North East Ambulance Service NHS Foundation Trust

4. Miss J complains about the Trust’s handling of calls about her father after he collapsed on 23 March 2022 and a delay in starting CPR. She says it took too long to answer the first call, full worsening advice was not given in the second call and too many ‘ad hoc’ questions were asked in the third call.

5. Miss J says the delay in starting CPR significantly reduced her father’s chances of survival. The bereavement has had an ongoing impact on her and her family, and they are still grieving.

6. Miss J would like the Trust to acknowledge its failings, apologise for the impact they had, and improve its service. She would also like us to consider making a financial recommendation.

7. Mr J was 42 years old and was out with his 12-year-old child. Mr J had a cardiac arrest, which is when the heart suddenly stops pumping blood around the body.

8. Mr J’s child called the ambulance service immediately, and called again when Mr J stopped breathing. Three calls were made to the Trust in total and an ambulance crew attended, but Mr J sadly died.

9. The first call to the ambulance service was at 6.56pm. The second call was at 6.58pm. The third call was at 7.06pm. The Trust carried out an audit of the calls after Mr J’s family complained and identified some learning actions.

10. The Trust said it could not provide feedback to the person who handled the first call, but they should have probed further for a definitive answer on whether the patient was breathing.

11. The Trust said the second and third call handler would receive feedback about this in their one-to-one meeting with their line manager. It was of the view the second call handler should have provided worsening advice at the end of the call.

12. It agreed with the family that too many ad hoc questions were asked on the final call. The caller had made it clear Mr J was not breathing and CPR was in progress, so the call handler should not have continued to ask questions regarding his breathing and consciousness levels. As an ambulance was already assigned and travelling, the Trust concluded this did not delay the response to Mr J.

Time taken to answer the first call

16. Ambulance Services in England use a Computer Assisted Dispatch system (CAD). The CAD is the system used to record all data related to 999 and urgent requests for ambulance assistance from the Trust. It is primarily used by Emergency Operations Centre (EOC) staff to assess, prioritise and, if necessary, dispatch ambulance crews to 999 calls.

17. NHS England’s ambulance standards involve using a set of pre-triage questions to identify those patients in need of the fastest response. There are four categories of call. Category 1 calls, from people with life-threatening illnesses or injuries, are the most serious.

18. Call pickup for 999 ambulance services is expected to be as fast as possible. Our adviser explained there are no current national standards, but we understand most ambulance services aim to answer within five seconds. It is important to note this does not take into account time for BT to answer the call and redirect it to the correct emergency service, i.e. police, fire, ambulance in the correct area.

19. The Trust’s complaint response explained BT connected the call to the Trust at 18:56:59 and it answered 72 seconds later. The complaint response acknowledged this was outside the expected level.

20. NHS England’s commissioning framework says ambulance services should ensure they answers all 999 calls promptly. AACE’s data shows in March 2022, call pickup times significantly rose nationally to a mean of 42 seconds, with 90% of calls picked up within 171 seconds. The call pickup time here was significantly higher than the mean. The Trust may wish to consider this as part of its Clinical Safety Plan.

21. However national standards for 999 services focus on how long it takes an ambulance to arrive on scene - not call pickup, as outlined in the NHS Standard contract and NHS ARP Review. In line with this, ambulances should respond to category 1 calls in seven minutes on average, and respond to 90% of category 1 calls in 15 minutes.

22. Additionally, part of the response times from call to arrival on scene can include time from when BT connected the call to the Trust. This is reflected on NHS England’s AmbSYS which says for category 1, if the call is not categorised within 30 seconds, then the ‘clock starts’ for ambulance response target starts at 30 seconds from BT’s attempt to connect (if it is not already connected).

23. The first call connected to the Trust at 18:56:59 so the clock started 30 seconds later, at 18:57:29. This is because the call was not categorised until 18:58:41 according to the Trust’s response.

24. In this case, the first ambulance arrived at 19:10:42 so using the national measure, the total response time was 13 minutes 13 seconds. This was within the 90% response target of 15 minutes for category 1.

25. While the Trust could potentially have had an ambulance on scene up to a minute earlier if the call pickup time had been shorter, it did meet the national standards. This is why we have not identified a failing here.

Worsening advice in the second call

26. The second call was clearly challenging as the caller was shouting across the road to get answers for the call handler. The caller did not seem able to go over to where the patient is, but confirmed he was unconscious.

