An independent provider in the City of Derby area

4. The K’s complain about the actions taken by 111 and WMAS, when their mother Mrs K was unwell in June 2024.

Complaint about 111: • the call handler incorrectly categorised their mother’s symptoms as a category two • the call handler failed to provide an accurate estimate of the time for ambulance arrival.

Complaint about WMAS: • the call handler incorrectly categorised their mother’s symptoms as a category two • the ambulance took too long to arrive • provided factually incorrect complaint responses, stating the crew obtained medical history from their mother and the second call was triaged even though it was just four minutes long • answered questions they did not ask in the complaint responses.

5. The K’s describe feeling like the NHS categorisation system is broken and they have lost trust. They believe their mother did not get a fair chance of survival. They consider if she had received a quicker response and more advanced treatment in hospital sooner, she may have survived. This is something that continues to cause them significant ongoing distress.

6. They also describe experiencing further distress because both organisations have not explained why their mother’s symptoms were categorised as a category two and not a category one.

7. They say because NHS 111 did not provide an estimated time of ambulance arrival and instead used the term ‘shortly’, it did not inform them of the actual waiting time, which affected their ability to make timely decisions about seeking further assistance.

8. They say the WMAS complaint responses have made them feel like just a number because it provided responses to questions they did not ask and incorrect information about how the crew obtained their mother’s medical history. They describe their mother as unable to speak at the time and say they provided her history. They describe feeling further upset and confusion making the events more difficult to process and understand.

9. By bring this complaint to us, the K’s are seeking an explanation regarding the categorisation of their mother’s call, an apology, an acknowledgement of failings, service improvements and a financial remedy.

10. On 26 June 2024 the K’s contacted NHS 111 at 4.49am as their mother was experiencing sudden onset chest pain, was clammy, pale and nauseous with pins and needles in both arms. Following its assessment, 111 categorised this call as a category two. We give further details about these categories in paragraphs 20 to 23.

11. At 4.57am, 111 transferred the case over to WMAS for it to dispatch an ambulance.

12. At 5.06am, WMAS assigned an ambulance.

13. At 5.27am, the K’s made a call to WMAS via 999 to follow up on when the ambulance would arrive. This call lasted four minutes and concluded as the ambulance arrived on scene at 5.31am.

14. The ambulance crew transported Mrs K to hospital by blue lights. Mrs K went into cardiac arrest in the ambulance and sadly died.

The 111 call handler incorrectly categorised their mother’s symptoms as a category two

18. The K’s say the call handler incorrectly categorised their mother’s, Mrs K’s symptoms as a category two, when they called 111 at 4.49am on 26 June 2024. The K’s believe 111 staff should have categorised an aortic aneurysm rupture/dissection as a category one ambulance response. An aortic rupture is a significant tear in all the layers of the aorta (the main artery of the body) wall where there is large aneurysm (a bulge in the wall of an artery), causing blood to leak out from the aorta. An aortic dissection is when the weakened wall of the aorta tears, causing blood to leak between the layers that make up the wall of the aorta.

19. In 111’s complaint response, it says call handlers are guided by the NHS Pathways system to ask the caller specific questions. 111 says the caller told the call handler Mrs K was experiencing sudden onset of chest pain, was clammy, pale and nauseous with pins and needles down both arms. Therefore, the system reached a category two ambulance response coded as ‘emergency ambulance response for aortic aneurysm rupture/dissection (category 2) (Dx0114)’.

20. We asked our adviser if based on the call to 111, the call handler categorised Mrs K’s symptoms correctly. Our adviser explained all NHS 111 and 999 providers must use a nationally licensed triage system to triage calls. There is only one, which is NHS pathways (the system). The system tells the call handler what questions to ask the caller, and their answers prompt the next question.

21. Our adviser explained these questions and answers are interlinked and designed by senior clinicians/consultants who are experts in their field. The questions continue until the system reaches an end code or category response level. Therefore, it is the system that reaches the categorisation level, based on the answers, not the call handler. NHS England decide what conditions fit in each category response level, from category one to four. This is referred to as the ambulance response programme (ARP).

