North East Ambulance Service NHS Foundation Trust

2. Mrs G complains about the care and treatment the Trust provided to her husband, Mr G, when he fell ill on 20 December 2023. She complains it took staff too long to get him into the ambulance.

3. Mrs G says the first ambulance that attended did not have the right equipment to move him. She says staff then requested a second ambulance carrying more specialist moving and handling equipment before asking her for the bed sheet they used to move him.

4. Mrs G also complains the staff involved have given false accounts of what happened on the day. She says the crew requested the bed sheet after the second ambulance arrived and they used this to move him. The staff say they requested the sheet before the second ambulance arrived and used equipment from this ambulance to move him.

5. Mrs G believes her husband might have survived had the Trust got him to hospital sooner. She says she did not get to say goodbye to him, and she will always think about what happened. She says events have had an emotional impact on her and continue to cause her distress. She would like the Trust to acknowledge what happened, apologise and correct its records.

6. Mr G was 89 years old. He attended hospital on the afternoon of 20 December 2023 to have a urinary catheter fitted. This is a flexible tube used to empty the bladder and collect urine in a drainage bag. Mr G went home after having something to eat and drink at the hospital.

7. Mr G started to feel unwell while at home later that day. Mrs G phoned District Nursing for a home visit to check on him at around 6.45pm. A district nurse arrived at around 7.30pm and phoned 999 at 7.44pm to request an ambulance. Sadly, Mr G lost consciousness shortly after this.

8. The Trust allocated an ambulance at 7.51pm and it arrived on scene at 8.01pm. Unfortunately, the crew had difficulty moving Mr G and requested a specialist evacuation (EVAC) ambulance at 8.15pm. This is an ambulance that carries more specialist moving and handling equipment and has a crew more experienced in difficult patient extractions.

9. The Trust allocated the EVAC ambulance at 8.15pm and it arrived on scene at 8.25pm. The crews were able to get Mr G into the first ambulance and it left the scene to take him to hospital at 8.57pm. The ambulance arrived at hospital at 9.06pm but Mr G very sadly died at 9.30pm.

10. We understand Mr G died from urosepsis. This is where the bacteria that causes a urinary tract infection spreads to the bloodstream. We are incredibly sorry for Mrs G’s loss and the difficult circumstances surrounding her husband’s death. We recognise how upsetting it must have been for her not to have had the chance to say goodbye to him before he died.

13. 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 something has gone wrong.

14. The Trust’s call logs show the first ambulance arrived on scene within 17 minutes. It triaged the 999 call as category two which NHSE’s ambulance standards describe as ‘a serious condition, such as stroke or chest pain, which may require rapid assessment and/or urgent transport’. These standards say Trusts should respond to these calls within 40 minutes meaning the Trust responded quickly.

15. The Trust’s investigation report says the first crew told the investigator Mr G was stuck in the toilet when they arrived. They described the room as small and only big enough for one person to be in there with him. We have discussed this with Mrs G, and she has confirmed this was the case and the room is very small.

16. The crew told the investigator how they recognised very quickly that Mr G needed to go to hospital. They said they tried using the equipment they had available to them on the ambulance, but they were unable to move him from the toilet. They said they only had a lifting belt and banana board available to use.

17. A lifting belt is a thin belt passed around the patient’s waist. A member of staff uses the belt to help lift and move the patient. A banana board is a small board placed under the patient’s buttocks. A member of staff helps the patient slide from one location to another with their assistance.

18. We can understand why these two pieces of equipment would not have worked in this situation. The limited space to use them and Mr G being unable to assist staff with moving him would have made them unsuitable.

19. The crew said they requested an EVAC ambulance to assist them and asked Mrs G for a bed sheet while they were waiting for this to arrive. They said they tried using the sheet to move Mr G, but it did not work either. The EVAC ambulance then arrived on scene within 10 minutes.

20. The crews told the investigator they used a pro move sling carried by the EVAC ambulance to move Mr G. A pro move sling is a v shaped piece of material with handles. The V-shaped cut is placed behind the patient’s back with the two longer sections passed around their sides and then crossed under the thighs. Staff then use the handles to lift and move the patient.

21. Mrs G complains the first ambulance should have carried the equipment needed to move her husband. We can appreciate why she feels this way given what happened. We understand she believes the first ambulance may have been able to get her husband to hospital sooner had they carried different equipment such as an adjustable lifting belt.

22. The Trust says there is a limit to what equipment a standard ambulance can carry due to the space available, and the equipment they do carry is suitable for most patients. We have checked NHSE’s ambulance specifications, and they do not say what moving and handling equipment standard ambulances should have with them.

23. Overall, we do not think we can criticise the Trust for its standard ambulances only carrying limited moving and handling equipment. There is limited room in an ambulance, this standard equipment will be suitable for most situations and the Trust has EVAC ambulances for when more specialist equipment and support is needed.

24. Mrs G also complains staff asked her for a bed sheet after the EVAC ambulance arrived and she believes this is what they used to move her husband. She believes staff could have got him to hospital earlier had it tried using a sheet sooner. However, she has also told us she was in another room when staff moved her husband, so she did not see this for herself.

25. We appreciate why Mrs G is concerned about what might have happened had staff got her husband to hospital sooner. We can see the first crew requested assistance from an EVAC ambulance around 14 minutes after they arrived. We think this tallies with the time it would have taken them to arrive, assess the situation and try the equipment they had available.

26. We can see there are differences in the accounts of when staff asked for the bed sheet and what was used to move Mr G. However, we recognise Mrs G has told us that she did not see what happened so she cannot be sure staff did not use the sling as they say they did. We think, on the balance of probabilities, the ambulance crew likely did use the pro move sling to move Mr G as they say.

27. If staff did use the pro move sling to move Mr G, it does not matter when they asked Mrs G for the bed sheet as it is not what they used to successfully move him. This means, no matter when they asked for it, it would not have changed what happened or meant they could have taken Mr G to hospital sooner.

28. NICE NG51 says patients with suspected sepsis should be transferred to hospital immediately with the hospital pre-alerted. We can see Mr G met several of the high-risk criteria for sepsis. He was unconscious, his respiratory rate was above 25 breaths per minute, his blood pressure was below 90 beats per minute, and he needed oxygen to help him breathe.

29. Looking at the Trust’s records, the ambulance crew quickly recognised they needed to get Mr G to hospital as soon as possible. They gave him oxygen and pre-alerted the hospital of his arrival.

30. Overall, we have not seen any indications the Trust did not act in line with what we would expect to see in this situation. The Trust got an ambulance to Mr G well within NHSE’s target timescales and staff attempted to get him to hospital as quickly as they could when faced with a difficult situation. We will therefore not be considering Mrs G’s complaint any further.

31. We are very sorry for Mrs G’s loss and that she is still concerned her husband may have survived had things been different. We hope she can see that we have carefully considered her complaint. We would like to take this opportunity to again pass on our sincere condolences for her loss.

1. We have carefully considered Mrs G’s complaint about North East Ambulance Service NHS Foundation Trust (the Trust). We have decided not to consider her complaint any further as we have seen no indication anything went wrong. We recognise the distress events have caused Mrs G and would like to pass on our sincere condolences for the sad loss of her husband.