East of England Ambulance Service NHS Trust

5. Mr L complains about aspects of the service provided to his late friend, Mr H, by the Trust in July 2024.

6. Specifically, he complains:

• the emergency 999 call Mr H made, was not triaged correctly and he was told he would have to wait up to six hours for help, when a healthcare professional had raised a concern that Mr H had potential sepsis • when Mr H was transferred between hospitals, the ambulance crew would not take his wheelchair to the hospital and Mr H had to travel without it, affecting his independence.

7. Mr L says the incorrect triage meant there was a delay in Mr H’s treatment, and he was not transported to the correct hospital straightaway. He says Mr H felt frightened, alone, abandoned and suffered in pain and distress because of this and if the delay had not occurred, his life may have been saved.

8. Mr L seeks an acknowledgement of what went wrong, an apology and service improvements.

9. Mr H was staying in temporary accommodation in a hotel, when a staff member made a 999 call for him on 18 July at 7.28pm. They explained to the call handler that Mr H was in a wheelchair and a district nurse had informed him that he was susceptible to sepsis. Mr H then spoke to the call handler and explained that in June, he had a leg amputation above the knee, and the area was very painful. He had earlier seen a district nurse who advised there was a severe chance of sepsis, and he required liquid antibiotics.

10. The call handler advised Mr H that a clinician would review his call and call him back within six hours, to arrange the most appropriate response. They also told him it may not take the full amount of time and Mr H explained his friend may be able to take him to A&E. The call handler asked him to call back and let the Trust know if that was the case.

11. At 7.46pm, the hotel staff member called the Trust again, via 999, to cancel the call, as Mr H’s friend was taking him to A&E.

12. Mr H’s friend took him to A&E. During the admission, the hospital called the Trust again to request a transfer to another hospital as Mr H required vascular surgery (treats diseases of the blood vessels) and he had potential sepsis. The hospital also requested a stretcher for his transfer.

13. The Trust transferred Mr H to another hospital, where unfortunately his condition declined. Sadly, Mr H died on 22 August 2024.

Call categorisation

17. 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. We explain the reasons for our decision, below.

18. Mr L complains the 999 call made for Mr H, was incorrectly triaged and he was told he would have to wait up to six hours for help, when he had suspected sepsis.

19. In its complaint response, the Trust said the 999 call was triaged correctly and assigned a category 5 response. This category is for patients whose condition requires an assessment, via telephone, by a clinician in the first instance. It said it gave a timescale of within six hours for this to take place and a note was made identifying concerns about sepsis.

20. The Trust said its service was under significant pressure at the time of the first call, due to volume of 999 calls and challenges with releasing ambulances in the community to respond to patients.

21. We reviewed the 999 call recording with help from our adviser.

22. 999-calls are not allocated a category by the call handler, ambulance services have to utilise licenced products to triage 999 calls agreed by NHS England, of which there are two, NHS Pathways and the Medical Priority Dispatch System (MPDS). Following triage, these systems allocate the category to determine an ambulance response. This ensures the triage, and their outcomes, are aligned to NHS England’s Ambulance Response Programme (APR) categories. This is used to set response times across the country.

23. These triage systems are interlinked questions, which how the questions are answered and logged, will prompt the next question until an outcome is reached by the system giving the call handler the category. The system works on presenting symptoms at the time, and not a diagnosis. The MPDS uses different protocols to categorise and prioritise calls.

24. When the 999 call was made for Mr H, the call handler correctly confirmed that Mr H was breathing and not bleeding heavily. This was to ensure Mr H was not in cardiac arrest, before moving on to what was happening to determine what protocol to apply.

25. Mr H then outlined his recent amputation and problems he was having, and the advice given to him by the district nurse, including concerns about potential sepsis. As Mr H gave a lot of medical information, it was correct that the call handler advised him that they would make a request for a clinician to call him back. They also made some notes on the system to explain the information Mr H had given, including his symptoms. The notes are not used by MPDS to assign a category, but for anyone who reviews the incident, to aid decision making.