22. Our adviser says the call handler followed the NHS pathways triage system correctly by asking the questions it generated. The system then allocated the code Dx0114, which on review of 111’s ambulance DX codes and categories guideline document, is a category two response. Our adviser says this document is consistent with NHS England’s ARP.

23. Category two calls are allocated to emergencies with potentially serious conditions that may require rapid assessment, urgent intervention or transport. This includes conditions such as aortic aneurysm, heart attacks and strokes. There is one higher category, which is category one. This is for time critical conditions needing immediate intervention or resuscitation to preserve life. This includes conditions such as cardiac arrest, choking and patients who are unconscious with abnormal or noisy breathing.

24. On review of the call recording, we can hear Mrs K responding to questions, with her family’s support. We recognise Mrs K was struggling to talk more than a few words and she was struggling to breathe, but she said not desperately. Mrs K was conscious and breathing and did not require resuscitation to preserve her life at that time. We understand Mrs K was not well and needed an emergency response for a potentially serious condition. Based on 111’s ambulance category document and NHS England’s ARP this is consistent with a category two response.

25. We understand the K’s concern that the call handler did not prioritise their mother’s symptoms appropriately, given she sadly died later that morning. We recognise this was an extremely distressing time for the family.

26. We must look at the evidence available at the time of the incident and whether this was in line with guidance. Based on the evidence above, we can see the call handler followed the process, directed by the system. The system then generated a category two outcome which was entirely consistent with relevant guidelines. Therefore, we see no indication that something went wrong and will not be taking any further action.

The 111 call handler failed to provide an accurate estimate of the time for ambulance arrival

27. The K’s say the 111 call handler did not provide them with an accurate estimate of the time it would take for the ambulance to arrive, and instead used the term ‘shortly’. They say this affected their ability to make timely decisions about seeking further assistance.

28. On review of 111’s complaint response, we could not see it had provided a response to this. We shared this concern with 111, to provide it with any opportunity to comment. It did not provide further comments and provided us with the call recording.

29. When we listened to the 111 call recording, we hear the call handler say we would like to arrange for an emergency ambulance which will be with her as soon as possible. We do not hear the call handler specifically say ‘shortly’.

30. We asked our clinical adviser if the call handler should have provided the K’s with an accurate estimated time for ambulance arrival. Our adviser told us there is no guidance to say 111 call handlers should estimate ambulance arrival times. In this case, the 111 service is operated by an organisation which is not part of WMAS. Therefore, 111 would not know what response times WMAS were achieving, so could not correctly relay how long it would take for the ambulance to arrive. There is no requirement for WMAS to share this information with 111, as this can constantly change.

31. Our adviser says when an ambulance is allocated to an incident, it can be reallocated to a different incident if a higher category of call is received in that area. This could lead to a longer response time for the first incident the ambulance was allocated to. Therefore, response times cannot be estimated or guaranteed.

32. We saw 111’s electronic & manual ambulance despatch guidance sets out no requirement for 111’s call handlers to provide an accurate estimated time for ambulance arrival. Considering the advice, we also cannot see 111’s call handler could have provided the K’s this information.

33. We are sorry to hear the K’s wanted 111 to estimate how long the ambulance would take to arrive. Based on the evidence above, we cannot see any guidance to say this should have happened, or any failing in 111’s call handler not providing this estimate. Therefore, we will not be taking any further action on this part of the complaint.

The 999 call handler incorrectly categorised their mother’s symptoms as a category two

34. The K’s say the call handler incorrectly categorised their mother’s symptoms as a category two, when they called 999 at 5.27am on 26 June 2024.

35. WMAS say the call handler triaged this call correctly using NHS Pathways, as a category two emergency.

36. We asked our adviser if based on the call to 999, the call handler categorised Mrs K’s symptoms correctly. Our adviser says the call handler correctly followed guidance by using the NHS Pathways system (the system), and asked the questions prompted by the system.

