Category and response time
25. Firstly, we considered how the Trust categorised the calls Mr B’s carer made, and how quickly an ambulance arrived. Mrs A is concerned the ambulance took one and a half hours to get to her son who was struggling to breathe. We recognise how deeply distressing this has been for her.
26. When considering complaints about delays in ambulances attending calls, our approach is to consider whether the Trust did all it could with the resource available. This includes whether it allocated the correct triage protocol and followed any surge plans. Surge plans are local protocols used when a Trust is experiencing unusually high demand for its service.
27. NHS England: Ambulance Quality Indicators says 999 call handlers should use a nationally recognised triage tool to categorise a call into the four categories set out in the ARP guidance.
28. The Trust did so by using the Advanced Medical Priority Dispatch System (the dispatch system). This uses a structured system of questions. Following triage these systems allocate the category of the call. The ARP guidance then determines how quickly a Trust should aim to send an ambulance to the patient depending on the category they fall into. An ambulance is then allocated in time order against its priority.
29. Mr B’s carer made an initial call for assistance at 8.47am and explained he was showing problems with breathing and a cough. The Trust allocated the call to a category two response at 8.50am.
30. The ARP guidance explains category two is for patients with a potentially life-threatening condition such as a heart attack, stroke or major burn. There is a target response time of between 18 to 40 minutes, meaning an ambulance should have arrived by 9.29am.
31. Mrs A is concerned the Trust did not understand the seriousness of the incident and did not consider Mr B’s underlying condition. She feels if it had known this, it would have sent an ambulance sooner. The Trust said it had no information about Mr B’s underlying health condition on its record.
32. When call handlers ask structured questions, the dispatch system in turn prompts more questions followed by the appropriate ambulance response. Our paramedic adviser explained it will allocate a category of response based on the patient’s current presenting symptoms, not a patient’s medical history.
33. As Mr B’s condition was urgent and he was breathing, it is our view the Trust categorised this call correctly.
34. At 9.39am, Mr B’s carer made a second call and confirmed he had stopped breathing and was in cardiac arrest. The call handler re-assigned this to category one.
35. The ARP guidance explains this category is for patients with the most urgent clinical needs who are in an immediately life-threatening condition, such as those in cardiac arrest, respiratory arrest or those with an airway obstruction. There is a target response time for category one calls of within seven and 15 minutes. Therefore, an ambulance should have arrived by 9.54am.
36. In line with this, the Trust categorised this call correctly because Mr B had at this time stopped breathing. This was clearly a very difficult time for him, his carer and his family.
37. The ambulance arrived at 10.07am, which was 38 minutes later than the response times set out in the ARP guidance for category two calls and 13 minutes later for category one calls.
38. We have considered the Trust’s evidence and data to understand the reason for the delay. We have seen there were no available ambulances to allocate, and many ambulances were unable to clear hospital to respond to outstanding emergencies. This was because the average hospital handover time was three hours, nine minutes.
39. NHS Statistical Note: Ambulance Quality Indicators says December 2022 was an extremely challenging month for all ambulance services to respond because of hospital handover delays, with the national average for category two response at one hour 32 minutes. The NHS England, Delivery plan for recovering urgent and emergency care service also acknowledged these challenges in their delivery plan.
40. We asked our paramedic adviser about the national concerns about delays. They helped us understand this would have impacted the Trust’s availability to dispatch an ambulance to waiting emergencies.
41. We then considered what the Trust was doing about the handover delays at the time of Mr B’s calls.
42. The Trust shared its escalation plan which includes details about its Resource Escalation and Clinical Safety Plan with us from the time of events. The primary aim of the Trust’s plan is to set out the Trust’s response to an increase in pressure to ensure continued delivery of safe patient care and to prioritise and protect service delivery.
43. The Trust has four levels of escalation. On 19 December, it was operating at level four which means ‘under extreme pressure which is affecting service delivery’. It required managers to make decisions and prepare staff. Its escalation plans involved directing less serious calls to make their own way to hospital, access 111 or contact a GP.
44. The Trust’s resource plan says all category one allocations ‘must receive a response from the nearest and quickest resource’.
45. At 9.39am the Trust allocated Mr B a rapid response vehicle. The Trust’s area dispatcher (the person responsible for allocating emergency resources in the area) also made a request for available resource to become available. This included an ambulance crew on their rest break.
46. At 9.46am the call handler updated the information to say Mr B was breathing now and again, but the call remained a category one. At 9.47am the Trust stood down the rapid response vehicle because the vehicle’s paramedic said they were only available to attend cardiac arrests.
47. We know how distressing this has been for Mrs A. It appears the Trust categorised Mr B’s carer’s calls correctly in line with the ARP guidance. Sadly, there were no ambulances available to allocate to Mr B due to reduced availability with long waits at hospital for the Trust’s staff.
