The Ambulance Trust
13. Mrs A complains on 6 October 2021 the Ambulance Trust delayed dispatching an emergency ambulance for her husband. She explains there was a delay of two hours before the ambulance arrived.
14. The Ambulance Trust explained it received three calls at 8.21am, 8.30am and 8.56am. An ambulance was assigned at 9.03am and arrived at Mrs A’s house at 9.18am. The Ambulance Trust upheld the complaint. It found the second call at 8.30am was not handled correctly. It apologised to Mrs A in its letter dated 31 January 2022. It confirmed feedback would be given to the call handler and a meeting would be held with their manager.
15. We asked Mrs A on 10 September to explain further the impact this complaint had on her husband. Mrs A did not give a specific impact. Mrs A felt the ambulance should have arrived sooner. Mrs A acknowledged the Ambulance Trust had apologised. She said she remained unhappy with its response to her complaint. She said the apologies were not enough and further training was needed.
16. Mrs A has said she is seeking an explanation, service improvements and financial remedy.
17. The Ambulance Trust in its complaint response has provided an explanation to the events. It explained the actions each call handler took and why the second call failed its own quality audit.
18. It confirmed feedback was provided to the call handler who potentially delayed the ambulance. A meeting was also held with their manager. We consider the Ambulance Trust implemented a service improvement with the action it took.
19. The Ambulance Trust issued Mrs A an apology. Mrs A has not specifically said she is seeking an apology. In her email to us on 10 September Mrs A said the apology it had issued was not enough. We consider the Ambulance Trust has appropriately apologised.
20. Lastly, Mrs A has indicated she is seeking a financial remedy. We asked Mrs A the impact of this complaint. Mrs A has not indicated there was any impact other than annoyance with the delay.
21. The time between her first call and the ambulance arriving was 57 minutes. Our scale of injustice says:
22. ‘Level one. These will usually be injustices such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or ongoing wider impact.’
23. For a level one injustice we would generally consider an apology to be an appropriate remedy.
24. We can see the Ambulance Trust do not dispute her complaint. We can see it issued an apology and implemented service improvements. It has also provided an explanation of the events. We would not have anything to add to its explanation. We have not seen evidence the impact to Mrs A was above level one on our scale of injustice. We think enough has been done to put things right. We will not investigate this complaint further.
25. We acknowledge Mrs A’s complaint is important to her. We understand how concerned Mrs A was for her husband while she waited for an ambulance. We consider the actions taken by the Trust were appropriate and in line with the NHS complaint standards. We have nothing further to add to this aspect of her complaint.
The Trust
A&E
26. Mrs A complains the Trust did not provide her husband with pain relief during his five hours stay in A&E (accident and emergency). She says her husband was in pain on arrival and was left to suffer in pain.
27. The Trust explained in its response Mr A was given pain medication on his arrival at the Trust. He was also given oral morphine and paracetamol.
28. Firstly, we have considered how long Mr A was in A&E. The records show a consultant review took place at 5.40pm. It is noted this document must be completed before a patient is transferred. We have reviewed the intrahospital patient transfer checklist. Mr A’s transfer to the Selsey Ward started after 6pm. The last observation on the transfer document was at 6.45pm. We consider Mr A was in A&E between 9.52am and 6pm.
29. We will now review the records relating to Mr A’s care in A&E.
30. Mr A arrived at the Trust at 9.52am on 6 October. On his admission record it is noted Mr A was complaining of abdominal pain. His pain score was recorded as nine. The document does not say what scale his pain score was recorded against. We can say Mr A was in significant pain.
31. We have reviewed the medications given to Mr A while he was in A&E. At 10.22am a cannula was placed in his right arm.
32. At 10.32am Mr A was given Oramorph orally. Oramoprh is a liquid form of morphine, a pain killer.
33. At 10.50am Mr A was given paracetamol intravenously. At 1.15pm Mr A was given morphine intravenously. It is noted morphine was given for a duration for eight hours.
34. We have considered GMC Good medical practice. It says:
‘1Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.’
‘Clinical records should include: • any drugs prescribed or other investigation or treatment’
35. The medication given to Mr A by the Trust was recorded at the time. It has been signed and dated by the clinician providing the medication. The name of each medication has been clearly noted. The records are in keeping with GMC good medical practice.
36. The records show a consultant review took place at 5.40pm. It is noted this document must be completed before a patient is transferred. We have reviewed the intrahospital patient transfer checklist. Mr A’s transfer to the Selsey Ward started after 6pm. The last observation on the transfer document was at 6.45pm. We consider Mr A was in A&E between 9.52am and 6pm.
37. We acknowledge how concerned Mrs A was to be informed by her husband he had not been given any pain medication. It is clear Mrs A and the Trust hold a different version of events. The account the Trust provided in its complaint response is in keeping with the medical records. We consider Mr A was given pain medication while he was in A&E. We see no indications of a failing.
