London Ambulance Service NHS Trust

6. Miss T complains about ​the Trust’s​ response to her requests for help on 27 January 2022 when she contacted 111 (a non-emergency service for advice and support) and 999 (an emergency service for life-threatening conditions). Specifically, she says 111 incorrectly categorised the ambulance response as ‘category two’ on two occasions. Miss T says this was in part because the clinical specialist on the video call dismissed her son’s symptoms without taking account of his Asperger’ syndrome.

7. Miss T says the ambulance took too long to arrive despite the Trust agreeing her son was acutely unwell. She says had an ambulance arrived sooner, clinical staff (either ambulance staff or hospital staff) would have been with her son to prevent his cardiac arrest or provide expert CPR (an emergency procedure involving chest compressions often combined with artificial ventilation in an effort to preserve brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest). Miss T says she believes this would have saved her son’s life.

8. Miss T wants the Trust to acknowledge its failings, apologise and make service improvements.

9. Mr T (age 29) lived at home with his mother and his stepfather. The family say he was diagnosed with Asperger’s syndrome, which is a former diagnostic term for some autistic people. Autism is a complex developmental condition that affects how people interact, communicate, learn, and behave. Mr T also had a learning disability.

10. Mr T had been feeling unwell over the weekend of 22 and 23 January 2022 with cold symptoms which worsened over the next few days. Miss T had sought some initial advice from 111 on 24 January and was advised to give Mr T paracetamol and ibuprofen to help manage his temperature.

11. Mr T continued to decline and began to have lower back pain and difficulties breathing.

12. At around 10.15am on Thursday 27 January, Mr T’s stepfather called 111 again to report Mr T was struggling to breath and was unresponsive. Following an assessment, the call handler concluded Mr T needed an ambulance, and a request was passed to the ambulance service at 10.18am.

13. At that time the ambulance service was at Clinical Safety Plan (CSP) level orange, this means ambulances would not be sent for and calls and protocols were in place to manage the demand on the service.

14. The Trust had also activated resource escalation action plan (REAP) level 3, which is activated when there is major pressure on the service. At around that time, the service had ten calls of the same category all waiting for an ambulance to be dispatched to them, but no ambulances available.

15. At 10.57am, as an ambulance had not yet become available, a clinical specialist from the Trust called Mr T’s stepfather back to assess Mr T in a video call. The assessment was completed by around 11.05am.

16. Around ten minutes later, Mr T’s stepfather called 999 as Mr T had lost consciousness and stopped breathing. The Trust dispatched an emergency response immediately. The first responder arrived on scene within seven minutes.

17. Very sadly, despite CPR attempts, the crew was unable to revive Mr T, and he did not survive.

First call – 10.15am - call handler

21. Miss T’s initial call to NHS 111 was triaged by a call handler using ‘NHS Pathways’. This is a triage system designed by consultants and specialists, and the non-clinical call handlers will ask a series of questions as prompted by the system. Each response to the questions prompts the next series of questions. When all the relevant questions have been answered, the system will automatically send details to 999 to dispatch an ambulance, if that is what is needed.

22. During the call, Miss T told the call handler that Mr T was fighting for his breath, making a gurgling sound, and was unable to talk in full sentences and had been struggling since Monday (24 January). The call handler completed the triage questions, and this concluded that Mr T needed an emergency ambulance. This was allocated a category two response time and passed to the emergency dispatch team at 10:18am.

23. To explain, a category one response is generally defined as a life-threatening condition such as cardiac arrest or respiratory arrest and requires immediate intervention otherwise the individual will die. The next category below this, category two is for emergency calls that require transfer to hospital, such as severe burns, epilepsy and strokes.

24. Our adviser told us that the call was triaged and categorised as a category two call appropriately because Mr T was alert and had difficulty breathing. Someone who is alert and breathing would not be in the same category as someone with a cardiac arrest (which would be category one).

25. Our adviser explains the correct questions were asked, as the call handler queried what the problem was, identified Mr T was having breathing difficulties and asked to speak to him. It is considered good practice to try to carry out the triage directly with the patient. By speaking to Mr T, the call handler was able to establish that Mr T was awake and was able to speak as he answered ‘hi’ when the call handler said ‘hi [Mr T]’.

26. The above interaction with Mr T addressed the initial checks, which are to identify if the patient is having an immediate life-threatening presentation. The initial questions are designed to understand if the patient is in cardiac arrest, pre-arrest, choking or currently fitting. Mr T’s presentation did not include any of these concerns at the time of this call.

27. The next series of questions identified that Mr T was not experiencing heavy bleeding, but that he was fighting for breath. The ‘NHS Pathways’ system then determined that Mr T’ presentation needed a category two response.

28. Overall, we consider the call handler’s triage was in line with the ‘NHS Pathways’ system. We have seen appropriate questions were asked and that this led to an appropriate outcome of a category two response.

Second call – 10.57am - clinical specialist

29. At 10.57am, an ambulance had not yet become available due to an increased demand for patients assessed as higher priority emergencies. Therefore, a clinical specialist from the Trust called Mr T’s stepfather back to assess Mr T in a video call.

