West Midlands Ambulance Service University NHS Foundation Trust

5. Mr K complains about the conduct of a senior paramedic employed by West Midlands Ambulance Service University NHS Foundation Trust (the Trust). He complains that following a 999 call, made on 7 April 2024, the paramedic contacted them by telephone and dismissed his symptoms as being due to his mental health.

6. Mr K was in septic shock and says it was not appropriate to dismiss his symptoms, which strongly indicated sepsis. He adds that the paramedic was not compassionate when speaking to his daughter.

7. He says this caused him and his family a great deal of distress, especially as the paramedics who attended his home indicated he would likely have died had he not been taken to hospital. It has also caused him to lose faith in the Trust’s services.

8. Mr K also complains that when he and Mrs J raised a complaint about the conduct of the paramedic, the Trust would not acknowledge what went wrong.

9. He says this further compounded the distress caused by its actions.

10. Mr K would like the Trust to acknowledge what went wrong and apologise. He would also like the Trust to compensate him for the distress caused by its actions.

11. Mr K is a 71-year-old gentleman. On 23 March 2024 he attended the Emergency Department (ED) of a local hospital due to poor nutritional intake and hypersomnia (sleeping more than is normal for that person). Tests in the ED revealed nothing abnormal and he was discharged with a referral to the Trust’s mental health team.

12. The mental health team assessed Mr K, and he continued to spend a lot of time sleeping and had poor diet and fluid intake. He was also seeing his GP for these symptoms and was prescribed antidepressants and morphine patches. His GP stopped his antidepressant medication as they felt it was not helping. On 6 April Mr K decided to not replace the morphine patch as his daughter suggested it may be causing the hypersomnia.

13. The next day, Mrs J, visited Mr K and described him as looking ‘terrible’. She says he was cold, shivering and his breathing was shallow. She also noted his urine had been very dark and strong smelling. She rang an ambulance for her father that evening.

14. Mrs J told the 999 dispatcher that her father had been in bed for two weeks and was not eating or drinking. She explained he had been on antidepressants, but they had made him worse, so the GP had stopped them. She also told the dispatcher her father had been on morphine patches but had stopped these the day prior. She explained he was now ‘very weak, shaking and feeling unwell. Mrs J told the dispatcher her father had the following symptoms:

• shivering a lot and shaking • heavy, shallow breathing • lethargic (‘laying down and doesn’t want to get up’) • weakness – unable to get downstairs • ‘freezing cold’ extremities but chest felt ‘quite warm’ • vomited blood.

15. Mrs J also told the dispatcher he had been admitted to hospital for these symptoms two weeks prior. She explained he had deteriorated quickly since this admission. She told the dispatcher he was ‘very depressed’ and the mental health team were involved in his care. The dispatcher arranged for an ambulance to attend and asked Mrs J to stay with her father until help arrived.

16. An ambulance arrived at Mr K’s house at 9.10pm.

Dismissal of symptoms

20. Mrs J has said during the call she made to the Trust on 7 April 2024 the paramedic dismissed her father’s symptoms as being down to mental health issues. However, she says he was in septic shock. She has said the paramedic who later visited her father’s home, explained Mr K would have died had he not been taken to hospital.

21. Given the serious nature of the complaint and Mr K’s condition, we obtained clinical advice from our adviser. This helped us understand whether the Trust acted appropriately or not and establish what the impact was.

22. We listened to the audio recording of the telephone call made by Mrs J on 7 April and discussed this with our adviser, who also listened to the recording. Our adviser explained the paramedic was robust and direct in their communication approach with Mrs J, in this case and in line with Health & Care Professions Council (HCPC) standards on communication section 2.1 – 2.5, which state:

• 2.1 You must be polite and considerate.

• 2.2 You must listen to service users and carers and take account of their needs and wishes.

• 2.3 You must give service users and carers the information they want or need, in a way they can understand.

• 2.4 You must make sure that all practicable steps are taken to meet service users’ and carers’ language and communication needs.

• 2.5 You must use all forms of communication responsibly when communicating with service users and carers.

23. However, our adviser said the paramedic appears to have pre-determined Mr K condition and diagnosis.

24. At one point in the call, Mrs J referred to other physical symptoms such as dark urine, blood in his vomit and queried whether her father could have had an infection.

25. Our adviser explained none of these triggered the call handler to consider potential causes and follow alternative templates. We can see this has been acknowledged by the Trust and resulted in a partial compliance score in its audit.

