Call prioritisation
18. Mrs C complains the Trust failed to correctly prioritise Mr H’s condition. She thinks the Trust overlooked that her father’s health deteriorated in between her first call and the ambulance arriving.
19. The Trust says its review of the 999 calls confirmed that it correctly triaged the calls as category two priority.
20. During the first 999 call Mr H’s wife and Mrs C told the Trust that Mr H was confused and was drifting in and out of sleep. They explained that his coordination was poor, he could not get out of bed and had experienced a very painful headache since the previous evening.
21. During the phone call, the call handler checked that he could only smile on one side of his face and he could not raise one of his arms when asked to hold his arms up.
22. Mrs C made a second 999 call, reporting Mr H was drifting in and out of sleep more frequently than when she had spoken to the Trust earlier.
23. In Mrs C’s third 999 call, she told the Trust that Mr H’s condition had worsened. She explained that he was less alert, he was drifting in and out of consciousness. When she tried to wake him, he would respond by opening his eyes and then go back to sleep. Mrs C explained that whenever he was awake, he was screaming out in agony because of a headache. We recognise this was a distressing time for Mr H and his family.
24. When she called for a fourth time, she explained that Mr H’s headache was much worse, he was holding his head in pain and screaming out in agony.
25. For each call, the Trust assessed Mr H’s symptoms using the medical priority dispatch system. This is a software system which generates a standard set of questions for an emergency call handler (ECH) to ask. The system then assigns the level of priority for the call based on the answers to the questions and decides when ambulances are dispatched and in which order.
26. The Trust assigned category two priority to Mr H’s case. The ambulance response guidance divides ambulances calls into four categories to make sure ambulances prioritise responding to the sickest patients, as soon as possible. According to the ambulance response guidance, category two is for emergency situations. For example, where someone is experiencing a stroke, major burns, or severe bleeding.
27. Our adviser has listened to the 999 calls and we consider that category two was the correct prioritisation for every call. While the Trust has acknowledged it would usually send a case for a review after receiving three calls, we have not seen any evidence to indicate this would have changed the priority.
28. The only category more serious than category two is category one. The ambulance response guidance says this category is for life threatening situations needing immediate intervention such as resuscitation. For example, where someone is actively drowning, choking, not breathing or experiencing cardiac arrest (their heart has stopped beating).
29. We understand Mrs C wanted the Trust to prioritise Mr H and get him to hospital as soon as possible. The prioritisation of 999 calls is based on the answers given to the structured questions. As Mr H was breathing and conscious and did not need immediate life-saving care, such as resuscitation at the time of the calls he would not meet the criteria for category one. We have reviewed the 999 calls and we think a further review by the Trust would not have changed Mr H’s prioritisation. This is because his symptoms fell into category two, and this did not change.
30. Undoubtedly, Mr H had a serious condition. As Mr H’s symptoms suggested he was having a stroke, we think category two was the correct category and an emergency response was required. Our decision is there was not a failing in the Trust’s prioritisation of Mr H’s condition.
Dispatch
31. Mrs C complains that the Trust did not promptly dispatch an ambulance. She highlights that a stroke needs urgent medical help in hospital because it can be life-threatening.
32. The Trust says it was experiencing high demand at the time of Mrs C’s calls, which made attempts to send an ambulance to Mr H challenging. It acknowledged that it missed opportunities to complete further general broadcasts after 11.12am to check for ambulance crew availability and to search for ambulances in a timely manner.
33. It also acknowledged any patients with three calls are escalated to its clinical hub for review, but it did not do this in Mr H’s case. It has fed these matters back to staff.
34. The NHS constitution sets out what the NHS is committed to achieving. The handbook to the NHS constitution says ambulance trusts should respond to category two calls in 18 minutes on average and respond to 90% of category two calls in 40 minutes. The national recommended times are a target, so unfortunately not all calls will be responded to within the timeframes. Meaning, some calls will fall outside of that response time.
35. After the initial 999 call at 10.35am the Trust allocated an ambulance at 1.37pm and an ambulance did not reach Mr H until 1.54pm. So, clearly the Trust fell below the 40-minute target for category two calls in Mr H’s case.