37. During the call, the first question the call handler asks is ‘is the patient breathing’, which the K’s responded yes to. Our adviser says this confirmed Mrs K was not in cardiac arrest. The call handler established Mrs K was breathing and conscious. Therefore, our adviser says she did not need any resuscitation at that time. The call handler also confirmed Mrs K was not choking, having a seizure or had any facial or tongue swelling which would indicate severe anaphylaxis (closing of the airway). Our adviser told us if Mrs K had any of these symptoms, this would have prompted a category one response.

38. The K’s described their mother as hot, clammy with central chest pains, pins and needles in her arms and was breathless. Our adviser says because of this, it is clear Mrs K was showing common symptoms of a heart attack. They added, Mrs K was conscious, breathing, and she did not have an obstructed or closing airway. Therefore, her condition did not meet a category one response and the system correctly allocated a category two response at this point.

39. We are sorry to hear the K’s believe 999 incorrectly categorised their mother’s symptoms. The evidence shows the call handler acted in line with relevant guidance by following the system. The system then generated a category two response, which follows NHS England’s ARP. Therefore, we see no indication that something went wrong, and we will not be taking any further action on this part of the complaint.

The ambulance took too long to arrive

40. The K’s complain the ambulance took too long to arrive to their mother, who was triaged with a potential aortic aneurysm rupture/dissection. The K’s called 111 at 4.49am and 999 at 5.27am.

41. The records show 111 sent the request to WMAS for an ambulance dispatch at 4.57am. WMAS assigned the ambulance at 5.06am and it arrived at 5.31am. WMAS say the time taken for the ambulance to arrive on scene after its assignment was explained by the distance it had to travel.

42. We asked our adviser if following relevant standards, the ambulance arrived within the correct timeframe. Our adviser explained at the time of this incident, NHS England’s ARP standards say ambulance services should attend category two calls on average within 30 minutes, with 90% being within 40 minutes. The records show it took the ambulance 34 minutes to arrive from the point WMAS assigned it to Mrs K.

43. At 5am, WMAS’s gold dashboard reported it had 116 incidents, with an average ambulance response time of 51 minutes, 90% of which it responded to within 2 hours and 17 minutes. At 5.57am, this increased to 136 incidents, with an average ambulance response time of 46 minutes, 90% of which it responded to within 2 hours 6 minutes.

44. We are very sorry to hear how long the ambulance took to arrive has caused the K’s distress. It is clear from WMAS’s gold dashboard document it was experiencing a high level of demand at that time. We recognise the ambulance took four minutes over the average target response time to arrive. However, we also acknowledge it did respond within the 90% target response time. Given the ambulance did meet the 90% target response time, it did meet the required standards. Therefore, we have not identified any indications of service failure, and we will not be investigating this part of the complaint further.

WMAS provided incorrect information in its complaint responses by saying it fully triaged the 999 call

45. The K’s say WMAS’s first response says the call at 5.27am was fully triaged. The K’s dispute this as the call only lasted four minutes. In WMAS’s complaint response, dated 10 October 2024, it says it triaged the call correctly.

46. Through our investigation we have not identified any evidence WMAS say the call was fully triaged. We recognise WMAS say it triaged the call correctly and the K’s have some reservations about this. Therefore, we asked our clinical adviser if WMAS triaged the call at 5.27am correctly, by following relevant standards and guidelines.

47. Our advisor says the call handler followed the NHS Pathways system and the system identified around three minutes into the call, it required a category two ambulance response. The call handler continued to ask questions and did not end the triage at this point, continuing and only ending when the ambulance crew arrived. Our adviser says there was no need for the call handler to carry on with the triage, as triage is to establish how fast a patient needs an ambulance and the ambulance had already arrived on scene.

48. Our advisor explained as part of the licensing agreement with NHS Pathways, 999 services must have trained auditors. These auditors randomly audit call handlers to ensure they applied the system and triage correctly. The WMAS’s call audit document shows this call achieved an audit score of 97%, with a pass rate of 86% expected.

49. We consider WMAS’s response about the triage is accurate, as the triage followed the relevant guidelines. We know the system allocated a category two response early into the call, yet the call handler continued with the triage to ensure nothing changed the response level. The call handler only stopped asking questions when the ambulance crew arrived. The purpose of triage is to assess a patient’s symptoms, to generate an appropriate response. There was no requirement for the call handler to continue with the triage, as the ambulance had arrived.

