North West Ambulance Service NHS Trust

9. Miss R complains the Trust failed to deliver CPR for 11 minutes when her sister Miss A was in peri-arrest on 13 May 2021. Peri-arrest is the time before a full cardiac arrest.

10. Miss R says knowing her sister did not receive the care she should have has been extremely distressing for her and her family. She has told us she thinks if the Trust had provided the correct care to Miss A, she could have survived and knowing this is heart breaking.

11. Miss R complains the Trust did not comply with the recommendations the CCG made in its review of the Trust’s Serious Incident Investigation.

12. Miss R has told us how devastating it has been to lose her sister and how the Trust handled the investigation and did not comply with the CCG’s recommendations exacerbated this grief. She says she has lost faith in the Trust and is concerned it has not learnt from the poor care it provided to her sister when she was critically ill.

13. Miss R would like an acknowledgement of failings and the impact they had on Miss A, service improvements, an apology for the suffering her family has endured and a financial remedy.

14. On 12 May 2021 at 6.34pm Miss A called a 111 service. She complained of pain and swelling in her right leg. She asked to speak with a GP.

15. At 10.24pm the 111 service called her back to apologise for the delay as she had not received the GP call back.

16. At 12.24am on 13 May, a GP contacted Miss A and took a detailed history noting she had the symptoms for two weeks which were now worse. They decided she needed to be seen face to face. Miss A confirmed she would make her own way to hospital and an appointment was made for 1am.

17. At 12.55am the Trust received a 999 call from a bystander who had found Miss A in her car on the way to the appointment. It dispatched an ambulance which arrived at 12.59am.

18. The paramedic carried out an electrocardiogram (ECG) at 1.06am. This is a test which records the electrical activity of the heart, including the rate and the rhythm. This showed Miss A’s heart rate was 30 beats per minute (bpm). A normal heart rate is between 60 and 100 bpm. A heart rate this low is called a bradycardic heart rate.

19. The paramedic sent a pre-alert to hospital reporting that Miss A was in peri-arrest and their expected time of arrival would be 15 minutes.

20. A rapid response vehicle (RRV) arrived at 1.15am. The RRV paramedic recognised Miss A was in cardiac arrest and she required CPR. The RRV paramedic started Advanced Life Support (ALS) and CPR was started at 1.19am.

21. The ambulance transferred Miss A to hospital at 1.40am and she very sadly died at 2.16am.

22. On 21 September the Trust issued it Serious Incident Investigation report.

23. 1 February 2022 Miss R complained to the CCG about how the Trust investigated her sister’s care.

24. 20 May 2022 the CCG issued its report.

CPR

28. The Trust said when the paramedic arrived following the 999 call, they did an initial check of Miss A’s pulse but could not find it. They suspected she had no pulse. The paramedic then moved her from her car into an ambulance.

29. At 1.06am the ECG showed Miss A had a bradycardic heart rate.

30. At 1.10am the paramedic decided to take Miss A to the nearest Emergency Department (ED).

31. At 1.11am the ECG showed a change, and that Miss A was in PEA. When this happens, the heart’s electrical activity is too weak to make the heart pump which causes the heart to stop. When the heart stops this is known as a cardiac arrest. The Trust investigation response says the paramedic said it was at this point they recognised she was in PEA and started CPR.

32. We have looked at the medical records and they indicate from the ECG that CPR did not take place until 1.19am. This is after the RRV had arrived. The Trust said there is evidence there was a delay in administering CPR.

33. JRCALC guidance says if the patient is not breathing normally:

● it may be difficult to be certain that there is no pulse ● if there are no signs of life (lack of movement, normal breathing, or coughing), or there is doubt, start chest compressions at a rate of 100 compressions per minute.

34. We sought clinical advice from a paramedic adviser to help us understand what should have happened when the paramedic arrived with Miss A. Our paramedic adviser said they should have assessed Miss A to check if she was responsive and then using the ABC approach, assess her airway. ABC stands for air, breathing, circulation.

35. Our paramedic adviser explained that while it is relatively easy to establish whether a person is breathing, it can be more difficult determine if there is a pulse. However, JRCALC guidelines says if a paramedic is in doubt if someone has a pulse, they should start chest compressions (CPR) immediately.

36. Taking this into account, we consider the paramedic should have started chest compressions as soon as they arrived with Miss A and could not feel her pulse. This is supported by the JRCALC guidance and the advice we have received. This did not happen; we find this to be a failing.

