rebleeding remaining high for days after the initial bleed. They confirm from information in the healthcare records, Mrs D did not have rebleeding, and was successfully treated with surgery before any rebleeding occurred.
77. While there were delays in diagnosing the subarachnoid haemorrhage, and subsequently arranging for Mrs D’s transfer to a specialist unit for treatment, we have not seen evidence these led to any delay in surgical treatment – as there was no indication this would be needed before the evening of 27 April.
78. In addition, even if the ambulance crew had been able to transport Mrs D directly to Southampton General Hospital from her home, this would not have changed the outcome. Earlier admission to the neurosurgical service at Southampton General Hospital would not have changed the progress of her illness and Mrs D would not have had surgery sooner.
79. Southampton Trust explained to Mr D that chest infections after subarachnoid haemorrhage are very common. Firstly, when people collapse at the time of the haemorrhage, they can lose control of their airway and end up with some contents from their stomach getting into their lungs which can develop into chest infections. They can also develop chest infections whilst under anaesthetic or on a ventilator, as the lungs cannot clear themselves as well as usual. Also, people who have had a subarachnoid haemorrhage are physically weak and do not breathe or cough as well as usual. Again, this can lead to development of a chest infection. Our neurosurgeon adviser considered the explanations provided by Southampton Trust and agreed they are correct.
80. Subarachnoid haemorrhage can lead to complications such as inflammation in the body. This happens because blood which has entered the subarachnoid space from the initial bleed cannot be removed by surgery, and is reabsorbed within the body through natural processes. This takes about two weeks, during which time it continues to cause inflammation and pain around the brain, which increases the risk of complications including chest infections. Successful treatment of the aneurysm prevents further bleeding from releasing more blood into the subarachnoid space. However this does not reduce the risk of complications, due to the presence of blood already in the subarachnoid space from the initial bleed.
81. Mrs D likely developed her chest infection from a combination of the effects of subarachnoid haemorrhage causing inflammation in her body including the lungs, some time spent on a ventilator (which increases the risks of lung infections) and possible inhalation of stomach or mouth contents after the initial bleed, due to weakness in her facial muscles (at the time of the haemorrhage) affecting swallowing.
82. We can see the delay in diagnosis meant there was a delay in contacting the specialist neurosurgery team and starting medical treatment with medication. However we do not find this led to any delay surgical treatment, as there was no requirement for this before Mrs D’s deterioration in the evening of 27 April. The treatment of the aneurysm through surgery was successful. Unfortunately, while recovering from surgery, Mrs D developed a lung infection. This is a known risk of subarachnoid haemorrhage, surgery and ventilation and it could not have been predicted or prevented. Mrs D developed sepsis as a result of the lung infection and sadly died on 5 May 2022.
83. We understand from speaking with Mr D just how much his wife’s death has affected him. We hope he finds some reassurance that the failings we identified did not directly lead to his wife’s death and that this provides him with closure.
UHD Trust’s response to the complaint
84. Mr D asked us to look at the way UHD Trust responded to his complaint, with information about the time Mrs D was admitted to the emergency department being inconsistent with SWAST’s response to the complaint and his recollection of events. He also says the UHD Trust did not gather information from clinical staff who were involved in his wife’s care, and so does not feel the response is accurate. He says his wife was wheeled into the emergency department on a trolley on two occasions to use the toilet but was then moved back into the ambulance afterwards to await assessment.
85. UHD Trust says in its response Mrs D was moved into a corridor at 9.18pm and to a clinical assessment area at 10.41pm. This does not match the information in the healthcare records, which show Mrs D remained in the ambulance under care of the ambulance crew until 11.01pm, with the discharge note/transfer sheet recording her admission to the emergency department as 11.40pm, when she was first seen by a doctor.
86. We can see from the ambulance records and Mr D’s recollections Mrs D was moved into the emergency department twice to use the toilet while awaiting admission, and on each occasion she returned to the ambulance afterwards. We think the records showing Mrs D was seen in a corridor at 9.18pm were likely one of the occasions she was taken into the department to use the toilet. Both UHD Trust and SWAST healthcare records point to Mrs D remaining in the ambulance (aside from visits to the toilet) until 10.41pm, when she was moved to the assessment area, and continuing to receive care from the ambulance crew until her handover was completed at 11.01pm.
87. UHD Trust’s response on the time of admission is not consistent with the evidence we have seen. It is understandable Mr D had concerns about the explanations provided by the Trust when its response on the time of admission clearly did not match with his recollections of what happened on 26 April 2022. We consider these inconsistencies in the Trust’s response caused Mr D additional distress at a time when he was grieving for his wife and trying to come to terms with what had happened.
88. UHD Trust also said, in its response to Mr D’s complaint, the manner in which Mrs D presented on arrival at the Emergency Department meant they could not prioritise her over other patients who were waiting. We do not agree with its assertion that Mrs D could not have been prioritised more urgently than she was. Mrs D had a classic presentation of subarachnoid haemorrhage and should have been prioritised and seen urgently by a doctor shortly after arrival.
