NHS in England Closed After Initial Enquiries Search on PHSO website

North West Ambulance Service NHS Trust

P-003534 · Statement · Decision date: 28 May 2025 · View North West Ambulance Service NHS Trust scorecard
Complaint (AI summary)
Mrs J complained about a long ambulance waiting time (1 hour 45 minutes) for her seriously ill husband, which she believes delayed treatment and contributed to his death.
Outcome (AI summary)
The ombudsman closed the complaint, finding no serious failings in the service provided. While there was a delay, the Trust appropriately allocated resources.

Full decision details

The Complaint

5. Mrs J complains about aspects of the service provided to her late husband, Mr J, by the Trust on 23 January 2024.

6. Specifically, she complains about the long waiting time for an ambulance. She says Mr J was seriously ill, with a suspected heart attack and the Trust should have sent an ambulance within 18 minutes, not one hour and 45 minutes.

7. Mrs J says as a result of the long waiting time, she decided to take Mr J to A&E herself which meant he had to wait to be seen and receive treatment. She says this delay resulted in his death, and if an ambulance had been sent quicker, Mr J would have bypassed A&E and received treatment quicker.

8. She says she witnessed Mr J’s death which was horrendous, and she has flashbacks to that evening. She says this has been very difficult to cope with and she is receiving counselling.

9. Mrs J is seeking service improvements and a financial remedy.

Background

10. On 23 January 2024 at 22.17, Mrs J called for an ambulance for her husband, Mr J who was experiencing chest pains. Shortly after at 22.25, she cancelled the ambulance as Mr J appeared to get better. Unfortunately, he started to deteriorate again, so she made another call at 23.54.

11. The Trust categorised the call as a category 2, which is classed as an emergency for potentially time-critical or serious conditions that may require rapid assessment, on scene intervention and/or transport to an emergency medical facility. These calls include a person having a heart attack or stroke.

12. At this time, the Trust’s call handler told Mrs J, it may take up to one hour and 45 minutes for an ambulance to arrive.

13. Mrs J made the decision to take Mr J to A&E herself due to the time given for an ambulance to potentially arrive, and the Trust cancelled the ambulance.

14. Mrs J told us that after they arrived at A&E, Mr J had a 40-minute wait before being seen. Mr J was diagnosed with an aortic dissection (a tear in the inner layer of a weak area of the main blood vessel through which oxygen and nutrients travel from the heart to organs in the body). While he was being transferred to another hospital for treatment, he sadly went into cardiac arrest and died on 24 January 2024.

15. The Trust’s complaint response said that on the evening, the potential wait time for a category 2 response, was one hour and 45 minutes and this was impacted by the handover delays being seen at hospitals throughout the region. It said that at 10pm, 17 minutes before Mrs J made the first call, it had six ambulances waiting to handover at the local hospital, with the longest having to wait 143 minutes. At 11.40pm, it said six ambulances were still queuing up outside the hospital, with the longest wait being 174 minutes.

Findings

Waiting time for an ambulance

19. 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 something has gone wrong in Mr J’s care. We recognise this was a distressing time for Mrs J and we will explain the reasons for our decision, below.

20. At the time of Mrs J’s final 999 call at 23.54, the Trust’s call handler explained it may take up to one hour and 45 minutes for an ambulance to be sent. This request was cancelled as Mrs J said she would take Mr J to hospital herself.

21. Mrs J says an ambulance should have been sent within 18 minutes and all ambulance trusts should respond to category 2 calls within 18 minutes on average and respond to 90% of category 2 calls in 40 minutes.

22. We looked at the reasons for the delay in the time given for an ambulance to be sent. We did this by considering the information and data sent to us by the Trust, including the Trust’s ‘Regional Operational Command Centre’ (ROCC) report from 23 January, which details the resources it had available and any pressures on the service. We also asked our adviser to review this.

23. The ARP details the response targets for ambulance trusts and determines how quickly a Trust should aim to send an ambulance depending on the category a patient falls into. The Trust categorised the final call Mrs J made, as a category 2. In line with ARP, ambulance trusts should aim to respond to a category 2 call in 18 minutes on average and to 90% of category 2 calls in 40 minutes. This means that some calls will fall outside of that response time.

