PSOW Individual Decisions

Miss K complained about the delay Mr Q endured on 24 January 2019 waiting for an ambulance. Miss K said that the call was categorised wrongly by Welsh Ambulance Services NHS Trust which resulted in a delay of nearly 4 hours. The Ombudsman’s investigation found that the Trust correctly coded the 3 calls it received and taking into account the volume of emergency calls it was receiving and the availability of resources, it dispatched an ambulance as soon as it could to Mr Q. The Ombudsman did not uphold the complaint.

Mr A complained about the delay before his father, Mr B, was attended to by an Emergency Ambulance following a fall outside his home. On admission to hospital, further investigations established that Mr B had broken his hip. Sadly, Mr B was never fit enough to have surgery to repair his broken hip as he developed pneumonia and died 12 days later. The Trust’s own investigation of Mr A’s complaint identified an avoidable delay of 55 minutes before Mr B was attended to by an Emergency Ambulance. The Trust subsequently issued Mr A with an interim complaint response advising him how to access free legal advice under the NHS redress scheme with a view to joint instruction of an independent expert to determine whether Mr B had suffered harm as a result of failings in his care, and compensation was owed. Mr A did not reply to the Trust’s interim complaint response before escalating the matter to the Ombudsman. During the evidence gathering stage of the the Ombudsman’s investigation, independent professional advice obtained suggested that the onset of Mr B’s pneumonia may have been attributable to the delayed Emergency Ambulance. The evidence was shared with the Trust and it agreed to re-issue its interim response to Mr A and to repeat the offer of free legal advice to determine the issue of causation. The Ombudsman settled Mr A’s complaint against the Trust based on that agreement.

Ms X complained that WAST had failed to transport her to and from her hospital appointments on various occasions resulting in missed appointments. In considering the complaint the Ombudsman was concerned that there was an issue of a time discrepancy with one of the appointments which WAST had failed to address in its response. As an alternative to an investigation, she asked WAST to complete the following in settlement of Ms X’s complaint: a) Apologise to Ms X for not addressing the time discrepancy in the original response b) Provide Ms X with an additional explanation 6 May 2022

Mrs A’s complaint against Hywel Dda University Health Board (“the Health Board”) centred on whether during times of pressure Withybush General Hospital’s Emergency Department had put in place reasonable adjustments for individuals with learning disabilities, autism and epilepsy particularly where they exhibit behaviour that is challenging. Mrs A’s complaint against Welsh Ambulance Services NHS Trust (“WAST”) related to: • the extent to which it had made reasonable adjustments for individuals with learning disabilities, autism and epilepsy when it comes to its paramedic service, particularly in terms of pain assessment and communication. • record-keeping by the paramedics who attended Mrs A’s home on 23 February 2020, especially regarding the mental capacity assessment and her son’s discharge of care. The Ombudsman discontinued his investigation into Mrs A’s complaint relating to the paramedics’ attendance at her home. However, as part of the settlement it was agreed that senior officers in the Health Board and WAST would meet to look at patients living with learning disabilities/autism and complex needs, such as Mrs A’s son, journey through the various stages of their patient care from primary care up to secondary care. The meeting would identify ways in which patients’ journey can be improved by way of reasonable adjustments and through the use of technology and help develop action plans to take forward any initiatives. The settlement also set out ways of engaging with Mrs A and that feedback would be provided to Mrs A and the Ombudsman’s office regarding the outcome of the meeting. The Health Board and WAST were given 3 months to carry out the settlement.

