NWAS 12.When Mr Q complained to it NWAS accepted there had been an error in handling the 999 call which had caused a delay (of approximately 1 hour and fifteen minutes) in the ambulance arriving and Mrs W’s admission to hospital.
13.The Trust apologised to Mr Q for what had happened. It explained to him why it had happened. It also explained what steps it had taken, both with the individual call handler involved and organisation-wide, to try to improve its services to make it less likely the same thing would happen again to anyone else.
14.Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation involved has already done enough to try put things right. In this case, we think it has, via the service improvements made, the apology offered, and the explanations already provided.
15.We do not condone the error that was made. We sympathise with Mr Q and his family and we do understand their dissatisfaction with the poor service Mrs W received on 7 April 2022.
16.Nothing can change what happened, but we think NWAS did all it reasonably could after the event to demonstrate it had tried to learn from it, to improve, and that it fully acknowledged and apologised to Mr Q, in a transparent way, for what it got wrong.
17.In terms of the information NWAS shared with Mr Q about the call handler, we do not think NWAS did anything wrong. It explained that action and been taken to help the call handler improve their performance and, later, confirmed the person had left the organisation. It also explained, correctly in our view, that it could not share any further personal information, or information about the individual’s employment, with Mr Q.
18.NWAS sent its first written response to Mr Q complaint on 20 December 2022. It accepted it had ‘taken longer than it should have’ to investigate his complaint and recognised the ‘additional stress’ this can cause. It said it was ‘working hard to provide more timely responses to patients and families’.
19.We realise it can be frustrating and upsetting waiting for a reply to a complaint. We sympathise with Mr Q for the wait he describes. We think NWAS’s response acknowledged that negative impact appropriately and that, at that stage, there was nothing else NWAS could reasonably do to try to resolve things but to accept it should have done better and promise to do what it could to improve.
20.We are completely independent of the NHS and play no part in its day to day running. We are not able to tell NHS organisations how to configure their services or spend their money. We do not make NHS policy or allocate resources, locally or nationally. We cannot help Mr Q in the way that he wants, by examining and taking a view on NWAS’s past and present Forward Planning and whether it has done enough/is doing enough to ensure it is properly organised and resourced to meet the (changing) demands of the local population.
The Trust 21.The Trust told Mr Q in December 2022 that antibiotics were administered within 20 minutes of Mrs W’s arrival in ED and expressed the view that ‘the administration of antibiotics one or two hours earlier would not have made a difference’.
22.The Trust, after a further review, told Mr Q on 17 February 2023:
‘on review of the case, x concurs with the conclusion of her medical examiner colleague that, given your mother was significantly unwell, the ambulance delay is unlikely to have made a difference to the sad outcome’
23.The delay in Mrs W arriving at hospital was not the Trust’s fault. In answering Mr Q’s question about the impact of that delay, the Trust was not commenting on a complaint about the care it had provided. It was commenting on whether its ability to provide effective care to Mrs W had been compromised by her delayed arrival at hospital. Mr Q’s complaint to us was about the opinion/s expressed by the Trust that arriving earlier, and commencing treatment earlier, would not, in the Trust’s opinion, have changed the outcome for Mrs W.
24.The Trust shared its opinion with Mr Q, having been invited by him to do so, and having first obtained the views of various suitably qualified clinicians. The opinion expressed does not seem unreasonable to us, or incompatible with the clinical evidence. We have seen no indications that the opinion expressed by the Trust was demonstrably ‘wrong’, or that it was reached without first properly considering the facts and obtaining expert clinical advice.
25.Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that the Trust did anything wrong by reaching the view it did and sharing that view with Mr Q in the way it did. We think it unlikely that we would be able to reach a different, definitive conclusion to the Trust were we to consider this further.
26.We understand Mr Q’s concern and accept that he had a different view to the Trust. He was entitled to his opinion, and we respect his opinion. The Trust could only tell him what it thought, which was different. The Trust was entitled to its view too, and we have seen nothing to indicate that the clinical view it reached was unreasonable.
27.Regarding Mr Q’s complaint about the Trust’s approach to Forward Planning, the comments we have made about NWAS in para 20 apply equally to the Trust. We cannot help Mr Q in the way he would like.
The Practice 28.We established with Mr Q that he had so far not complained directly to the Practice and given it the chance to respond formally to his concerns. As we are the last stage of the NHS complaints process and expect all efforts to resolve things locally to have been exhausted before getting involved, we have explained to Mr Q that we are not able to consider this aspect of his complaint further for the time being.