24. The ROCC report from 23 January, details that around the time of Mrs J’s final 999 call, it was taking nearly one hour and 45 minutes, for category 2 calls to be answered across the region.

25. Ambulance statistics from January 2024, show that across all ambulance services in England the average response for a category 2 response was just over 40 minutes, however 90% of services were taking up to one hour and 27 minutes to respond to category 2 calls. The Trust’s position was therefore consistent with the national one.

26. The Trust response times were being significantly impacted by hospital handover delays. The data from the ROCC report demonstrates the operational capacity the Trust was losing to handover delays. Shortly before Mrs J made the final call to the Trust, six ambulances were queuing up outside the local hospital, with the longest wait being 174 minutes before patients were handed over to hospital staff.

27. National ambulance data shows us there was a similar picture across England in January 2024, where 12,839 hospital handovers were taking over three hours, and 498 hospital handovers were exceeding 10 hours. Where these handovers take significantly longer than expected, this stops an ambulance being available to respond to another emergency and has a negative impact on overall response times.

28. The hospital where Mrs J took her husband to, had long handover times. The Trust had deployed a specialist paramedic team leader to the hospital, and there was a plan from 23.00 to create four more hospital beds. This indicates the Trust had provided ground management support at the hospital to try and release operational capacity for the ambulances waiting to hand over patients.

29. When Mrs J made the final call to the Trust, this was identified as a category 2 response at 23.57, a dispatcher reviewed this at 23.58 and allocated the nearest ambulance before the call was cancelled. So, despite the average waiting times being high, when the call was made it was rapidly reviewed.

30. Average response times are the best estimate an ambulance service has as to what a response might be. The actual response may be faster or slower. Whilst the ambulance is travelling, it may be diverted to a higher category emergency, suffer from a breakdown or be involved in a road traffic accident. This means that even if an ambulance is currently travelling, the best estimate of what a response might be remains as the overall average and this is the information that was provided to Mrs J.

31. The time given for an ambulance to be sent to Mr J, was higher than the times given in the ARP, and we recognise this was worrying. The national recommended times are a target, so unfortunately not all calls will be responded to within the timeframes. We can see the waiting time was impacted by handover delays at hospitals across the region, which affected the Trust being able to meet demand on the service. The evidence shows the Trust was acting at the time to try and improve ambulance availability and call handling staff were identifying there was a resource available and allocating this without delay. This indicates the Trust was utilising its resources appropriately.

32. We are sorry Mrs J was given a long wait time for an ambulance to arrive, and we recognise it was a difficult time. We cannot criticise the Trust for this as it did what it could with the resources it had available on that evening, to try and get an ambulance to Mr J as soon as it could. We are therefore taking no further action on the complaint, and we are sorry if this is disappointing for Mrs J. We hope we have explained our decision clearly.

Our Decision

1. We have carefully considered Mrs J’s complaint about the Trust. We have seen no indication that anything went seriously wrong in the service provided to Mr J.

2. We understand how important Mrs J’s complaint is to her. We are sorry for her loss and to hear of the difficult time she has been through.

3. We reviewed the waiting time given for an ambulance to arrive. We can see there was a delay in the time given to Mrs J, but the Trust utilised its resources appropriately to find and allocate an ambulance as soon as it could.

4. We have therefore decided to take no further action on the complaint, and we are sorry if this adds any further upset to Mrs J.

Other Decisions About North West Ambulance Service NHS Trust

P-004337 · 25 Nov 2025
Miss A complains North West Ambulance Service NHS Trust failed to identify the cause of her mother’s condition and provide …
Not Upheld
P-003400 · 27 Mar 2025
Mrs E complains the Trust did not categorise the 999 calls she made appropriately, provided the incorrect information to her …
Closed After Initial Enquiries
P-003319 · 11 Feb 2025
Mr O complains that in October 2023 the Trust failed to recognise his father needed urgent treatment, meaning he waited …
Closed After Initial Enquiries
P-003239 · 17 Dec 2024
Mrs L complains the ambulance Trust left her mother without the appropriate treatment for 30 hours.
Closed After Initial Enquiries
P-003108 · 11 Nov 2024
Miss R complains it took the Trust 11 minutes to start CPR when her sister had suffered from a pulmonary …
Partly Upheld
View all decisions for this organisation →