36. The evidence indicates the Trust was in high demand and no ambulances were available. At 11.12am, the Trust issued a general broadcast to nearby ambulance crews to check for availability. A ‘general broadcast’ is when a dispatcher will advise resources operating on a radio channel of a call waiting to be dispatched on, with the intention of anyone able to become available to do so. It is usually undertaken for a specific incident but it may be used to let ambulance crews know several calls are waiting for a crew to respond.
37. The Trust sent a vehicle to Mr H on five occasions at 11.43am, 12.23pm, 12.50pm, 12.58pm and 1.04pm. Showing the Trust was actively searching for an available vehicle to send to Mr H. However, every time they were redirected to higher priority category one calls. As discussed above, category one calls must take priority over other calls. In practice this means a vehicle on its way to a category two call, will be diverted to a category one call, if required.
38. The Trust’s clinical safety plan sets out when staff can declare a certain level of pressure. This is normally when demand exceeds certain thresholds. The Trust implemented its clinical safety plan due to the amount of pressure it was under.
39. This suggests ways the Trust can consider reducing ambulance demand and increase ambulance capacity when it is under severe pressure. This includes things such as asking callers if they can make their own way to hospital and asking GPs to be particularly careful when deciding whether to call for an ambulance.
40. The Trust deployed additional ambulances from other areas across London throughout the day to try to help relieve the pressure.
41. Our adviser has reviewed the data provided by the Trust and has not seen a missed opportunity for the Trust to send an ambulance sooner.
42. We think a review of the 999 calls would not have changed what happened, as there were no other ambulances available and the ones that became available were sent to category one calls.
43. Ambulance services have finite resources and cannot guarantee a response with the target times. If there is an unexpected significant rise in the number of calls, then response times can suffer, particularly for lower priority cases. Unfortunately, when Mr H needed an ambulance the Trust was experiencing such an event.
44. When there has been a delay in an ambulance arriving, we do not automatically find a failing has occurred. This is because national guidelines do not require ambulance services to meet target response times 100 percent of the time and we have considered the actions taken by the Trust, during periods of high demand.
45. Ambulance trusts need to ensure those who require an ambulance more urgently receive one first. Ambulance services should not consider a patient to be a greater priority based on how long they have waited for an ambulance.
46. The evidence indicates the Trust was acting to try and get an ambulance to Mr H as soon as it could, and it was also trying to improve ambulance availability. This shows the Trust was utilising its resources appropriately. Our decision is we have not seen failings in the Trust dispatching an ambulance to Mr H.
47. That said, Mrs C’s perspective is completely understandable. We appreciate how distressing waiting for an ambulance must have been.
Estimated time of arrival
48. Mrs C also complains that the Trust gave her inaccurate information about the ambulance’s estimated time of arrival. She says if the Trust had not kept advising her an ambulance was on its way, she would have found another way to transport her father to hospital.
49. The Trust says at 12.35pm, the ECH incorrectly advised that an ambulance was on the way, which can be misleading. However, the Trust said later that the timeframe provided at the time of the call was based on average response times for category two calls.
50. Our principles say that public bodies should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances.
51. During the first call at 10.35am the ECH told Mrs C that due to demand on the service there might be a delay, and the average ambulance response time was 20 to 40 minutes. The ECH explained an ambulance might arrive quicker or slower than this.
52. The second ECH at 11.44am said the Trust had gone over its estimate and they could not give an estimated time of arrival for the ambulance as they were experiencing heavy delays. They confirmed Mrs C could consider making her own way to hospital if she wished.
53. During the third call at 12.35pm the ECH told Mrs C an ambulance was on its way with a 20-minute estimated time of arrival. During the fourth call at 1.37pm the ECH apologised that the previous ECH had given a specific timeframe. They said they could not provide a specific estimated time of arrival as they were very busy.
54. The initial average time of 20 to 40 minutes which the ECH gave in the first phone call is based on the target response time for category two ambulances. This ECH did also caveat this by explaining the ambulance could be quicker or slower than this.