30. The clinical specialist used the Manchester Triage System (MTS) for the triage on the second call. This is a well-known and leading triage system in Europe and is also used worldwide. It has flowcharts to help aid decision making on how quickly a patient needs to be seen and is used by a number of ambulance services.

31. The clinical specialist maintained the response time as category two as Mr T remained short of breath and was still awake.

32. The Trust’s response says ‘they [the clinical specialist] confirmed that [Mr T] could sit up and it is reported that he was “a bit unresponsive and yellow in the face and a bit blue around the chin area” and that he had chest pain’. During the call, it was also confirmed that the main problem was difficulties with breathing, and this had been the same since Monday. Mr T also had back pain, was in a cold sweat and had a temperature as high as 40 degrees Celsius. The clinical specialist identified that an ambulance would be required.

33. Our adviser told us the clinical specialist should be considering whether there are any ‘red flags’ at the start of the call. There is a priority list which enabled the clinical specialist to filter presentations by priority, red being the highest priority. The questions asked will help to categorise the presentations or symptoms based on the severity of the patient’s condition. For example, is the patient breathing and alert? When this question was asked by the clinical specialist, a red flag was raised for the shortness of breath, which was the correct outcome. The clinical specialist did acknowledge that Mr T had autism and documented this in their clinical triage review notes.

34. We can see from the records the clinical specialist did not get very far into the questions because there was no point asking any further questions as the red flag had been identified early on in the call. It was also good practice that the clinical specialist used ‘Good Sam.’ This is a videoing service, which helps with assessing a patient’s physical condition or symptoms. It was useful to use this in Mr T’s situation as it is uncommon for someone at age 29 to have new breathing problems. The videoing service meant Mr T’s physical presentation could be assessed by the clinical specialist.

35. Overall, we consider the clinical specialist’s review of Mr T and keeping the categorisation as category two was appropriate and in line with the MTS guidance.

Ambulance response time

36. At the time of the incident, a category two response meant a response time of 18 minutes on average, and at least 90% of these responses should be within 40 minutes.

37. In Mr T’s case, this meant an ambulance should have arrived at the scene by 10.36am, to meet the average response time of 18 minutes following the request at 10.18am call, or by 10:58 to meet the 90% of cases within 40 minutes. The first responding vehicles reached the scene at 11:23am and 11:24am. The response time was therefore outside of the timescales for a category two response.

38. The Trust explained it was operating under ‘severe pressure’ on the date of Miss T call. This was indicated by the fact it was operating at CSP orange and REAP level 3 (please see the explanation in background section above). The Trust explains at this particular time, it was holding a number of category two calls (on average 10.2 calls) and was experiencing significant hospital delays as a result of ambulances awaiting handover.

39. The evidence we have seen so far suggests both calls were appropriately triaged and categorised as category two, but the Trust did not have the resources to dispatch the ambulance within the category two response times. At present we consider the Trust took appropriate action in these circumstances in dispatching an ambulance as soon as possible. We appreciate the distress this caused, particularly given Mr T age and vulnerability.

40. Unfortunately, if there is an unexpected significant rise in the number of calls or the reduction in resources, this can impact response times, which happened in this situation. Ambulance services have finite resources and cannot guarantee a response within the target times. The evidence we have seen so far indicates the resources were managed appropriately and the Trust did recognise how unwell Mr T was. This is demonstrated by the fact that a clinical specialist called back to check on Mr T. As such, we consider the unfortunate delay was not due to a failure in the Trust’s service to Mr T.

Conclusion

41. We recognise the ongoing impact and distress that the events have on Miss T and her family. We hope that our report has provided some clarification on the systems used to triage the call, how they work and why we consider that the calls were appropriately categorised in line with the guidance.

1. Miss T brings a complaint to us about the actions of the Trust when she contacted them in relation to her son, Mr T, who was experiencing breathing difficulties. Miss T feels the Trust did not correctly prioritise her call and did not take into account Mr T’s Asperger’s syndrome (a neurodevelopment disability that affects the ability to effectively interact and communicate with people) when assessing him by video call.

2. Sadly, Mr T lost consciousness and stopped breathing before an ambulance could attend him. Despite efforts to revive him, Mr T died. We do not doubt the significant and ongoing impact these events have had on Miss T and her family.

3. We consider the Trust appropriately triaged and categorised Miss T’s calls on 27 January 2022. We recognise the Trust was not able to dispatch an ambulance within the response time for a patient with difficulty breathing.

4. We have seen the Trust was experiencing massive pressures at this time and did not have an available resource to send. We have carefully considered how the Trust managed its resource on this day, and we can see this was managed appropriately and all relevant escalation protocols were followed. We therefore do not consider the delay in attending Mr T was a failing. We therefore do not uphold the complaint.

5. We recognise how difficult this decision will be for Miss T. We hope that our decision clearly sets out our reasoning and provides Miss T with some reassurance about the actions of the Trust.