26. The call was assigned as a category 5 which means clinical input was requested to gain the correct response for Mr H’s needs. Given that Mr H gave a lot of medical information during the call, it is reasonable that this was the category that was assigned and clinical support requested. The call handler initially utilised the correct protocol within MPDS and after more information was given by Mr H about what was happening, escalated the call to a senior clinician for rapid review.

27. We recognise Mr L was also concerned about the timeframe the call handler gave Mr H for help.

28. A category 5 call would not be allocated an ambulance, unless the clinician who called the patient back, upgraded the call. There is no national timeframe for a clinical call back but there is evidence the call handler escalated the call for a clinician to review it as soon as possible. The call handler therefore identified that Mr H needed input from a clinician quickly and recognised the potential urgency of Mr H’s possible presentation.

29. We also considered information and data the Trust sent to us about its capacity on 18 July. This shows there was a long queue of emergencies awaiting help and not enough ambulances to allocate to them, indicating it was a challenging evening. There is also evidence the Trust was acting to try and increase availability.

30. The evidence indicates the Trust categorised the 999 call correctly and it was escalated for a clinical review, to happen as soon as possible. We recognise the call was then cancelled, as Mr H was able to make his own way to hospital, so this review did not take place.

31. We also understand Mr L’s worry that as an ambulance did not collect Mr H, this meant he was not transported to the correct hospital straightaway. A paramedic cannot decide if a patient needs surgery, and it is unlikely that even if Mr H had been picked up by an ambulance, he would have been transported to a specialist site for treatment. This decision is usually made by the treating doctor in A&E. We hope this provides some extra reassurance to Mr H.

Wheelchair

32. Mr L also complains that when the Trust transferred Mr H between hospitals, the ambulance crew did not take his wheelchair, and he had to travel without it. We understand this was a worrying time.

33. In its complaint response, the Trust said it is the responsibility of the driver to ensure the vehicle is not overloaded and all equipment or items carried, are safely secured. It also explained that ambulances are equipped with two different styles of wheelchairs that can be used for transferring patients in and out of the ambulance and therefore no requirement to take a patient’s personal wheelchair. It said this is because the space is very limited, and there is no way of securing a patient’s own wheelchair on the vehicle.

34. Our principles state that public bodies must act in accordance with recognised quality standards, established good practice or both.

35. Our adviser explained it is common practice for emergency ambulances not to take a patient’s own wheelchair in the vehicle, as ambulances have their own wheelchairs to get patients to and from the ambulance, if needed.

36. When Mr H was transferred between hospitals, the request said he required a stretcher and therefore needed to lie down when the transfer happened.

37. Ambulances often break the speed limit and like any other equipment in the back of the ambulance, it has to be tied down correctly and in the right space, so it does not move whilst travelling and harm anyone. An ambulance also requires a lot of equipment in a small space, that can be narrow and does not have the space or means to secure an extra wheelchair, which could block entrances and exits.

38. We recognise Mr L’s strength of feelings that Mr H was left without his wheelchair when the Trust transferred him between hospitals. The information tells us he had to lie down for the transfer, so a stretcher was requested. Ambulances also have their own wheelchairs available for patients if needed. We therefore think it was reasonable the Trust did not take Mr H’s wheelchair when it transferred him between hospitals.

39. We note the Trust’s complaint response also explained there are options for reuniting a wheelchair with its owner at a later time. We hope this provides some reassurance to Mr L.

40. We recognise this has been a difficult time for Mr L and understand the events complained about are important to him. We have not identified that anything went wrong with the service provided by the Trust and therefore we are taking no further action on the complaint. We hope this statement explains the reasons for our decision clearly.

1. We have carefully considered Mr L’s complaint about the Trust. Having done so, we have seen no indication that anything went seriously wrong in his late friend, Mr H’s care.

2. We acknowledge how important Mr L’s complaint is to him and recognise this has been a difficult time. We are sorry to hear of Mr H’s sad death and the impact this has had.

3. We reviewed how the Trust handled the 999-call made for Mr H, and we think it was categorised correctly. We also think it was reasonable that the ambulance crew did not take Mr H’s wheelchair when it transferred him between hospitals, and this is in line with standard practices.

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