Impact

37. Miss R says knowing her sister did not receive the care she should have has been extremely distressing for her and her family. She has told us that she thinks if the Trust had provided the correct care to Miss A she could have survived and knowing this is heart breaking.

38. We have sought advice from a cardiology adviser to help us understand what would have happened had the failing we have identified not occurred. Our cardiology adviser told us that generally speaking, there is a very low survival rate for people who suffer from cardiac arrests out of hospital.

39. We know from the available evidence that Miss A was responsive when the ambulance was arriving as we can hear her talking on the 999 call recording.

40. Our cardiology adviser explained at this point, as Miss A was responding, she would have still been breathing. We therefore think on balance she arrested when the paramedics were with her. Our cardiology adviser also said the paramedics noted there was ‘no cyanosis’. This is when the skin or lips appear to be blue or grey, this happens when there is not enough oxygen in the blood. Our cardiology adviser explained this gives weight to the view that Miss A had been breathing when the paramedics first arrived.

41. We have carefully considered whether we can reach a view on if the failing we identified meant Miss A’s death was avoidable as Miss R suggested.

42. Miss A suffered from a pulmonary embolism (PE). This is when a blood clot gets stuck in an artery in the lung, blocking blood flow. Blood clots most often start in the legs and travel up to the lungs, as was the case for Miss A. Our cardiology adviser explained there is overall a poor survival rate for non-cardiac causes of cardiac arrest, such as a PE.

43. Our cardiology adviser highlighted a study (study 1) which explains the survival rate in a PEA cardiac arrest is sadly very low, the 30 day survival rate is 4-7% with early resuscitation.

44. Our cardiology adviser highlighted another study (study 2) which emphasises the importance of timely CPR. The study shows that for every minute CPR is delayed, chances for survival decreases by 4.4% in PEA cardiac arrests.

45. Our cardiology adviser highlighted the patients used in this study were not representative of Miss A’s circumstances as the median age is 77. They explained there are no studies which directly represent the circumstance of Miss A’s cardiac arrest.

46. NICE guidance on out of hospital cardiac arrests says that fewer than one in ten people survive cardiac arrest outside of a hospital. It says two of the most important factors which influence survival include the time between cardiac arrest and attempted CPR, and early defibrillation. Defibrillation is when an electric shock is used to restore a stable heart rhythm.

47. In this case Miss A had a PEA, this is non-shockable rhythm and therefore defibrillation is not a viable treatment.

48. The NICE guidance also says people who are found in PEA or asystole have the lowest chance of survival. Asystole is a type of cardiac arrest, which is when the heart has stopped beating.

49. We have seen the overall survival rate of an out of hospital cardiac arrest with PEA is sadly very low.

50. In Miss A’s case it is not clear from the records exactly what time the paramedic failed to feel Miss A’s pulse, which is when they should have started CPR. This means we cannot be precise about the number of minutes delay in starting CPR. If the delay was 11 minutes as the Trust’s Serious Incident Investigation report has said, then based on our clinical advice the likely survival rate of 4-7% was reduced by approximately half by the delay.

51. Taking this into account, we consider it more likely than not that Miss A would sadly still have died had CPR started when it should have.

52. While we have not been able to say Miss A would have survived had she received appropriate care, the Trust’s delayed treatment did reduce Miss A’s likely chance of survival. This causes a degree of avoidable uncertainty about what may have been different for Miss A had she received the correct care. Miss R has told us this is understandably a source on ongoing distress for her and her family.

53. Miss R has told us how knowing her sister received poor care has caused her and her family to question whether Miss A could have survived, and this has meant they have not been able to grieve. She has told us this is something they will have to live with for the rest of their lives.

54. We do not underestimate the distress this finding will cause Miss R and her family. She has told us she has had outstanding concerns and questions about the care Miss A received and we hope our work helps to answer these for her.

CCG recommendations

55. The CCG completed a report into Miss R’s concerns about how the Trust completed a Serious Incident Investigation and enacted Duty of Candour. As a result of this investigation the CCG made several recommendations for the Trust. Miss R complains the Trust did not comply with these recommendations.