48. We have decided that the delay in allocating an ambulance is not a failing and are unable to criticise the Trust for this because it is a wider national concern. It did everything it could do to manage the delay and try to allocate a response vehicle.
49. We have decided the Trust should not have stood down the rapid response vehicle and this was against the Trust’s own resource plan. The Trust accepts this and says its rapid response vehicles can attend all category one calls.
Impact
50. We have found the Trust should not have stood down its rapid response vehicle. Mrs A said her son died because of the delay and this has been extremely distressing. We can see from the clinical records and the Trust’s response that had the rapid response vehicle attended, it is likely they would have arrived eight minutes before the ambulance crew at 9.59am.
51. To help us reach a decision about the impact of this failing, we need to understand what would have happened had the rapid response vehicle arrived eight minutes earlier. We know Mr B had a rare condition which meant he was already respiratory compromised.
52. When we listened to the second call from Mr B’s carer at 9.39am, we heard the carer started CPR and stopped when he started breathing now and again. We heard that between 28 and 29 minutes into the call Mr B was not responding. The call handler told the carer to start CPR again at 29 minutes and 10 seconds into the call, around 10.08am.
53. We heard the call handler telling the carer that their compressions were too slow and told them to go faster. At 30 minutes and 10 seconds into the call, the carer said the ambulance had arrived.
54. The ambulance crew record tells us it arrived at 10.07am and we know from the call recording that the crew were on scene by 10.09am. Mr B was already in cardiac arrest.
55. The clinical records say they lowered him onto the floor and took over CPR from the carer. If the rapid response vehicle had arrived eight minutes earlier, the vehicle’s paramedic would have been on scene to start CPR until the ambulance arrived. This means that CPR from a medically trained professional would have started sooner.
56. We then considered whether the chances of Mr B surviving the cardiac arrest would have changed had the rapid response vehicle arrived sooner and started CPR earlier.
57. The NICE guidance, says around 7-8% of people survive and those who do survive an out of hospital cardiac arrest may experience long term sequelae (lasting and long-term effects) including neurological, pulmonary, cardiac, hepatic, renal or musculoskeletal complications. It also says immediate initiation of CPR can double or quadruple survival from out of hospital cardiac arrest.
58. Our paramedic adviser said it is difficult to say whether Mr B could have survived if the rapid response vehicle had arrived sooner. The NICE guidance suggests the chances were low. They told us that survivability of cardiac arrests does increase when in the presence of a health care professional providing good CPR.
59. We therefore decided to ask an emergency medicine adviser about this because of their experience of dealing with emergency cardiac arrest situations and knowledge of emergency respiratory conditions. They referred us to the Duchenne Research Fund website.
60. It explains the average age of death with someone suffering with the disorder is in their 20’s to 30’s, with breathing complications and heart failure as a common cause of death.
61. They also noted the NICE guidance says fewer than one in ten people survive an out of hospital cardiac arrest. Our emergency medicine adviser helped us understand that Mr B’s chest infection made his Duchenne condition worse.
62. We cannot say, even on the balance of probabilities, whether the outcome would have been different if the rapid response vehicle had arrived and started treatment sooner.
63. We are unable to say, on the balance of probabilities, Mr B would have survived the cardiac arrest.
64. We consider that if the rapid response vehicle had arrived sooner, the likelihood of Mr B receiving immediate treatment would have been higher. The medically trained professional would have been on scene when Mr B went into cardiac arrest for the second time. If he had responded well, there was a higher chance the ambulance crew could have transported him to the hospital.
65. We know this leaves Mrs A with uncertainty about the outcome of her son’s care and sad death. We appreciate this has left the family with distress and worry.
Complaint handling
66. Mrs A also raises concerns about the Trust’s complaint handling. She has concerns that the Trust’s Head of Clinical Quality, a registered paramedic, said the outcome of her son’s tragic death, would not have been any different. She does not feel they had suitable qualifications to say this.
67. The NHS Complaint Standards say organisations should make sure staff have the appropriate level of training and skill to look at complaints. It provides guidance on explaining decisions.
68. It says organisations should give a clear, balanced account of what happened. Organisations should explain why things went wrong, give meaningful and sincere apologises and explanations that openly reflect the impact on the people concerned.
69. Paramedics will be aware of the national data through NICE guidance we have referred to above and the likelihood of a patient surviving an out of hospital cardiac arrest.
70. The Trust explained to Mrs A that its registered paramedic had reviewed all available documentation, and it was their clinical opinion that an earlier attendance would unlikely have changed the outcome for Mr B.
71. It will have been incredibly distressing for Mrs A to read the Trust’s response and comments about her son’s death. It appears it was reasonable for the Head of Clinical Quality, a registered paramedic to answer Mrs A’s questions and provide their clinical view about the impact of her concerns and her sons sad death.
72. The paramedic had the relevant skills to do this and provided an explanation of their clinical view, which was in line with the NHS Complaint Standards. We have decided this does not amount to a failing.