Mrs O’s complaint
15. Mrs O complains the Trust failed to send out an ambulance to Ms I after she repeatedly raised concerns in three different calls. Mrs O says had the Trust done so, her sister would not have died alone.
16. Ms I had three calls with the Trust: a 999 call, 111 call and a further call with a GP. We have considered each call separately below.
999 call
17. As set out above, Ms I called 999 on 28 April 2024. The call was triaged by an emergency call handler. Ms I complained of severe pain in the lower back area and said she was hardly able to move. Ms I told the call handler the pain started less than an hour ago, it was not known what caused the back pain and Ms I was not experiencing any difficulty in breathing or chest pain. Ms I said she had never been diagnosed with an abdominal aortic aneurysm.
18. The Trust’s call log states the pain had come on suddenly, worsened when moving and was progressively getting worse. Ms I was placed on the ‘Non-traumatic Back Pain’ pathway which said she needed to speak to a clinician from its service immediately.
19. Our ambulance adviser explained Advance Medical Priority Dispatch System (AMPDS) is an international system which provides the call handler prompts to ask the 999 caller about their symptoms. AMPDS follows a set of protocols and then generates a code based on the information shared by the caller.
20. This code identifies the presenting complaint, the clinical priority and any other pertinent information. Once the triage is completed and AMPDS generates the code, the code is matched to a national agreed set of response categories outlined by the Ambulance Response Programme. This determines the most suitable outcome and response for the patient.
21. As the outcome is guided by the caller’s answers to the standardised questions, there is no set guidance as to what should happen.
22. Our ambulance adviser explained based on the symptoms and answers to questions Ms I complained of and shared during the 999 call, she was correctly categorised as a 5A1 – a none-traumatic back pain of lowest clinical priority. Ms I described back pain, and she confirmed she had never been diagnosed with an abdominal aortic aneurysm.
23. Our ambulance adviser explained the code generated was then matched up with the NHS Ambulance service response code. They explained the AMPDS code 5A1 is the lowest category within the back pain protocol and is aligned to a ‘category 5’ response under the Ambulance Response Programme.
24. Category 5 incidents are identified as having a higher likelihood of there being a more suitable onward pathway than an ambulance response, such as a referral to another service like 111.
25. Our ambulance adviser explained the call handler correctly referred Ms I to contact 111 for further advice given the category 5 outcome.
26. As such, based on the information Ms I shared with call handler, she was appropriately triaged and referred to the 111 service. It is important to note that call handler is not clinically qualified and so is limited to utilising the AMPDS triage system and cannot make independent clinical judgements or deviations away from the system.
111 call
27. Following the 999 call, Ms I rang 111 at 5:27pm. Ms I told the health adviser the same symptoms listed in paragraphs 17 and 18 above. The Trust’s response says she was assessed using the ‘lower back pain pathway’ and the outcome was to ‘speak to a Clinician from our service immediately’.
28. Our ambulance adviser explained that call handler took the same information as the original 999 call. The call handler followed the NHS Pathway Clinical Decision Support System relying on the information Ms I shared with them over the phone.
29. The NHS Pathways system is a clinical decision support and triage tool used in number of urgent and emergency services such as 111 and 999. This system is made up of algorithms and pathways which prompts the call handler to ask questions. The system then provides a code based upon the answers to the questions.
30. Our ambulance adviser explained the NHS Pathway generated a DX333 code which meant the patient needed to speak to a clinician immediately. We understand from the records the call handler correctly referred Ms I to the clinician service, and they arranged for a GP to call Ms I.
31. Having considered the calls and the information shared by Ms I over the phone, our ambulance adviser explained Ms I was correctly categorised during both calls and the correct advice was given to her each time. As such, we can see the Trust appropriately triaged Ms I’s 111 call, recognised that she needed to speak to a clinician and arranged for a GP to call her back. We have not seen any indication of failings.
GP call
32. A GP from NHS 111 called Ms I back at 5:39pm. Ms I reported the pain began 30-45 minutes earlier whilst she was seated. The Trust response says Ms I initially provided a pain score of nine out of 10, but the pain had decreased to seven out of 10 by the time of the call.
33. Ms I described the pain as ‘heavy and sharp, in a band across the waist’ and there was minor radiation into the top of one leg, which Ms I questioned whether it was attributed to arthritis in her left hip. Ms I had taken paracetamol with minimal relief and a heat pack had exacerbated the pain. Ms I said she could not take additional medication due to her warfarin therapy.
34. The GP noted the absence of fever and some improvement with paracetamol and offered a prescription for codeine, but Ms I declined due to the adverse side effects she had previously experienced. The GP explained to Ms I the pain may be muscular in origin and arranged a follow-up GP appointment with Ms I’s GP for the next day. Ms I was advised if the pain worsened, to seek hospital assessment.
35. NICE CKS guidance on low back pain helps us understand what should happen. This says when a patient presents with low back pain symptoms, exclude any underlying cause and assess for prognostic indicators to help guide management.
36. From the GP clinical advice, we understand the GP acted in line with NICE guidance when it assessed Ms I’s low back pain for red flag symptoms. The GP ruled out cauda equina syndrome (spinal cord compression), infection and other issues that could lead to back pain. The GP asked Ms I about the pain severity and where the pain was located as well as whether Ms I had taken pain relief.
37. Our GP adviser explained the GP was thorough in their assessment of Ms I and was reassured the pain was muscular based and was improving.
38. We understand from our GP adviser the GP gave appropriate safety netting advice such as to call 999 should Ms I’s symptoms worsen and inform 999 she had already spoken to 111. This was in line with GMC ‘Good Medical Practice’ guidance, which says at section 28 to give patients information they need or in a way they can understand. The GP also arranged a further follow up appointment for Ms I’s GP the following day.
39. In conclusion, we consider the GP appropriately assessed Ms I symptoms in line with NICE guidance and gave appropriate safety net advice. There was nothing to suggest that Ms I required an ambulance based on the information she shared with the Trust over the phone.
40. With the above in mind, we will take no further action. We know this complaint means a great deal to Mrs O, so we hope Mrs O finds some reassurance in our impartial review of the evidence available, how we reached our decision and our consideration that the Trust acted appropriately based on the symptoms Ms I reported.