Recommendation 1: Duty of Candour

56. The CCG’s report says the Trust failed to correctly apply Duty of Candour. This is a legal duty for health and care professionals to be open and transparent when things go wrong. The CCG recommended the Trust should review its compliance mechanisms to ensure this does not happen again.

57. The Trust has told us that in 2021 it carried out a full review into its statutory Duty of Candour. It identified a number of areas where it could improve to ensure compliance but also improve the quality of its engagement with patients and families.

58. Our NHS Complaint Standards say an effective complaint system demonstrates an organisation’s commitment to promoting a just and learning culture that is open and accountable when mistakes occur and uses learning to improve its services.

59. We consider since the time of Miss R’s complaint to the CCG, the Trust has made significant learning in how complies with the Duty of Candour. The Trust has told us about a number of actions it has taken to improve its services to ensure compliance with Duty of Candour. We find the Trust has complied with recommendation 1. We have not seen evidence this information has been shared with Miss R to assure her the recommendations were complied with.

Recommendation 2: future training

60. The CCG recommended the Trust should learn from Miss R’s experience and how its interaction with her had a significant impact on her mental health. The CCG said this should be used in future training of all staff involved in Duty of Candour as a reminder of real-world consequences of failure to follow procedure. In its cover the letter the CCG said this learning should be referred to in Miss A’s name.

61. The Trust explained in its response letter that Miss R’s family have been instrumental in driving system change in how the Trust enacts and monitors compliance with Duty of Candour. The Trust explained it would like to understand how their experience impacted on them as an example case study to be shared with colleagues during training and to generate conversations on how they will learn from this further.

62. As part of our work, we asked the Trust whether it had complied with this recommendation. It has said it does use case studies during training but at this point Miss R’s experience is not one of them. It said it did consider the CCG’s recommendation but thought at the time it was inappropriate to approach Miss R and her family as it felt it would cause them further distress.

63. Miss R has told us how important it is to her and her family that this training is done in Miss A’s name. She has explained this is especially important to her as Miss A worked in the NHS and took great pride in her work and the impact she had on people’s lives. Miss R has told us how upsetting it has been knowing the Trust has not done this.

64. Our NHS Complaint Standards say that when something has gone wrong, organisations should make sure staff can ‘identify suitable and appropriate ways to put things right for people’. When providing a remedy, the organisation is not just putting things right for the person concerned, but staff should also think about how they can improve their wider services.

65. We have not seen evidence the Trust complied with the CCG’s recommendation 2 here or put things right for Miss R. We find this to be a failing.

Recommendation 3: joint investigations

66. The CCG recommended the Trust reflect on the stressful effect their early interactions had on Miss R and that a joint investigation which included all the organisations involved in Miss A’s care, with a single point of contact would have improved her experience. The CCG said the Trust should actively seek to find and involve other organisations early when a serious incident has occurred.

67. The CCG has said in 2021 the senior patient safety manager completed a master’s degree, and it has provided evidence to us to show the changes that were made to ensure investigations are collaborative.

68. The Trust has acknowledged the importance of ensuring joint investigations are carried out and the impact not doing so has on complainants. It has explained what actions it has taken to learn from Miss R’s experience. We find the Trust has complied with this recommendation and this is in line with our NHS Complaint Standards. We have not seen evidence the Trust has shared this information with Miss R to assure her it has complied with this recommendation.

Recommendation 4: apology

69. In the CCG’s cover letter, it explained it would make it clear to the Trust that Miss R did not feel the Trust had apologised to her about how it handled the investigation or how this affected her and her family. The CCG said it would ask the CEO to consider how they might help her move forward.

70. The Trust has provided us with copies of two letters sent to Miss R following a meeting held at the Trust to discuss the investigation. In these letters it explains two executive directors and a consultant paramedic were in attendance and it had taken the meeting seriously.

71. Our NHS Complaint Standards say that when something has gone wrong, organisations should make sure staff can ‘identify suitable and appropriate ways to put things right for people’.

72. We have not seen evidence in either of the Trust’s letters that it apologised to Miss R or her family for how the Duty of Candour was enacted, or their experience of the Serious Incident Investigation process. This is not in line with our NHS Complaint Standards and we find the failure to comply with the recommendation to be a failing.

73. Miss R has told us how upsetting it has been for the Trust not to comply with the recommendations the CCG made. Miss R told us the way the Trust enacted Duty of Candour, and the Serious Incident Investigation affected her mental health and has caused great distress to her and her family. She has told us how deeply they have felt Miss A’s loss and how the Trust’s investigations and how it responded to the CCG’s investigation has exacerbated this.

