Ambulance time 9. We listened to the recording of Mr N’s call. On the call, Mr N told the call handler it was his sixth day of receiving radiotherapy for cancer. He said his concern was anxiety and breathing, that he was breathing slightly harder than usual, explaining that when he gets anxious his breathing is worse.
10. The call handler advised he sit comfortably upright and take any medications he may have been prescribed. The call handler said help would be arranged and told Mr N the service was under a significant amount of pressure, and it may be several hours before an ambulance becomes available. Mr N said he felt better just talking with the call handler, that he thought he was just panicking. The call handler assured Mr N and gave him advice to call back if his symptoms worsened.
11. When 999 calls are made, the call handler must obtain relevant information from the caller and categorise the call according to how urgently the patient needs assistance. This process is called triage. The NHS Pathways triage system takes the form of a series of scripted questions which the call handler asks the person making the emergency call.
12. Mr N’s call followed this process of triage in line with NHS Pathways and was assessed as a category 3 call. Calls are categorised as a 1 for life-threatening injury or illness, category 2 for emergencies and category 3 for urgent calls.
13. Our adviser confirms a category 3 response was appropriate to the information Mr N gave. Whilst he reported breathing harder and his breathing being worse, throughout the seven-minute call Mr N spoke clearly and calmly, in a normal tone and manner. There is no audible or verbal suggestion from him at any time, that he was struggling to breathe.
14. Response Standards say ambulance services are expected to respond to 90% of category 3 calls within two hours. At the time of Mr N’s call, WMAS reported that they were responding to 90% of category 3 incidents within 304 minutes, just over 5 hours. An ambulance arrived at Mr N’s address 5 hours and 10 minutes after the close of his 999 call.
15. We recognise this was several hours longer than the Response Standards target. However, even those national targets do not require the aimed response time to be met in 100% of cases. We therefore cannot expect ambulance services to meet these targets in every individual case. We have carefully considered the circumstances in this particular case.
16. At the time of these events, WMAS was reporting Surge Demand Level 4. Information from the WMAS website explains this is when the demand on WMAS service rises so significantly that in some areas, activity is over 15-20% above forecasted levels. WMAS records contain the data to support this response.
17. WMAS explained that at the time of Mr N’s call and wait for an ambulance, it had approximately 250 calls awaiting ambulance response. It also explained significant hospital delays, meaning many of its ambulances were waiting multiple hours to handover patients to hospital, before those ambulances could become available to attend other calls. WMAS records show the longest at-hospital wait at the time in question was over four hours. For context, the AACE report explains the national target included in the NHS Standard Contact is for handover within 15-minutes.
18. Records show there was a clear increase in demand on WMAS as well as a considerable impact from hospital delays, both of which were outside of WMAS’ control. We would not criticise WMAS for factors outside of its control. Records show it was unable to get an ambulance to Mr N sooner, essentially as it did not have the resources available to do so.
19. The evidence available to us shows WMAS was managing the resources it had appropriately. We can see it got an ambulance to Mr N’s address around the same time it was responding to other category 3 calls. In the circumstances, we cannot see that WMAS had anything else they could do to reach Mr N sooner, and we consider the explanation for the delay reasonable. We do not see any indication of service failure on WMAS’ part here.
Call back 20. Miss N is concerned that WMAS did not call her brother back. In response to her complaint, WMAS explained that the initial risk assessment following her brother’s call marked his case as a ‘priority’ so that a clinical assessment could be done over other category 3 calls waiting in the queue. It said unfortunately due to the demand of the clinical queue this did not happen.
21. WMAS said where calls are still awaiting a call back, further risk assessments should take place every two hours and this timeframe was breached in Mr N’s case. It said when the next risk assessment went ahead, Mr N’s case was transferred to dispatch for an ambulance response.
22. Our adviser explains there is no national standard, target or expectation for when call backs should take place after the initial 999 call, that this is for individual ambulance services to determine. Whilst we are not critical that a call back was not made by a specific time, we do think a call back should have been made.
23. During the 999 call, Mr N advised he was receiving radiotherapy treatment. Our adviser says as explained in NICE guidance, this alongside his presentation may have increased his risk of sepsis (a life-threatening response to infection). This would have needed a clinical call back, for a remote telephone assessment to consider further. With this risk and need for further assessment, alongside the known wait for ambulance availability, we think marking the case as a priority was appropriate and the expectation would have been for a patient call back.
24. Miss N says if WMAS had called her brother in those hours and if he had worsened or if he didn’t answer, it might have sent an ambulance sooner and he may not have died.
25. We know how upsetting it must be for Miss N to know her brother should have been called back, in the time before the ambulance arrived and sadly found him deceased at home. Yet we cannot say the call back would have changed the sad course of events.
26. As we have explained, Mr N was speaking normally on the 999 call he made that evening, and the NHS Pathways triage did not recognise any symptoms at that time requiring a more immediate response. Whilst we think a call back should have happened, we cannot say when this would have happened. We also do not know when Mr N sadly died.
27. If there had been a call back and Mr N had answered, it is possible he may have described symptoms that would have led the call handler to update his call to a category 2 response, but it is also equally possible he would have presented in a similar way to his earlier call, and the same category 3 response decision would have been maintained. We cannot say an answered call back would have resulted in a change to what happened.
28. Even had the call back resulted in a category 2 response, we cannot say an earlier ambulance would have arrived before Mr N sadly died.
29. If there had been a call back and Mr N had not answered, it cannot be said that this would have resulted in a category upgrade. Our adviser explains there is no automatic expectation that when someone doesn’t answer the phone from a clinical call back, that they receive an upgraded ambulance response.
30. In its response to Miss N’s complaint, WMAS acknowledged where it got things wrong, and sincerely apologised to Miss N for this. It also explained having reviewed what happened under its Learning from Deaths policy, and listed a number of actions undertaken and as ongoing learning. This includes explanation that WMAS has increased the number of clinicians available in the control room, with the aim of receiving more timely community care.
31. NHS Complaint Standards say organisations should openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They say organisations should explain why things went wrong, give meaningful and sincerely apologies and explanations that openly reflect the impact on the people concerned, and identify suitable ways to put things right.
32. We consider WMAS’ response and the actins it has taken are in line with the NHS Complaint Standards, in giving a fair and accountable response and promoting a learning culture. In our view, the response is proportionate to what went wrong and the actions already taken go far enough to remedy the impact, of the distress caused to Miss N. We do not find there is anything left to remedy, and we consider this matter resolved by the response given and actions already taken.