50. Our NHS Complaint Standards say organisations should explain what happened based on evidence. They should also compare these events with what should have happened.

51. WMAS has done this in its response in explaining why it considers staff triaged the call correctly. Therefore, we have not seen any indications something went wrong, and we will not be considering this complaint further.

WMAS provided incorrect information in its complaint response by saying Mrs K provided her own medical history

52. The K’s say WMAS provided incorrect information in its complaint response by saying the ambulance crew obtained Mrs K’s medical history from her directly. They say their mother could not speak and it was the family who provided the crew with her medical history. We are very sorry to hear this made the K’s feel WMAS did not properly consider their complaint. We recognise from what they have told us this has caused the family distress.

53. In the WMAS’s complaint response, dated 10 October 2024, in response to the question ‘why did the attending clinicians not ask about Mrs K’s previous medical history?’ it says the attending clinicians asked Mrs K about her past medical history, as this is evidenced within the electronic patient record form (EPRF).

54. We cannot see any evidence in the response that WMAS say Mrs K provided her own medical history. We recognise WMAS do say the crew asked Mrs K for her history. We understand from what the K’s have told us, they say the ambulance crew did not ask Mrs K and it was the K’s who asked the ambulance crew if they wanted Mrs K’s medical history.

55. We have reviewed the EPRF, which evidences the ambulance crew obtained Mrs K’s medical history. It does not say who asked for this, or who provided it. We asked WMAS if it had any further information, which evidences the ambulance crew asked for Mrs K’s history.

56. WMAS told us it has reviewed the EPRF and acknowledges it does not say who asked or provided Mrs K’s medical history. WMAS say its interpretation of the question was whether the attending clinicians obtained Mrs K’s medical history. It could not confirm if the ambulance crew asked. Therefore, it reflected on the wording it used in response to this question and has offered to apologise to the K’s for the distress it caused them.

57. Our NHS Complaint Standards state we must investigate and comment on the facts of the case and not give our opinion on events. They also explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services’. Finally, our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.

58. On balance, it is not possible for us to robustly determine whether the ambulance crew asked for Mrs K’s medical history based on the available evidence. The K’s say they asked the ambulance crew if they wanted Mrs K’s medical history. WMAS now say it knows the ambulance crew obtained Mrs K’s medical history but cannot confirm who asked for this, or who provided it.

59. WMAS has reflected on the wording it used in its response and how the K’s interpreted this. To resolve the matter, it has offered to apologise to the K’s for the distress it caused them by saying the ambulance crew asked for Mrs K’s medical history.

60. It also told us it is willing to take learning from the K’s complaint to improve its complaint handling service. It will feed back to the patient and liaison service (PALS) team to summarise complaints during calls with complainants, to confirm understanding, help avoid misinterpretation, and in turn improve responses to complaints.

61. By bringing their complaint to us, the K’s want an acknowledgement of failings, an apology, service improvements and a financial remedy. We have considered our severity of injustice scale, and we usually consider an apology to be an appropriate remedy for the type of emotional impact the K’s have experienced from this and we would not recommend a financial remedy.

62. We recognise the K’s told us reading WMAS’s response was upsetting at the time. The K’s have not told us this distress has impacted on their day-to-day functioning. These impacts align with those described in level one in our severity of injustice scale. In these circumstances, our severity of injustice scale says an apology is enough to put right impacts like this.

63. This means we consider WMAS has now offered to take appropriate action to remedy the K’s impact relating to this complaint in line with our NHS Complaint Standards and severity of injustice scale. It has offered to apologise to the K’s and take learning to improve its service.

64. We consider this is a suitable resolution for this part of the complaint, and it requires no further investigation. We hope the resolution we have agreed with WMAS helps bring the K’s closure on this matter.

WMAS answered a question in its response the K’s did not ask

65. The K’s say WMAS answered questions they did not ask in its complaint responses, specifically, ‘why were you initially told it would be two hours for an ambulance to attend’. The K’s say they were not told this. Therefore, they did not ask this question when they first complained to WMAS. The K’s raised this with WMAS after receiving its first response.

