Ambulance delay
11. When the ambulance service receives 999 calls, these are triaged and categorised to help prioritise the calls. We considered whether Mrs Y’s call was categorised appropriately.
12. The call from the district nurse was triaged and categorised as Category 2, which is considered an emergency call. At the time, NHS England had set targets for Category 2 calls to be responded to within 18 minutes on average, and for 90% of calls to be responded to in 40 minutes. It is accepted that not every call will be responded to within these target times, and some calls will take longer to respond to.
13. Based on the evidence available and the clinical advice received, we consider Mrs Y’s call was categorised correctly. The call was made by a healthcare professional at the care home. During the call it was identified Mrs Y was conscious but had low oxygen saturation levels and a National Early Warning Score (NEWS2) of 7. NEWS2 is a system of recording a patient’s observations and calculating a score to help identify those who are seriously unwell or at risk of deteriorating. The AACE ‘National Framework for healthcare professional ambulance responses’ provides guidance on categorising calls from healthcare professionals and says patients with a NEWS2 of 7 or greater may trigger a Category 2 response.
14. Mrs Y waited approximately 14 hours for an ambulance, which is significantly longer than the average target of 18 minutes. We considered what caused the delay and any evidence relating to how the Trust managed its resources.
15. It is documented the Trust was operating at Surge Level 4 under its ‘Surge/Demand Management Plan’, which indicates different levels of pressure regarding demand on the service, with Level 4 being the most significant. There is reference in the reports to a higher number of 999 calls received than expected. Based on the advice from our adviser, the number of incidents was lower than expected. There are often several 999 calls relating to one incident, so when there are a higher number of calls than expected, this does not mean there are a higher number of incidents to respond to.
16. There is evidence in the reports of delays with hospital handovers, which is the process of ambulance crews handing over care of a patient to the hospital. One of the standards set by NHS England and NHS Improvement is that ‘Ambulance handover…is reliably completed within 15 minutes of arrival…’ (see ‘Reducing ambulance handover delays: key lines of enquiry’). The handover process is the responsibility of the hospital and delays are outside the control of ambulance services. The evidence provided by the Trust shows handover times were excessively longer than the standard expected. This would have impacted the availability of ambulances, and in turn the ability of the Trust to dispatch ambulances to waiting emergencies in a timely manner.
17. When faced with hospital handover delays, there are steps ambulance services can take. Some of these are set out in the Trust’s ‘Surge/Demand Management Plan’. We have not seen any evidence to show the Trust took any actions in line with this. Despite this, we have seen evidence the Trust took several other steps in response to the impact of the handover delays on ambulance availability.
18. Firstly, during the first call the handler asked whether the patient could make their own way to hospital rather than waiting for an ambulance. Secondly, the Trust used the process of cohorting, where one ambulance crew looks after more than one patient at the hospital while awaiting their handover. This allows the other crew(s) to be released to respond to other emergencies. Thirdly, there is documentation to support that handover delays were escalated to NHS England, the Integrated Care Board (which is involved in the planning and delivery of care) and management at the hospitals. In addition, the call handler advised the healthcare professional to call back if Mrs Y deteriorated. Although this was not specifically an action to address the limited ambulance availability, this provided a safety net to seek further help if needed, at which point the ambulance service could consider whether the call needed to be prioritised differently.
19. There is no set guidance on how ambulance services should allocate their resources. Each ambulance trust covers a large geographical area which covers different regions. They will not necessarily send the next available ambulance to an incident if the travel distance is too far, as this will have an impact on the whole service with the potential for ambulances to be travelling excessive distances. Each ambulance service will decide which resources it can allocate to incidents based on local knowledge. The Trust has confirmed it appropriately allocated ambulances to incidents in time order, and we have not seen anything in the evidence available to us to indicate otherwise.
20. Mrs Y’s call was received during a time when there were severe pressures on ambulance services, which resulted in a significant increase in response times for Category 2 calls in England. This led to NHS England implementing a ‘Delivery plan for recovering urgent and emergency care services’. This explains December was the busiest month on record for emergency departments in England. It also highlighted one of the main causes of longer waits for ambulances is delays handing patients over to hospital staff.
21. We acknowledge Mrs Y waited a significant amount of time for an ambulance and this has caused distress to Mr Y, as he worries this contributed to her death. Based on the evidence available, we do not consider the delay was due to any individual failings by the Trust. This was more likely due to delays in the hospital handover system, which was outside the control of the Trust. Overall, we consider there is sufficient evidence to show the Trust responded appropriately to the ambulance handover delays.
Oxygen levels
22. It is documented in Mrs Y’s ambulance records she had been unwell over the weekend with a chesty cough and there was a query as to whether she had pneumonia. It is also documented the district nurse was concerned about her low oxygen saturations, which were 88%. The impression of the ambulance crew was that Mrs Y had sepsis.
23. According to the JRCALC Clinical Guidelines, the target range for oxygen saturations is 94-98% for adults with serious illnesses. This applied to Mrs Y as the ambulance crew considered she had sepsis, which is a serious illness. Mrs Y’s oxygen saturation levels were first measured by the ambulance crew at 9.03am on 20 December and were 82%. Mrs Y was given 28% oxygen at 6 litres. Further oxygen recordings over the next hour ranged from 91% to 88%. Our adviser explained the maximum amount of oxygen that can be given is 15 litres. They explained if the patient’s target oxygen levels were not being reached, the ambulance crew should deliver higher levels of oxygen than 6 litres. Mrs Y’s oxygen levels did not get near to the target range, yet the ambulance crew continued to give only 6 litres.
24. Our adviser explained it would only be appropriate to limit the oxygen for patients whose normal oxygen saturation is lower than the average person or those with a respiratory illness, such as Chronic Obstructive Pulmonary Disorder (COPD). This is because such patients can retain carbon dioxide in the blood, so too much oxygen can cause harm.
25. The ambulance clinician explained they would have aimed for a reading of 88-92% if it was believed Mrs Y had COPD. It is documented Mrs Y had asthma, but there is no documented evidence she suffered with COPD or that there was any other reason to limit her oxygen.
26. We consider there was a failing by the ambulance crew to provide appropriate treatment to increase Mrs Y’s oxygen saturation in line with the JRCALC Clinical Guidelines. After considering the clinical advice, our view is this is unlikely to have had an impact on Mrs Y’s chances of survival for several reasons. Firstly, Mrs Y had already had low oxygen saturation for approximately 14 hours before the ambulance arrived. Secondly, Mrs Y was treated after she attended hospital and her oxygen saturation increased to 95%. This happened within four hours of the ambulance crew arriving. Lastly, it was not until five days later that Mrs Y sadly died.
27. We appreciate it must be distressing for Mr Y to learn his mother did not get some of the treatment she needed initially. We hope our explanations have provided reassurance to Mr Y that this did not have any impact in the way he feared.