27. Our Principles say public bodies must act in accordance with recognised quality standards, established good practice or both, for example about clinical care. The established practice when handling a call like this one is to provide worsening advice. This informs the caller what to do if they experience any deterioration.

28. The call handler did double check that someone was on a call to the ambulance service but did not give worsening advice. The Trust response confirms this, and that worsening advice should have been given. We consider there was a failing here.

‘Ad hoc’ questions in the third call

29. Our adviser explained the call handler will be presented with relevant questions to ask with notes at the side of the screen for clarification to assist getting the correct answer. Using ad hoc questions may result in an answer being recorded that could change the ambulance response (such as downgrading the call from category 1).

30. The Trust’s response also confirms the call handler asked too many ad hoc questions. We consider this a failing, as the call was not handled in the way it should have been.

31. The call handler seemed task focused rather than appreciating the relevance of everything the caller was saying. This is based on the fact it took two minutes from the start of the call to come back to the fact the caller had said the patient was not breathing. Then the call handler jumped to fitting rather than not breathing.

32. It took the call handler in this call four minutes to give CPR instructions despite the caller saying immediately the patient was not breathing. The call handler asked the caller to stop CPR before starting to give instructions on how to perform it less than a minute later.

Impact

33. Given the failings identified above we have considered the impact of what happened. Miss J says the Trust’s actions led to a delay in starting CPR which significantly reduced her father’s chances of survival.

34. Resuscitation Council UK basic life support guidance and the NICE CKS on cardiac arrest both set out that CPR should be started immediately where possible. The CKS says immediate CPR can double or quadruple survival from out of hospital cardiac arrest, and defibrillation within three to five minutes of collapse can produce survival rates between 50 and 70%.

35. Defibrillation should be used if available. If there are any Community Public Access Defibrillators (CPADs) in the area, and they are recorded centrally, the system will suggest these to direct bystanders to. Sadly, there were no CPADs in the area Mr J was in.

36. Mr J had already been allocated the highest level of response and an ambulance was already on route, the ad hoc questions in the third call did not delay an ambulance to the scene. The caller stated CPR was already being given when this call was made.

37. The call handler asked the people giving CPR to stop for less than a minute before starting to give instructions. Listening to the call, it is not clear if CPR did stop in that period.

38. Overall, we are therefore unable to say the care Mr J received was significantly affected by the Trust’s handling of the calls following his collapse.

39. Sadly, data from the OHCAO Registry shows more than 11 in 12 patients (92.2%) do not survive to 30 days after experiencing an out-of-hospital cardiac arrest.

40. This does not detract from the concern Miss J experienced from learning those calls were not handled in the way they should have been. We are very sorry for her family’s loss and recognise the Trust’s call handling added to their bereavement. We are making recommendations on that basis.

1. We were very sorry to hear of Miss J’s concerns about the Trust’s call handling. We recognise this added to her bereavement following the death of her father, Mr J.

2. The Trust has already acknowledged issues in how it handled the three calls made following Mr J’s cardiac arrest. While we share its view it is unlikely the issues had a significant clinical impact, we do recognise they added to the distress of Miss J’s bereavement. We consider there is an opportunity for wider learning. We therefore partly uphold the complaint overall.

3. We recommend the Trust writes to Miss J and us to explain how it will improve its service. We also recommend the Trust pays her £425 in recognition of how the failings we have identified added to her bereavement.

41. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. We are satisfied the Trust has already provided an apology during its complaints process.

42. Our Principles say public organisations should look for continuous improvement, and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. We were not assured the Trust had done enough to prevent the failings we identified occurring again. While we recognise the Trust has identified issues, we consider learning should not be limited to individual call handlers.

43. At the end of our investigation, the Trust told us it had taken steps to support wider learning. It said it had issued reminders to staff to reinforce key patient safety messages and guidance. It has commissioned a thematic review to explore the broader systemic issues highlighted by this case and others. This includes a Patient Safety Incident Investigation (PSII) focused on non-breathing guidance, the national pathways used by call handlers and associated decision-making processes.

44. With this in mind, we recommend the Trust writes to Miss J within six weeks of the date of this report to assure her it will learn from this complaint. It should explain: • if it has identified reasons for the failings in its call handling • what action it has already taken and what learning it has already implemented, and when • what further action it will take (with timescales), to prevent the failings happening again.

45. Our Principles say public organisations should put things right and, if possible return the person affected to the position they would have been in the poor service had not occurred. If that is not possible, they should compensate them appropriately.

46. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the Trust should pay Miss J £425 in recognition of the impact the call handling had in adding to the distress the family experienced.