Yorkshire Ambulance Service NHS Trust

4. Mr N complains about the care an ambulance crew working for the Trust gave to his father on 7 December 2021. He is particularly concerned about how they managed his oxygen supply and their response to his sudden deterioration in the hospital. Mr N believes his father’s death was avoidable. He wants the Trust to acknowledge its failings and to make changes to procedures. He also seeks a financial remedy

5. On 7 December 2021 Mr L’s GP was concerned about his increasing breathlessness and arranged for an ambulance crew to attend his home. They decided to take him to the hospital and gave him oxygen during the journey.

6. On arrival at the hospital Mr L went to the toilet with assistance from one of the crew members. On his return Mr L became short of breath and said he did not feel the oxygen supply was working. His wife also considered it was not working. One of the crew members checked this and considered that the supply was flowing correctly. Mr L then collapsed from a cardiac arrest and the crew member asked a paramedic who was in the department for assistance.

7. After a few minutes hospital staff arranged for Mr L to have a bed. Clinicians tried to resuscitate Mr L but he remained unresponsive and, sadly, he died the next day.

8. Mr N complained to the Trust the day after the incident. Over the following months the Trust issued two complaint responses to Mr N and also arranged for the family to attend a meeting to discuss their concerns. Mr N remained dissatisfied, so he complained to us.

11. 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.

12. The Clinical Adviser told us the clinicians should have followed the Clinical Guidelines when they were providing oxygen for Mr L. They say clinicians should provide patient-centred care. They include a section about the use of oxygen which explains how clinicians should ensure people who need oxygen therapy get the appropriate dose. For people like Mr L, who have COPD (chronic obstructive pulmonary disease – a group of conditions that make it hard for someone to breathe), the Oxygen Guidelines recommend an oxygen administration rate of four litres per minute.

13. Records show Mr N’s home oxygen was usually between three and five litres per minute. This was continued during his journey to the hospital. After Mr N returned from the toilet there was a discussion about whether the oxygen supply had been turned off. The crew members noted they showed Mr L that oxygen was flowing, and they could hear it. Mr N is clear that both his mother and father noted that the oxygen was not flowing.

14. The emergency department had a CCTV camera which recorded the events in the complaint. Mr N and the Trust reviewed the images, which are no longer available. There is no dispute that the images show Mr L raising concerns with the crew and them checking the oxygen supply.

15. This is a situation where there are two different accounts about what happened. Mr L’s family believe the oxygen supply stopped and the ambulance crew members say this was incorrect. It is not possible for us to take a view at this stage about whether either account is correct. There is no independent evidence of any failings by the Trust.

16. The Clinical Adviser told us there is nothing to suggest the ambulance clinicians failed to assess Mr L appropriately. They also requested appropriate support when Mr L had the cardiac arrest. There was no indication that Mr L was likely to experience a cardiac arrest beforehand.

17. There is no evidence the ambulance clinicians fell below the standard required in the Oxygen Guidelines. They appear to have provided patient-centred care and appropriate oxygen therapy. As there are no indications of failings we have decided not to start a detailed investigation of Mr N’s complaint.

18. Clearly, these events have been incredibly difficult for Mr N and his family. We hope they can appreciate why we have decided not to investigate further.

1. We have carefully considered Mr N’s complaint about the Trust. We have decided not to start a detailed investigation because we have seen no indication that anything went seriously wrong. We recognise Mr N strongly disputes this.

2. Mr N complains about the care clinicians working for the Trust gave to his father while he was waiting in a hospital emergency department. Sadly, Mr N’s father experienced a cardiac arrest and died the next day. We can see how devastating these events have been for Mr N and his family. We offer our sincere condolences to them for their loss.

3. We have seen no indication the clinicians fell below the required standards when caring for Mr N’s father, who we have referred to in this statement as Mr L.