Delays with ambulance
13.Miss A says there were delays in an ambulance reaching her father on 3 April 2023 despite repeated 999 calls. This was an incredibly stressful and upsetting situation for Miss A and her family as they felt Mr B was having a heart attack.
14.Based on our consideration of the records received from the Trust, there were three calls made in relation to Mr B on 3 April 2023. These were timed at 1.09am, 1.35am and 1.54am.
15.Having listened to the first call, our adviser says the caller clearly states Mr B is conscious and breathing, although not normally, that he was awake and lying on his side. The call handler confirms it has been logged as an emergency. Then there is discussion about whether someone can get an Automated External Defibrillator (AED), and the call handler gives clear advice to call back if Mr B gets worse as they now must disconnect to answer waiting calls.
16.The sequence of events (SOE) document for the first call confirms that the call handler documented that Mr B was conscious and breathing, he had collapsed and had chest pains. Therefore, the call was allocated category 2 status which our adviser says was appropriate in the circumstances. The SOE further confirms it was logged that Mr B was not responding normally. Category 2 calls are allocated to emergencies for ‘emergencies’ such as possible heart attacks or strokes under the Ambulance Response Programme (ARP) set by NHS England.
17.The ARP guidance on category 2 calls (page 50) states they are ‘calls with life-threatening, time dependent conditions’. Our adviser says the only higher category is category 1 which is for presentations such as cardiac arrest or choking that require immediate intervention to preserve life, for example through resuscitation. This is why one of the first questions in 999 calls is ‘is the patient breathing’ to identify cardiac arrest immediately.
18.On the second call, our adviser says the caller was asked if Mr B was breathing which was confirmed and he was awake. The call handler identified that this was a second call and asked why they had called again. After confirming that Mr B ‘has got worse,’ the call handler undertook another triage to assess if Mr B’s presentation now required a change in the category of the call. Although Mr B had got worse, he was still conscious and breathing. Mr B can be heard in the background on the recording of this call. AED was again discussed with clear advice by the call handler to call again if Mr B deteriorates. The SOE document confirms that this call was maintained a category 2 (which our adviser says was appropriate) for Mr B who was conscious and breathing but whose chest pain had deteriorated.
19.Our adviser says the third call clearly asks if Mr B is breathing and when it is confirmed that he is not breathing, the call handler tells the caller to put Mr B on his back and gives clear CPR advice. In the SOE document, it confirms the call was allocated a category 1 response for ‘male not conscious and not breathing’. Our adviser says it was appropriate to escalate the call to category 1 at this point. Furthermore, the SOE confirms the call was received at 1:54:38am and by 1:54:44am, Mr B was logged as not breathing and a category 1 response allocated. An emergency resource was allocated at 1:55:12am, so within 30 seconds of the call being answered by the Trust. It is noted that the Trust’s audit of the three calls as documented in its Serious Incident Report found that all of the calls had been categorised correctly. Furthermore, there were no available ambulances to allocate to this incident when it was a category 2 call.
20.In terms of how long it took to reach Mr B, our adviser acknowledges there was a delay in getting to Mr B for the category 2 response, but category 1 response times were achieved. That said, this would be classed as a delayed response overall as the ambulance should have arrived before Mr B deteriorated into cardiac arrest and the category was changed. This is in accordance with page 82 of the ARP guidance.
21.Under the ARP guidance (page 4), standards set out by NHS England for a category 2 response is 18 minutes mean or a 90th centile (9 out of 10 times) 40 minutes. The Trust’s SOE document confirms that the call was categorised as a ‘Cat 2’ so a category 2 call at 1:11:11am on 3 April 2023. Our adviser says this is when the ‘clock will start’ on the response time, in accordance with the ARP guidance (page 10).
22.The first resource on scene according to the SOE document was at 1:56am, and this is also confirmed on the Trust’s Electronic Patient Record (EPR). This makes the total response time for this incident of 45 minutes, so just outside the category 2 ARP 90th centile by 5 minutes. The Trust did achieve the category 1 response time with the SOE document event time confirming that the call was upgraded to a category 1 at 1:54am arrival on scene at 1:56am so a response time of 2 minutes. Our adviser says this is well within the ARP (page 4) category 1 7-minute mean and 15 minutes 90th centile target.