55. Once this time had passed, the ECH in the second and fourth calls explained they could not give Mrs C an estimated time of arrival. We think the information given in these calls was appropriate and in line with our principles about communicating effectively. We also cannot see that the Trust gave Mrs C inaccurate information during these calls
56. Our adviser told us the ECH in the third call did not give inaccurate information at the time as an ambulance was on its way to Mr H at 12.23pm, however it was diverted to a higher priority call.
57. At the time the Trust was operating under high pressure, and it is common for ambulances to be diverted when they are on their way.
58. There are no national guidelines relating to this situation, but our adviser explained it is not usual practice to provide specific information about when an ambulance will arrive. It is more usual to give the average time because of the dynamic nature of ambulance dispatch. Giving a specific time may also raise expectations. We understand this error in communication was upsetting for Mrs C, but we do not think it amounts to a failing in the service. We have explained this further below.
59. In the second 999 call at 11.44am, 45 minutes before the third call and an hour after the first call, the ECH had already explained to Mrs C that the Trust was experiencing significant delays and they could not give an estimated time of arrival for the ambulance.
60. The ECH at this point also confirmed they had the option of making their own way to hospital if they wished.
61. During the third call, the ECH gave an estimated time of arrival, so this was still subject to change.
62. We are sorry to hear Mrs C has been left believing she could have acted differently had the Trust given her different information. While the later message from the ECH in the third call could have been clearer, the ECH in the earlier call had already given Mrs C clear information about the likely delays, with the option of considering arranging alternative transport to hospital.
63. We also note the Trust has apologised for this error in communication and provided feedback to the ECH concerned. We hope this provides some reassurance to Mrs C.
Major trauma centre
64. Mrs C complains that the Trust did not take Mr H directly to a major trauma centre. In the Trust’s response to Mrs C’s complaint, it said it would have been more appropriate to convey Mr H to a major trauma centre due to the reported head injury.
65. A major trauma centre is a hospital which specialises in treating patients with severe and often life-threatening injuries. The NICE guideline on major trauma describes it as ‘serious injuries that could cause permanent disability or death. Examples of major trauma include serious injuries to the head, the spine or the chest, injuries that cause a person to lose a lot of blood, and complicated breaks to bones called complex fractures (such as a broken pelvis or a broken bone that is sticking out through the skin)’.
66. We can see in the Trust’s investigation of Mrs C’s complaint it queried whether Mr H’s headache could have been caused by a head injury from the road traffic accident he was in the day before.
67. We have reviewed Mr H’s records for reference to a head injury, including the ambulance crew’s records from the time they assessed Mr H at his home. The ambulance crew explored the possibility of Mr H having experienced trauma in the car accident he had had the previous day.
68. The ambulance crew’s records say both Mr H and his wife, who was in the car at the time of the accident, said he did not hit his head or have a head injury. The ambulance records do not note any other injuries which would indicate major trauma.
69. A head injury is also not mentioned in any of the 999 calls nor in the emergency department records from that day. After reviewing records from several different sources, we cannot see that Mr H ever reported hitting his head or having a head injury as noted by the Trust in its response to Mrs C’s complaint.
70. The ambulance crew conducted a FAST test on Mr H. This is a quick check to see if someone has stroke symptoms by looking at their face, arms, and speech to see if they are normal.
71. At this time Mr H had ‘very significant left sided facial droop and left arm and left leg weakness and […] significantly reduced coordination’. This means Mr H was FAST positive which is a strong indicator to suspect he had had a stroke.
72. JRCALC guidelines are used across the UK to guide ambulance clinicians’ decision-making. They recommend that if an ambulance crew suspects someone has stroke symptoms they should take them to a HASU as quickly as possible.
73. As Mr H was presenting with stroke symptoms and had not reported having a head injury, we think it was appropriate for the Trust to focus on Mr H’s stroke symptoms.
74. Based on the evidence we have seen, we think the Trust’s decision to take Mr H to his nearest hospital with a HASU was correct. Our adviser explained had the hospital decided a major trauma centre more appropriate, it could have transferred Mr H to a major trauma centre, but it did not.
75. The Trust’s decision to take Mr H to a HASU rather than a major trauma centre is in line with JRCALC guidelines and there is no failing.
76. We are grateful to Mrs C for raising her concerns with us after everything her and her family have been through.