66. During our investigation, we asked WMAS if it would like to provide a response to this, as we could not see it had done so in its complaint responses. WMAS acknowledged it missed responding to the K’s concern about it answering this question when they did not ask it to. WMAS has offered to apologise to the K’s for this.

67. WMAS provided us with the recording of the K’s call to its PALS team to make their complaint. Two and a half minutes into the call we hear the K’s say ‘we found a lady on the driveway and we were told that it would be two hours until an ambulance arrived’. Following this, there appears to be a discussion which may relate to someone else’s experience. However, the call quality reduces, so it is not entirely clear what the K’s say. Nine and a half minutes into the call, Mrs K’s husband says ‘within two hours she was gone’.

68. During the call the K’s mention the term ‘two hours’, on two separate occasions. We consider it is reasonable the call taker believed this may have relevance to the complaint. However, given the quality of the call during that time, had they repeated the complaint back to the K’s, this may have identified the call taker had misheard this part of their complaint.

69. WMAS told us when a complainant raises a complaint with PALS, it manages this informally. Staff do not provide complainants with a written formal acknowledgement of their complaint concerns for informal complaints.

70. WMAS explained it is currently working on improving its complaints process. It is using our NHS Complaint Standards and feedback from complainants to guide these changes. WMAS say it will take learning from the K’s complaint, and feedback that complaints call takers should repeat concerns back to complainants to ensure their understanding when taking complaints over the phone. WMAS has also offered to apologise to the K’s.

71. We recognise having additional answers to questions the K’s feel they did not ask has caused them distress. We are sorry to hear this and that they feel as though their complaint was not properly investigated.

72. WMAS has now offered to write to the K’s to acknowledge this. WMAS say it will apologise to the K’s about how this made them feel and take learning from their complaint to improve its service. We consider this to be an appropriate remedy, in line with level one on our severity of injustice scale.

73. The distress the K’s described is similar to that which we explained in paragraph 62. This means we would expect WMAS to apologise about this but not provide a financial remedy.

74. We are satisfied the actions WMAS is taking are in line with our NHS Complaint Standards. It is taking accountability of its mistake and learning from the K’s complaint. We appreciate how repeating a complainant’s concerns back to them during phone calls will help staff avoid addressing questions complainants have not asked later.

75. As WMAS is taking what we consider appropriate action to resolve the matter, we consider it would not be proportionate to investigate this part of the complaint further.

76. We are very sorry to hear about the K’s experience when their mother became unwell and sadly died. We recognise this has been an extremely distressing time for the family.

77. We are satisfied WMAS has now taken full accountability for the mistakes it made during its complaint handling. It has offered to apologise to the K’s and take learning from their complaint. This is in line with the outcomes the K’s want by bringing their complaint to us. We are satisfied we have been able to successfully resolve this part of their complaint.

78. We hope we provided the K’s with further explanation around the categorisation of their mother’s symptoms. We would like to thank both parties for their cooperation and understanding during our investigation.

1. We have carefully considered the K family’s (the K’s) complaint about the actions taken by an independent provider in the Midlands area (111) and West Midlands Ambulance Service (WMAS) when their mother Mrs K became unwell in June 2024. We recognise this has been an incredibly upsetting time for the K’s, based on what they told us the impact this, and WMAS’s complaint handling has had on them.

2. We have considered the K’s complaint about WMAS’s categorisation of their mother’s symptoms, how long the ambulance took to arrive and that it said the call handler fully triaged the call. We have also considered 111’s call categorisation and the call handler’s communication regarding how long it would take for the ambulance to arrive. We would like to reassure the K’s that we have seen no indications of failings in WMAS’s or 111’s actions for these parts of their complaint. We have explained the reasons for this further below.

3. We have also considered the K’s complaints about WMAS’s handling of their complaint. We are satisfied WMAS has now done enough to resolve the impact of its mistakes. As such we have decided to take no further action on these parts of the complaint. We have explained our reasons for this further in this statement.