Surgery Delay
38. Mrs A complains the Trust did not operate on her husband until 14 hours after his admission. Mrs A feels her husband should have been operated on sooner given his condition and pain.
39. The Trust explained Mr A’s condition was considered urgent but not an emergency. It said Mr A was diagnosed with an incarcerated hernia during an evening round. An incarcerated hernia is a part of the intestine or abdominal tissue that becomes trapped in the sac of a hernia.
40. The Trust requested a Computerised Tomography (CT) scan to be undertaken to exclude another intra-abdominal cause of incarceration before performing surgery. The Trust apologies it had not explained this to Mrs A sooner. The Trust found no failings in the 14 hour wait Mr A experienced prior to his operation.
41. We have reviewed the records.
42. Mr A arrived at the Trust at 9.52am on 6 October. Mr A’s symptoms included abdominal pain for the last seven days with increasing pain today and vomiting.
43. Mr A was reviewed again at 10:45am. It is noted the Trust suspected a bowel obstruction. A referral was made to the surgery team.
44. A consultant review took place at 5.40pm. The consultant recorded an impression of a hernia based on Mr A symptoms. The records show Mr A was not aware of a hernia and had not noticed it. It is recorded Mr A was to receive a CT scan.
45. We asked our surgical adviser about the Trust’s request. Our surgical adviser said when a patient has a blocked/obstructed/strangulated inguinal hernia, a patient will give a very specific history of noting a swelling in that area which became very painful. Mr A was completely unaware he had a hernia and that it was causing him symptoms. In this circumstance, the clinician has to be suspicious that there may be another cause for the obstructive symptoms directly inside the abdominal cavity. The best way for checking this is will a CT scan of the abdomen and pelvis.
46. GMC Good medical practice says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • promptly provide or arrange suitable advice, investigations or • treatment where necessary’
47. The decision by the Trust to request a CT scan is line with GMC Good medical practice. It was an appropriate action by the Trust to request a CT scan as diagnosis had not been made at this point. To provide good care the Trust must arrange suitable investigations. We cannot say there was an indication of a failing delaying Mr A’s surgery to ensure of an accurate diagnosis.
48. The records show Mr A received a CT Scan at 8.14pm. The CT scan report was completed at 9.38pm. The report confirms a large inguinoscrotal hernia.
49. The NCEPOD (National Confidential Enquiry into Patient Outcome and Death) classification of surgical emergencies explains operations classified as urgent should be within theatre within hours of decision to operate. Our surgical adviser confirms the correct classification for an obstructed inguinal hernia is ‘urgent’ and ideally surgery on the same day or within hours of the decision to operate is correct.
50. Mr A’s arrived at the Trust’s theatre at 12.09am. Mr A was admitted to the intensive care unit (ICU) at 2.45am on 7 October after his surgery.
51. We can see from the records Mr A was operated on within four hours of his diagnosis. This is in line with NCEPOD guidance. Our surgical adviser agrees standards were met and Mr A received surgery within four hours of his diagnosis.
52. We acknowledge Mrs A’s concern there was a delay before the Trust operated on her husband. This would understandably cause worry for Mrs A. We have seen the Trust took appropriate actions in relation to the symptoms described by Mr A. The actions of the Trust are supported by guidance. Mr A was operated on within an acceptable timeframe after his diagnosis was confirmed. We see no indications of a failing.
Bowel blockage
53. Mrs A complains the Trust did not treat her husband’s bowel blockage. She explains incarcerated bowel was listed on Mr A’s death certificate. She says this left her husband in pain and caused her distress to witness. Incarcerated bowel, also known as an incarcerated hernia, is a condition where a part of the intestine gets trapped in a hernia sac, blocking the flow of stool.
54. The Trust explained it did treat Mr A’s blockage. Incarcerated bowel was listed on Mr A’s death certificate because it was relevant, but it did not actively contribute to Mr A’s death.
55. The surgical records say Mr A’s operation began at 12.09am on 7 October.
56. The operation report says an open repair to the right inguinal hernia was completed. An inguinal hernia, also known as a groin hernia, is a bulge or lump that occurs when tissue pushes through a weak spot in the abdominal muscles. Under procedure, the operation report says the inguinal canal was opened.
57. Our surgical adviser explains the bowel blockage caused by the right inguinal hernia was adequately treated by the first operation.
58. The records show a CT scan was performed on 14 October. The results were documented at 8.36pm. Our surgical adviser confirms the scan did not show any mechanical obstruction to the bowel.
59. We acknowledge Mrs A’s concern her husband’s incarcerated bowel was not treated. It would have understandably be worrying as this was included on her husband’s death certificate. The records show the incarcerated bowel was treated. We see no indication of a failing.
Nurses
60. Mrs A complains the Trust did not have enough nurses on Mr A’s ward following his admission to the ICU on 7 October.
61. The Trust explained in the morning of 7 October the ward was adequately staffed. The Trust confirmed in the afternoon the ward was short by two members of staff. The Trust did not say this led to a failing in care.
