East of England Ambulance Service NHS Trust

East of England Ambulance Service (the Trust)

4. Mrs F complains about aspects of care and treatment her father, Mr A received from the Trust on 30 December 2023.

5. Specifically, she said the Trust: • paramedics did not follow procedures for contacting Next of Kin (NOK) / Power of Attorney (POA) or the Respect document • shared incorrect information with Out of Hours GP from NHS 111 regarding Mr A’s condition • had poor record keeping, and recoded information inconsistently.

6. Mrs F said as a result of the delay in getting her father to hospital, he contracted aspiration pneumonia (by breathing in food, liquid or vomit). She said this also delayed a pneumonia and stroke diagnosis. She said these delays led to a further delay in receiving appropriate treatment. Mrs F said this ultimately led to her father’s death.

7. Mrs F is looking for service improvements.

Integrated Care 24 Ltd (NHS 111)

8. Specifically, Mrs F said NHS 111: • did not follow procedures for contacting NOK • did not follow the Recommended Summary Plan for Emergency Care and Treatment form (Respect Form). The Respect document states the NOK/POA should be consulted on decisions around health.

• had poor record keeping, and recoded information inconsistently • incorrectly prescribed oral medication.

9. Mrs F said as a result of the delay in getting her father to hospital and in prescribing oral medication he contracted aspiration pneumonia. She said this also delayed a pneumonia and stroke diagnosis. She said these delays led to a further delay in receiving appropriate treatment. Mrs F said this ultimately led to her father’s death.

10. Mrs F is looking for service improvements.

11. Mr A was in his 90s and living in a Care Home in Norwich. He moved there initially for two weeks respite placement in April 2023.

12. His son was a GP who provided care to some of the residents at the Care Home. He was also NOK.

30 December 2023

13. On 30 December 2023, at 9.34am, the Care Home called NHS 111 as Mr A was dizzy, vomiting and showing signs of having had a stroke.

14. The Care Home called Mrs F at 10.00am. It left a voicemail asking her to call back. She called at 10.12am. It told her Mr A had been unwell at breakfast. He had low blood pressure and pulse and was vomiting.

15. At 11.48am, the Care Home called NHS 111 again. The NHS 111 clinician completed a comprehensive telephone assessment. They documented Mr A had stopped all daily activities. They also noted he had a new speech difficulty. They noted this as possible stroke and bradycardia, which is a slow heart rate. They advised he should go to hospital immediately, via ambulance. They arranged an ambulance and advised Care Home staff not to give Mr A, any food, drink or oral medication.

16. At 12.30 pm, Trust paramedics arrived at the Care Home. They saw Mr A vomit. They noted he was dizzy, was leaning to one side and had reduced mobility. He was unable to sit up unattended.

17. The Trust paramedics discussed Mr A’s care with his son, Dr P. He was also NOK/POA for Mr A. They also consulted with an NHS111 out of hours (OOH). The Trust paramedics said Mr A was FAST Negative. (This is a set of observations which help determine whether someone has had a stroke. FAST negative means signs of a stroke were not present).

18. NHS 111 OOH prescribed Mr A oral prochlorperazine. Prochlorperazine is prescribed for dizziness and sickness. The Trust paramedics noted that NHS 111 had said Mr A should be taken to hospital.

19. At 1.44 pm, Mrs F spoke the Care Home deputy manager. The Care Home deputy manager said told paramedics had seen Mr A and OOH had prescribed medication. The deputy manager also said Care Home staff were monitoring him.

20. The OOH advised Mr A’s son and the Care Home to contact Norwich Escalation Avoidance Teams (NEAT) who provide services and information to prevent hospital admissions, to help manage Mr A’s care over the bank holiday weekend.

21. Dr P called NHS 111 three more times that afternoon. He said there was deterioration in Mr A’s condition. He asked for an OOH GP to visit Mr A at the Care Home. NHS 111 recommended a hospital assessment was complete.

22. At 6.11pm, Mrs F called the Care Home who told her Mr A was in bed. Care Home staff were trying to keep him upright with a board, as he was not in an adjustable bed. They said Dr P was arranging for a hospital bed to be delivered. She was told Mr A was very dizzy and producing a lot of phlegm. The Care Home would be monitoring him until his own GP practice opened on Tuesday.

