Triage and prioritisation of Mrs F’s 999 calls
17. Ms E says the call handler did not correctly triage and prioritise Mrs F’s 999 calls.
We are sorry to hear Ms E feels her aunt was not triaged correctly. We understand her concerns given a stroke is a very serious health condition. The Trust says a safe and thorough assessment was completed by the original call handler and the call was correctly prioritised. The Trust says it triaged Mrs F as a category three (C3) for suspected stroke on NHS Pathways.
18. We asked our adviser if based on the call to 999, was Mrs F triaged correctly. Our adviser says the call handler appropriately asked the relevant questions as directed by NHS Pathways to screen for stroke features. These questions are in line with JRCALC and NICE guidance, which define pre-hospital stroke screening through the FAST test (facial weakness, arm weakness, speech disturbance). Our adviser listened to the call recording and says no FAST-positive features were identified.
19. The symptom Mrs F described was isolated one-sided leg weakness, which she had experienced since 3am, over six hours earlier. Our adviser explained that one-sided leg weakness would not have been captured in the FAST screening and can be a symptom of many causes unrelated to a stroke. This is reflected in JRCALC and NICE guidance. JRCALC says a deficit in any one of the face, arms or speech domains wosillettuld be enough to identify the patient as ‘FAST positive.’
20. At the time of these events NHS Pathways would determine if a suspected stroke should be a category two or three priority depending on whether the symptoms had started within the last four hours, and if the patient took medication to thin their blood.
21. This is because patients could receive stroke clot busting treatment (thrombolysis) if given within the first four and a half hours of symptoms’ onset or if the patient was at risk of blood clots. For patients whose symptoms began outside of this timeframe and were not on any blood thinning treatment (which Mrs F confirmed during triage), NHS Pathways would generate a category three priority.
22. We understand Ms E’s concern the call handler did not prioritise Mrs F appropriately, given we now know her to have had a stroke. We must look at the evidence available at the time of the incident and whether this was in line with guidance.
23. Based on the evidence above, we can see the category three triage outcome was entirely consistent with relevant guidelines. Therefore, we see no indication that something went wrong.
Time taken to dispatch an ambulance
24. Ms E complains the ambulance took too long to arrive to her aunt who was triaged as a potential stroke patient. Mrs F called 999 at 9.15am. The records show the ambulance arrived on scene at 1.43pm. We are sorry to hear Mrs F had to wait so long for the ambulance to arrive and appreciate how distressed she would have felt during the wait. We understand why Ms E is so concerned about the time Mrs F was waiting for an ambulance, given her stroke had a life changing impact.
25. The Trust acknowledged the delay was unacceptable and apologised it was unable to send help within the expected time. It explained it was under immense pressure with 45 incidents requiring attendance from crews in the area on that day, 33 of which were categorised as a higher priority than C3.
26. The Ambulance Response Programme (ARP) framework says ambulance services should attend to 90% of category three calls within two hours . When a Trust is under extreme pressure it should follow the steps in its surge plan and a report should be completed. The Trust’s surge plan from 1 April 2022 shows at 11.38am the Trust declared Surge Management Plan (SMP) level 2, which escalated to level 3 by 12.08pm.
27. When the Trust is operating at level one of the SMP the Trust can dispatch ambulances in accordance with the expected response times. When the Trust is operating at SMP level two, it is under pressure with at least 30 patients waiting longer than the expected response time. The Trust’s surge plan sets out several internal measures the Trust takes to try and free up resources.
28. If these measures do not work and the number of patients waiting longer than the expected time increases to 45, the Trust escalates to level three of the surge plan. This involves further local and strategic action such as staff overtime, calling in staff who are off duty, and requesting support from other organisations.
29. The Trust’s surge plan requires higher review of outstanding calls at both levels and says “clinical review of all Category 3 and 4 incidents before allocation” at level 3. This is to make sure limited ambulance resources are prioritised appropriately for the patients who need them most. The people carrying out clinical reviews can change the prioritisation of a call when appropriate.
30. Our adviser says the Trust took appropriate action to reduce the delay and risk to Mrs F , following its surge plan. An ambulance practitioner (AP 1) made welfare calls to Mrs F at 11.07am, 11.42am and 1.30pm. At 12.48pm, a clinical safety navigator (CSN) reviewed Mrs F’s case and placed a priority one (P1) marker in the job and instructions box. This meant she became the top priority for the next category three response.
31. This shows the Trust was reviewing calls in line with the surge plan. The CSN recognised that Mrs F was the highest priority amongst the category three patients. However, as there remained outstanding category one and two calls who were a higher priority, Mrs F still had to wait around an hour even from this point.
32. We recognise the ambulance took far longer to arrive than the target response time of two hours. We understand this caused distress to Mrs F and her family.
33. The Trust was under extreme pressures with far more people needing ambulances than the resources that were available. When an ambulance trust is operating in such a challenging situation, we look to see the Trust was appropriately following the surge plan to support patients and allocate resources appropriately.
34. We consider the Trust put enough support in place to ensure Mrs F received the right support and care as quickly as possible whilst also considering the safety and needs of others using the ambulance service at the same time.
The ambulance service took Mrs F to a hospital without a stroke unit
35. Ms E complains the ambulance service took her aunt to a hospital without a stroke unit. She says the ambulance crew questioned why they were sending Mrs F to Hospital A and not Hospital B, which had a stroke unit.
36. We can see JRCALC guidelines recommend patients with suspected stroke are transferred to an appropriate hospital as rapidly as possibly once the diagnosis is suspected. Similarly, NICE guidance says patients with suspected stroke should be admitted to a specialist stroke unit.
37. The Trust say there is no evidence of a conversation held between the Trust and the stroke team at hospital. As a result, it was unable to explain why the crew were advised to take Mrs F to Hospital A. It also says given the time since the call and the complaint response, it would not expect a member of staff to recall specific telephone conversations.
38. As there is no record of advice from a stroke specialist or control room clinician about the hospital destination, we asked our adviser if, based on the evidence available, it was appropriate to send Mrs F to Hospital A. Our adviser says at the point of ambulance assessment, Mrs F was FAST negative, had isolated leg weakness and was outside the four-hour window for thrombolysis treatment. Therefore, there was no clinical need to send her to a specific stroke unit.
39. This is in line with JRCALC and NICE guidelines which state FAST is the recommended pre-hospital screening tool for stroke. As Mrs F was FAST negative, this did not indicate she needed to go to a specialist stroke unit.
40. We understand Ms E’s frustration in her aunt being transferred to Hospital A given it was later determined her aunt did have a stroke. Given Mrs F’s presentation at the ambulance’s assessment, we consider the transfer to the local emergency department ay Hospital A was not inappropriate. We acknowledge the rationale for the decision to go to Hospital A should have been recorded, however given Mrs F was FAST negative, the transfer to Hospital A was appropriate.
41. In summary, we have seen no indications the Trust did anything wrong when it triaged Mrs F’s call. Though the ambulance did not arrive within the target response time of two hours, we can see the Trust appropriately followed its surge plan to try and get a resource to her as quickly as possible. We cannot say the delay in the ambulance arriving was due to mistakes or faults on the Trust’s part. We also can see no indication the Trust acted incorrectly in taking Ms F to hospital A.