1. Miss R complains about the care and treatment provided by the Trust to her sister, Miss A, in the early hours of 13 May 2021. Miss A very sadly died the same morning. We extend our sincere condolences to Miss R and her family. We recognise these events continue to cause significant upset and deep distress.

2. We have carefully considered Miss R’s concerns about the care the Trust provided to Miss A. We identified it failed to carry out cardiopulmonary resuscitation (CPR) when it should have.

3. We have found the Trust’s failure to provide timely CPR meant there was a missed opportunity for Miss A to receive appropriate care. On balance, we do not believe Miss A would have survived if she had CPR when she should have. This is because of the poor overall survival rates for people who suffer from Pulseless Electrical Activity (PEA) cardiac arrest which was the type Miss A had.

4. We do however consider this failing caused Miss R and her family to question if things could have been different had Miss A received the care she should have. This is an ongoing source of distress for Miss R.

5. We have found the Trust has complied with the Clinical Commissioning Group’s (CCG) recommendations around Duty of Candour and joint investigations. We have not seen evidence the Trust has shared the detail of the actions it has taken with Miss R to assure her it has complied with these recommendations.

6. We have also not seen evidence the Trust has complied with the CCG’s recommendations to deliver learning in Miss A’s name, or that the Trust’s chief executive officer (CEO) has considered how they could help Miss R move forward, to apologise to her for how it handled the investigation or enacted Duty of Candour.

7. We partly uphold this complaint. We recommend the Trust writes to Miss R to acknowledge and apologise for the failings we have identified, to comply with all the CCG’s recommendations, and to explain to Miss R the actions it has taken. We ask the Trust to identify the reasons why it did not comply with the CCG’s recommendations and creates an action plan detailing what actions it will take to help prevent similar occurrences in the future.

8. We also recommend it pays her £3,125 in acknowledgement of the deep distress caused to Miss R and her family.

74. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

75. In line with this, we ask the Trust to write to Miss R within four weeks of this our final report to acknowledge what went wrong and apologise for the impact this had on her. We also ask the Trust to comply with the CCG’s recommendations (recommendations 2 and 4) and write to her to explain what actions it has taken to comply with the recommendations 1 and 3.

76. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

77. As part of the Trust’s investigation, it identified the reason the failings in care occurred and developed an action plan of improvements. The Trust’s investigation identified the paramedic who treated Miss A was newly qualified, they had become focussed on a specific symptom and missed clear signs of a PEA. It identified this could have been the first time the paramedic had led a resuscitation. As a result, the Trust created an individual plan for the paramedic involved in Miss A’s care which involved further training and mentoring by more experienced paramedics. It discussed the incident at a learning forum focussing on staff welfare.

78. The Trust also identified that the paramedic involved in Miss A’s care had been working overtime. As a result, it amended its policy so that newly qualified paramedics must not work overtime or rostered shifts as a paramedic until they have completed the induction and supernumerary phase. The Trust has also shared information to all student paramedics regarding their responsibility to escalate if their planned mentor is no longer available on any given shift. It has also explained that operation managers now receive regular reports on staff who work over 80 hours of overtime per month, to prevent risk of fatigue.

79. We find the Trust has taken sufficient service improvements to ensure newly qualified paramedics are given increased support and have completed all relevant training. It has also taken action to ensure staff who work increased overtime hours are monitored.

80. We ask the Trust to identify the reasons why it did not comply with the CCG’s recommendations and creates an action plan detailing what actions it will take to help prevent similar occurrences in the future.

81. The action plan should say who is responsible for each action, when it will be completed and how the impact of the actions is being monitored. The Trust should complete this within 12 weeks of the date of this report and share a copy of it with us, Miss R, the Care Quality Commission and NHS England.

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

83. 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 within four weeks of this report the Trust pay Miss R £3,125 in recognition of the deep distress caused to her and her family.

Conclusion

84. Very sadly nothing can change the distressing events surrounding Miss A’s death. We hope Miss R can take some comfort from our investigation and the actions we have asked the Trust to complete to remedy her personal injustice.

85. We do not underestimate how difficult it has been for Miss R to raise this complaint and to share her experience with us. We are very grateful to her for bringing this complaint to our attention.