31 December 2023

23. On 31 December 2023 at 8.55am, Mrs F called the Care Home. It said he was in bed, dizzy but smiling. It said they were going to assist Mr A to eat breakfast.

24. At 6.48pm, Mrs F called the Care Home. She was told, he remained in bed, his oxygen levels were stable, but it sounded as though he had phlegm on his chest.

25. At 9.10pm, the Care Home called Mrs F to say Mr A’s oxygen levels had dropped. They were going to call an ambulance. Mrs F said she wanted him to have a hospital admission.

26. At 9.41pm, Trust paramedics arrived. They recorded he had breathing difficulties, a high temperature, rapid shallow breathing, a non-productive cough, prior stroke suspicion, and a prior choking episode.

27. At 10.30pm, Mrs F called the Care Home for an update. It said the Trust had taken Mr A to A&E.

1 January 2023

28. On 1 January 2024, at 12.37am, Mrs F called A&E. A hospital nurse said Mr A had had a brain scan and blood tests.

29. At 6.43am, Mrs F called the hospital. Hospital staff said no-one was available to speak to her. She said she was NOK and held POA. Hospital Staff said it only recognised Dr P as NOK and POA.

30. At 9.06am, Mrs F emailed the Lasting Power of Attorney document to the hospital. It showed she also had POA and was NOK.

31. At 9.22am Mrs F spoke to hospital staff. She told us the brain scan showed Mr A had had a stroke. Hospital staff told her, it had transferred him to a stroke ward. It had started him on intravenous antibiotics and fluids.

32. On 6 January 2024, Mr A sadly died.

34. We use relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. In this case we have referred to the Health Commissioner’s Act 1993 (the Law).

35. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mrs F to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Mrs F.

36. Mrs F said her date of knowledge was 30 December 2023. In order for her complaint to be within our 12-month time consideration, she should have brought her complaint to us by 30 December 2024. Her complaint is six months out of time.

37. Mrs F told us she understood the time limit for bringing her complaint to us. She said she brought her complaint to us December 2024 during a telephone call. She said believed this would count as bringing her complaint to us. During this call, we explained our role, how she should submit her complaint to us in writing, and the time consideration.

38. Mrs F returned to us in June 2025. This was when probate was complete. She said she was worried about probate and the impact her complaint might have on this, if her brother knew she had brought her complaint to us. She said she believed her brother be unhappy if he became aware of her complaint. She told us she believed this would have affected the probate in a negative manner.

39. Mrs F said it took a long time to complete the complaints process for both organisations. She said she only felt she could proceed with her complaint to us in June 2025, after her solicitor closed the file to her father’s estate.

40. Mrs F complained to both organisations in January 2024. Local resolution with the Trust took seven months to complete. Local resolution with NHS 111 took nine months to complete. We believe Mrs F should have brought her complaint to us in October 2024.

41. We can see that Mrs F received the Trust response in August 2024. We believe it was reasonable for her to wait until she had the final NHS 111 response in October, before bringing her complaint to us, as her complaints are linked.

42. The NHS 111 response said it would complete an after-action report as a result of Mrs F complaint. It sent this to her in December 2024. At the very latest, we believe Mrs F should have brought her complaint to us by the end of December 2024. We acknowledge this was a very difficult time for Mrs F. We do not underestimate the impact events had on her. We understand Mrs F reasons for waiting for probate on her father’s estate. She did not need to wait for probate to be completed, before she brought her complaint to us. Mrs F has told us she made the choice to wait.

43. We believe it would have been reasonable for Mrs F to bring her complaint to us sooner than she did.

44. We understand how difficult it can be to make a complaint. We would like to thank Mrs F for bringing her concerns to us.

1. We have carefully considered Mrs F’s complaint about East of England Ambulance Service NHS Trust (the Trust) and Integrated Care 24 Ltd (NHS 111). We were sorry to hear about the treatment her father, Mr A, received on 30 December 2023. We acknowledge these events will have had a significant effect on Mrs F.

2. The complaint falls outside of our time limit, and we have decided there is no good reason for us to put the time limit aside to consider it further.

3. We recognise that the death of a loved one can be very difficult and do not underestimate the impact this had on Mrs F. Taking into account all the information provided there was a delay of ten months between Mrs F receiving the Trust final response and bringing the complaint to us. We are not satisfied the reasons Mrs F has provided for the delay are enough for us to put our time limit to one side.