89. The NHS complaints standards say organisations should investigate complaints thoroughly and fairly. This should include making sure those involved in a complaint (including but not limited to people specifically complained about) have the opportunity to give their views. It does say where possible, staff who have not been involved in the issues complained about should look at the complaint. We consider these standards in relation to Mr D's concerns staff directly involved in his wife’s care did not contribute to UHD Trust’s investigation into his complaint.
90. Mr D complained to UHD Trust on 9 June 2022. Senior staff were asked to obtain statements from staff involved in Mrs D’s care that same month and a senior nurse in the emergency department requested statements from other nursing staff on duty at the time in August 2022.
91. The senior nurse provided a statement in August 2022. They could not recall fully from memory what happened and did not have access to Mrs D’s notes as these were missing. They said the emergency department’s ‘usual practice’ with a patient presenting as Mrs D did would be to complete a full set of observations and neuro-observations on arrival. They said the headache pathway and ROSIER scale (Recognition of Stroke in the Emergency Room, a scale used by emergency departments to assess patients who may have had a stroke) would be done. They said staff would usually contact the stroke outreach team even if symptoms had resolved. The nurse added red flags for headaches would be escalated and the patient seen as a priority.
92. We note observations were done by the ambulance service regularly from 7.11pm until 10.41pm. Observations were started by emergency department staff at 8.30pm, with the next observations taken by them at 10.40pm. The emergency observation sheet says neuroobservations were not completed – this was not done until 8.50am on 27 April 2022 (shortly before Mrs D was transferred to Southampton hospital). There is no mention of headache pathway or ROSIER score in the healthcare records that we could see. It appears to us Mrs D was not managed in line with UHD Trust’s usual pathway for patients presenting with her symptoms. This information from the nurse’s statement was not included in UHD Trust’s response to Mr D and contradicts its assertion that Mrs D could not be prioritised.
93. A request was made to the senior emergency department consultant requesting review on 30 September 2022 (three months after initial requests were made for staff statements). This consultant had not been involved in Mrs D’s care and treatment and did not have access to her full medical records. The consultant pointed out if this request had been made months earlier a more reflective response would have been possible and clinicians involved would more likely have remembered the patient. The consultant provided a narrative based on what information he could access from the available healthcare records which were incomplete.
94. UHD Trust told us these were the only two statements obtained and it had not obtained statements from any other staff in relation to this. It adds staff were asked in a timely manner for statements, and timings it used in its response were based on the emergency department records. It said there was no reason to question the accuracy of those records and as SWAST were doing their own investigation, there was no reason to suggest timings would be different between the two Trusts’ responses. It acknowledges its response was delayed due to missing notes, but it completed additional investigations using notes from Southampton General Hospital.
95. Although it appears statements were requested from two nurses on duty in the emergency department that night, these were not provided. There is no evidence the doctors who treated Mrs D in the emergency department were asked to provide statements about what had happened. UHD Trust has not explained why it did not chase up statements from the nurses involved or ask for statements from the doctors involved in Mrs D’s care.
96. We have seen several references within the complaints file from clinical staff stating Mrs D’s e-records were not available. We can see the Trust’s response to Mr D’s complaint was not completed until they had got a copy of the emergency department records from Southampton Trust. This would have been a copy of the notes UHD Trust sent to Southampton General hospital when Mrs D’s transfer was arranged.
97. UHD Trust told us there was no reason to question its own emergency department records for Mrs D, while acknowledging that relevant records were missing and it had to rely on information provided by Southampton Trust in order to complete its response. We think UHD Trust could have asked Southampton Trust for a copy of the shared healthcare notes sooner, once staff involved in investigating the complaint realised Mrs D’s records were missing.
98. We cannot see any evidence the Trust obtained a copy of the ambulance healthcare records for 26 April 2022. Had it done so, it would have had more accurate information about what had happened that night and Mrs D’s presentation and symptoms after she arrived at hospital. This may have reduced or prevented the inaccuracies and discrepancies in its response to Mr D. We also think UHD Trust would have provided a more accurate and evidence-based response if it had obtained statements from nursing and medical staff who were on duty on that night.
99. We have seen failings in the way UHD Trust investigated and responded to Mr D’s complaint. These led to its response to Mr D’s concerns being inaccurate and inconsistent with information within its own and SWAST’s healthcare records. We think these failings caused Mr D additional distress at a time when he was grieving for his wife, and caused more uncertainty about whether things had gone wrong with his wife’s care.
Conclusion
100. We have not found failings in relation to the actions taken by SWAST ambulance crew on 26 April 2022. We do not uphold Mr D’s complaint about SWAST.
101. We have seen failings in the aspects of clinical care and treatment provided to Mrs D in the emergency department, and in the way UHD Trust investigated and responded to Mr D’s complaint. We find these failings led to a delay in diagnosis and treatment of a subarachnoid haemorrhage and caused additional distress and uncertainty to Mr D. We uphold Mr D’s complaint about UHD Trust.