23.We have not seen failings by the Trust regarding the service it provided to Mr B on 3 April 2023 when an ambulance was called for him. We acknowledge there was a 5-minute delay in an ambulance reaching Mr B, considering the ARP guidance for category 2 ambulance response calls. We appreciate that Miss A will be upset and disappointed by this delay, but we cannot say it amounts to service failure by the Trust. This is because all the calls in relation to Mr B were triaged correctly by the Trust and the wider target for category 2 calls (90% within 40 minutes) accepts that, unfortunately, not all ambulance attendances happen in time. Furthermore, we have seen evidence from the Trust that no other ambulance resources were available at the time to deal with a category 2 call. We have also seen evidence that the third call which was appropriately escalated to category 1 was responded to in accordance with the relevant timings outlined in the ARP guidance.
Complaint handling
24.Miss A says there were delays in the Trust’s response to her complaint due to it being lost in the system and she was not notified about this.
25.Miss A made a complaint to the Trust on 11 April 2023. This was acknowledged by the Trust on 12 April 2023 and discussed at the Incident Review Group on 13 April 2023. Miss A was informed that her concerns would be considered under the Trust’s Serious Incident Process (SIP) on 24 April 2023 and advised that she could contribute to the process which she wanted to do. Miss A says she was originally informed by the Trust in June 2023 that her complaint was going to the Serious Incident Team, but she had to wait until it was assigned to an investigator.
26.On 5 July 2023, the Trust says that Miss A contacted them to query the status of the SIP in relation to timeframe and requested a meeting. The Trust acknowledged there were delays, but said a meeting would be arranged once an investigator was assigned. On 27 September 2023, the Trust says that Miss A contacted them requesting timeline information regarding the night that an ambulance was called for her father. This information was provided to her. Miss A says that she was assigned an investigator by the Trust at the end of September 2023.
27.On 20 October 2023, Miss A was informed by the Trust that the SIP had been completed without her input. Miss A had a meeting with the Trust on 3 November 2023 where a draft report from the SIP was shared by email. Further meetings were held on 29 November 2023 and 2 February 2024. The Trust provided a written reply on 15 February 2024. It offered further local resolution, but Miss A decided to approach the Ombudsman with her complaint.
28.Paragraph 14(3) of the NHS Complaints Regulations states: ‘In paragraph (4),“relevant period” means the period of 6 months commencing on the day on which the complaint was received, or such longer period as may be agreed before the expiry of that period by the complainant and the responsible body’.
29.Paragraph 14(4) of the NHS Complaints Regulations states: ‘If the responsible body does not send the complainant a response in accordance with paragraph (2) within the relevant period, the responsible body must-
(a) notify the complainant in writing accordingly and explain the reason why; and
(b) send the complainant in writing a response in accordance with paragraph (2) as soon as reasonably practicable after the relevant period’.
30.Paragraph 3(2) of the NHS Complaints Regulations states: ‘The arrangements for dealing with complaints must be such as to ensure that-
(a) complaints are dealt with efficiently.’
31.We have not seen failings by the Trust regarding the time it took to respond to Miss A’s complaint submitted in April 2023. While we acknowledge that the Trust did not provide a substantive response to Miss A’s complaint within 6 months from when her complaint was received, it did maintain contact with Miss A during this period and explain the reasons for the delay. For example, by email on 25 July 2023. It then met with Miss A and provided her with a draft report of findings from the SIP (in November 2023) which served as a written response to her complaint. Therefore, although there was an acknowledged delay in responding to Miss A’s complaint, we cannot say this contravened the relevant NHS Complaints Regulations highlighted above.
32.Furthermore, we have not seen evidence that Miss A’s complaint was ‘lost’ by the Trust during this period, as she has suggested. As the Trust has explained in its complaint response, the delays in responding to Miss A’s complaint were due to the pressure of other complaints the Trust was dealing with at the time and inadequate communication which is addressed below.
33.We have seen a failing in how the Trust handled Miss A’s complaint in that it did not obtain her input as part of the SIP when it had agreed to do so. Unfortunately, the Trust informed Miss A approximately 6 months after she made her complaint that the SIP had been completed without her input. Miss A was shocked and disappointed by this and understandably felt aggrieved that her input was not sought when she expected it to be.
34.Nevertheless, we note the Trust has apologised in its complaint response for not seeking Miss A’s input which was due to a breakdown in communication between two of its internal teams. We also note the Trust’s assurances that learning has been taken from Miss A’s complaint and measures are now in place to prevent similar occurrences of inadequate communication in the future. Given this, we consider there is no further action for us to take.
35.This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.