26. Our adviser explained the paramedic appears to have used the Pathways Clinical Consultation Support (PaCCS tool) to carry out their clinical assessment of Mr K. They felt the paramedic should have utilised a variety of tools to reach a more robust conclusion, as outlined in the Trust’s Clinical Validation Protocol, section 2.1:

“2.1. Clinicians are accountable for ensuring the following: […]

8. Utilising additional triage tools to enhance clinical assessments, including, but not exhaustive.

a. Video consultation and photo tool.

b. Nationally recognised clinical guidelines and assessment tools such as JRCALC/NICE Guidelines/Sepsis screening tool c. Toxbase web/Toxbase helpline”

27. Our adviser also explained the paramedic should have undertaken further clinical questioning to develop a differential diagnosis as the symptoms presented by Mr K could have presented in a variety of medical conditions.

28. They explained that the PaCCs tool does allow clinicians to use their own clinical judgement to assess the patient and determine the most appropriate pathway to use. This is supported as outlined above, and although the Clinical Validation Protocol in section 2.1 (7) states:

“Completing a full clinical assessment of patients utilising PaCCs/Pathways as deemed appropriate for the category of case.”

29. In this case again it appears the paramedic had pre-determined Mr K’s symptoms being down to mental health issues and subsequently failed to carry out a full assessment. If a full assessment would have been carried out, this would have allowed a more appropriate template to be used to assess Mr K’s symptoms and support clinical decision making.

30. As such, we agree with the Trust in its response that the paramedic on the call should have investigated Mr K’s symptoms further. We considered what impact this had.

31. In her complaint to us Mrs J has said her father would likely have died had paramedics not turned up.

32. It is important to note that when we consider complaints, we do not speculate on what might have happened as we must consider what did happen. In this case the key thing to recognise is that the paramedic on the call did explain to Mrs J that she would send an ambulance if she wanted one. In line with Mrs J’s wishes, an ambulance was subsequently sent.

33. We can see when ambulance staff arrived, Mr J was acutely unwell, with reduced air entry into both lungs, foul smelling urine, low blood oxygen levels, and low blood pressure, which paramedic staff believed was indicative of sepsis.

34. Although, we understand the distress and upset caused to Mr K we are satisfied there was no clinical impact, given an ambulance did arrive and took him for immediate hospital treatment. Furthermore, given the Trust has acknowledged it should have carried out further investigations on the call and apologised for the distress caused, so we are satisfied it has taken appropriate steps to put things right.

35. This is in line with NHS complaint standards, which state: ‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff’.

Level of compassion on the telephone call

36. Mrs J has told us the paramedic on the call on 7 April 2024 showed a lack of compassion when handling her call.

37. We again discussed this with our adviser. It is our view that although the matter is extremely subjective, we are satisfied the call was handled professionally overall and again in line with HCPC standards on communication section 2.1 – 2.5 (see above point 21).

38. We accept there were times when the paramedic could have been more compassionate and supportive given the distressing nature of the situation. We cannot say this was so far below the level of service we would expect, to constitute service failure. The Trust has already apologised for any distress caused by the professionalism of the call handler, which is sufficient and as far as we would reasonably expect in acknowledging Mrs J’s perception and interpretation of the call.

39. Once again, although we fully appreciate Mr K and Mrs J’s concerns ultimately the call handler did request an ambulance was sent, which demonstrates a level of compassion and understanding.

Complaint handling

40. Mr K complains that when he and his daughter raised a complaint about the conduct of the paramedic, the Trust would not acknowledge what went wrong.

41. Having read the responses from the Trust and based on our findings above, we are satisfied the Trust has done enough to acknowledge Mr K’s concerns and acknowledge the paramedic could have done more to investigate his concerns. The Trust has apologised for the distress caused.

42. In line with NHS complaint standards, which state: ‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff’.

43. In relation to the professional conduct of the paramedic, the Trust has said it found their conduct to be polite and professional but apologised if Mr K and Mrs J felt it was less than satisfactory. Again, given we are satisfied with the conduct of the paramedic, we cannot criticise the Trust in respect to their response or investigation.

44. We would like to thank Mr J and Mrs K for bringing the matter to our attention. We appreciate the actions of the Trust made an extremely distressing situation even worse, and hope our report clearly outlines the reasons to why we reached our decision.

1. We have carefully considered Mr K’s complaint about West Midlands Ambulance Service University NHS Foundation Trust (the Trust).

2. From the evidence we have seen, there are indications of failings in respect to how the Trust diagnosed Mr K during the call on 7 April 2024. However, we are satisfied the Trust has done enough to put things right.

3. We have seen no indications of failings in respect to the communication and compassion of the Paramedic and the Trust has appropriately responded to Mrs J’s complaint in line with relevant guidance.

4. For these reasons, we do not propose to investigate further. We know how important this complaint is to Mr K. We recognise the distress Mr K has experienced which was clearly exacerbated by the handling of his complaint, and we appreciate him kindly sharing these details for our consideration during an extremely upsetting time. We appreciate Mr K was extremely poorly when he was admitted to hospital but are happy to hear he made a full recovery.