Mrs A’s complaint against Hywel Dda University Health Board (“the Health Board”) centred on whether during times of pressure Withybush General Hospital’s Emergency Department had put in place reasonable adjustments for individuals with learning disabilities, autism and epilepsy particularly where they exhibit behaviour that is challenging. Mrs A’s complaint against Welsh Ambulance Services NHS Trust (“WAST”) related to: • the extent to which it had made reasonable adjustments for individuals with learning disabilities, autism and epilepsy when it comes to its paramedic service, particularly in terms of pain assessment and communication. • record-keeping by the paramedics who attended Mrs A’s home on 23 February 2020, especially regarding the mental capacity assessment and her son’s discharge of care. The Ombudsman discontinued his investigation into Mrs A’s complaint relating to the paramedics’ attendance at her home. However, as part of the settlement it was agreed that senior officers in the Health Board and WAST would meet to look at patients living with learning disabilities/autism and complex needs, such as Mrs A’s son, journey through the various stages of their patient care from primary care up to secondary care. The meeting would identify ways in which patients’ journey can be improved by way of reasonable adjustments and through the use of technology and help develop action plans to take forward any initiatives. The settlement also set out ways of engaging with Mrs A and that feedback would be provided to Mrs A and the Ombudsman’s office regarding the outcome of the meeting. The Health Board and WAST were given 3 months to carry out the settlement.

Ms X complained that she had not received a response to her complaint made to WAST in February. In considering your complaint, the Ombudsman was concerned that Ms X had not received a response and she had been inconvenienced by the organisation’s actions. The Ombudsman decided to settle the matter without an investigation. In settlement of the complaint, WAST agreed to provide Ms X with a response by 10 January 2022.

Mrs Y complained to the Ombudsman about the care that was provided to her late mother, Mrs Z by Betsi Cadwaladr University Health Board (“the Health Board”), Welsh Ambulance Services NHS Trust, District Nursing Service and the Out of Hours Service. There were many concerns raised about Mrs Z’s treatment, but the crux of the complaint was the lack of palliative care and an end of life pathway. The Health Board led with the investigation and provided one single and co-ordinated response in April 2021. However, in making her complaint to the Ombudsman, Mrs Y pointed out that she remained dissatisfied with parts of the Health Board’s response. Following discussions with the Ombudsman, the Health Board agreed that it would provide a further response to Mrs Y by 29 October 2021.

Mrs X complained about the ambulance response time and prioritisation assigned to the calls made to the Trust on 9 July 2020. The Ombudsman found that the Trust’s investigation and subsequent Serious Incident Investigation Report had caused Mrs X to raise further questions. The Ombudsman sought and gained the Trust’s agreement to provide a further written response to Mrs X, which expanded on and explained its findings and processes within 30 working days.

Ms X complained on behalf of her late father, Mr Y, that the Welsh Ambulance Services NHS Trust(“WAST”) did not provide reasonable and timely care and treatment to Mr Y on 12December 2019. Ms X also complained that her complaint to WAST was not handled properly. The investigation found that WAST did not provide reasonable and timely care to Mr Y. In particular, it found that although WAST was very busy on the day in question, there were times when it was not operationally stretched, or when it should nonetheless have prioritised callers in Mr Y’s position. Further, call backs were not made to Mr Y on a number of occasions, and triggers for further actions to address Mr Y’s call were missed. The priority level of his call was finally escalated 15 hours after he initially telephoned, and almost 9 hours after he had last been spoken to. Mr Y was also repeatedly advised not to drink anything, meaning he was ultimately deprived of fluid for 22 hours. The service failures identified caused Mr Y, an elderly gentleman, a considerable injustice as he was left alone and in pain, waiting for an ambulance, and on arrival at hospital he was dry and probably dehydrated as a result. The investigation also found that Ms X’s complaint was not handled properly, as the complaint response was delayed, and no explanation was given for what happened to Mr Y, WAST simply reiterating that it was very busy that day. The Ombudsman therefore upheld both elements of Ms X’s complaint. As WAST had already identified areas that required updating following its own internal investigation into this complaint, the Ombudsman recommended that WAST feedback to Ms X on the progress of those specific recommendations. In particular, WAST agreed to feedback on progress regarding training additional staff, reviewing welfare check guidance (particularly in relation to escalating calls if contact is not made with the patient, and in relation to advice provided to callers when the patient has had a long wait) a