62. We are unable to comment on staffing issues. We can however consider if Mr A was provided appropriate care on 7 October.
63. We have taken nursing advice on this matter. Our nursing adviser explains the intensive care society (ICS), guidelines for the provision of intensive care services, categorises patients based on their needs. The guidelines say:
‘Level 3 Patients requiring advanced respiratory support alone, or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure’
64. Mr A was receiving medication to both sedate and paralyse him to enable him to tolerate mechanical ventilation. He also had sepsis and organ failure. In line with ICS guidance Mr A was considered level three. Our nursing adviser agrees.
65. We have considered what the ICS guidance says regarding the level of care needed for level three patients. It says:
66. ‘Level 3 patients must have a registered nurse/patient ratio of a minimum 1:1 to deliver direct care’.
67. The Trust have acknowledged in the afternoon the ward was short staffed by two members of staff. The Trust’s complaint response on 4 February 2022 confirms nurses had to double up in the afternoon.
68. The ICS guidance also says:
‘Clinical judgement should be used to determine which level of care would be most appropriate based on the level one to three criteria. Although a lower level of care will usually require a lower nurse-to-patient ratio or reduced critical care support, this may not apply in all circumstances, and the aim should be flexibility in the provision of staff resources to meet the needs of the patient. The level of care assigned to a patient will influence, but not determine, staffing requirements.’
69. The ICS guidance says the aim should be flexibility in the provision of staff resources to meet the needs of the patient. We will now review the records to see if Mr A’s needs were met.
70. As noted above, Mr A was admitted to the intensive care unit (ICU) at 2.45 am on 7 October after his surgery. Mr A was reviewed at 9.52 by a general surgeon. At 10.03 a doctor reviewed Mr A. At 1.54pm daily ward round was completed.
71. A second doctor review was completed at 4.54pm. The medical records show an evening and night ward round were completed. The records do not say exactly what time these were completed.
72. Our nursing adviser explained the Trust documented clear management plans for Mr A. There is no evidence of missed care or a failure to implement Mr A’s management plan on 7 October.
73. We acknowledge ICS guidance says a patient who was considered level three should be provided one to one care. This would understandably be concerning for Mrs A as it appears this was not provided to her husband on 7 October. The guidance also explains there should be flexibility in resource to meet the patients’ needs. We are persuaded by the records and clinical advice Mr A’s needs were met. We have seen appropriate care was provided. There is no indication of a failing.
Moving her husband
74. Mrs A complains the Trust did not inform her Mr A’s body was to be moved to Worthing for a postmortem. She says the experience added to her bereavement.
75. The Trust did not address this complaint directly in its response. It did acknowledge its communication could have been better and apologised for the distress caused.
76. We asked the Trust for a response to this aspect. The Trust informed us the bereavement office was informed of Mr A’s death on 18 October 2021, a Monday. This was one working day after his death on 15 October. The Trust says a coroner’s referral was sent on 18 October.
77. The Trust explain the coroner’s office emailed the bereavement team requesting additional information on 19 October 2021, and this was provided to it on 21 October. The decision to conduct a coroner’s postmortem was received by the Trust on 22 October.
78. The Trust say once a body has been referred for a coroner’s postmortem, it is the responsibility of the coroner’s office to keep the family updated regarding the onward process, including where the body is moved to.
79. The records show Mr A died on 15 October. The nursing notes say following his death a bereavement booklet was given to Mr A’s family. No further information is given. As we were not there, we will not be able to say exactly what information was given.
80. We have reviewed documentation from the coroner’s office. The coroner confirmed on 12 February 2022 it authorised a post mortem on 21 October 2021.
81. We have reviewed the coroner’s society of England and Wales frequently asked questions. It says:
‘Where will the post-mortem examination take place? Who will perform it?
In almost all cases the post-mortem examination will take place at a local Hospital (some exceptions apply, if your relative’s body needs to be moved between hospitals). The post-mortem examination will usually take place and the body released for funeral within a week of the death but the Coroners office and your funeral director will keep you informed.
Communication with you?
The next of kin or alternative agreed point of contact for the family will be contacted by telephone usually by the Coroner’s Officer who will discuss post-mortem examination arrangements. The Officer will call again as soon as possible after the examination to explain the results and discuss what happens next. On occasions it is sometimes not possible to trace or contact relatives, after making reasonable efforts, so the post-mortem examination may have to proceed without notifying them.’
82. We acknowledge the distress caused when Mr A’s body had been moved and Mrs A had not been informed. This understandably caused upset for Mrs A at what was already an incredibly difficult time. The Trust explanation is line with the Coroner’s society of England and Wales guidance. The responsibility for contact Mrs A was the coroner’s office, not the Trust. We are pleased to see the Trust have apologised for the distress caused and acknowledge it could have improved communication. We see no indication of a failing.
83. We thank Mrs A for bringing her complaint to us for consideration.