PSOW Individual Decisions

Mrs N explained that she and her family made numerous calls to 999 and the 111 service on behalf of her father, Mr L, throughout 1 January 2023. Mrs N complained that they were advised that the waiting time for an ambulance to attend was 6 8 hours. She said that Mr L’s care should have been prioritised sooner and that it was only when he stopped breathing that an ambulance was sent. By that time, Mrs N and her brother had been forced to start CPR. Sadly, Mr L could not be revived. The Ombudsman found that the Trust’s response did not fully address the question of whether the care it provided was clinically appropriate. It had not clarified whether it believed that all the calls made to 999 and 111 were dealt with appropriately, particularly in light of some apparent contradictions in the documented information about Mr L’s clinical condition. The Trust agreed to provide a further response to Mrs N, clarifying whether an ambulance was correctly allocated at the first appropriate opportunity and whether it considered that the calls were all handled and categorised appropriately. The Trust agreed to do this within one month of the date of the Ombudsman’s decision.

Ms B complained that she was dissatisfied with Welsh Ambulance Services NHS Trust’s complaint response. The Ombudsman decided that WAST did not establish Ms B’s desired outcomes for her complaint, and it did not explain what options remained open to her. WAST did not explain what information it considered in its investigation, or its position regarding qualifying liability and redress. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained WAST’s agreement to apologise to Ms B for the omissions in the complaint response, and to provide the necessary information and explanations within 10 working days.

Mrs A complained about Welsh Ambulance Services NHS Trust (“WAST”) and Swansea Bay University Health Board (“the Health Board”). The investigation considered Mrs A’s complaint about the care her late husband, Mr B, received from WAST. Mrs A complained about the delay in an ambulance arriving following her 999 calls and questioned whether the 999 calls were correctly categorised. She also complained that a further delay in transporting Mr B to the Emergency Department (“ED”) at Morriston hospital (“the Hospital”) affected his prognosis. In relation to the Health Board, the investigation considered whether the care provided to Mr B was timely and appropriate and a failure to communicate her husband’s deteriorating condition meant that she was unable to be with him during his final hours. The investigation found that the 999 calls to WAST were correctly categorised and appropriately prioritised and that the delay in an ambulance reaching Mr B was outside of WAST’s control due to the pressure on its services. The Ombudsman did not uphold this part of Mrs A’s complaint. The investigation found a missed opportunity to recognise Mr B’s heart failure and change the treatment regime and consider further treatment intervention. That said the Ombudsman was satisfied that it was extremely unlikely that, had Mr B been taken to hospital earlier and heart failure treatment had started sooner, the outcome would have changed. The investigation concluded that the lack of a documented reason for the paramedic delay and the lack of timeliness in transporting Mr B to the Hospital was not reasonable or appropriate and, to that extent, represented a service failure which caused distress and upset to Mrs A, and her complaint was upheld to a limited extent. In relation to Mrs A’s complaint about the Health Board and the care Mr B had received in Hospital, the investigation concluded that the care provided to Mr B was timely and appropriate and therefore the Ombudsman did not uphold the comp

We investigated a complaint by Mr A about the delay in obtaining an Out of Hours GP visit for his late wife, Mrs A, which was requested via 111. Specifically, we considered whether Mrs A’s symptoms were appropriately assessed by the 111 service, which is provided by the Trust, and then whether the referrals to the OOH GP service (provided by the Health Board) were acted on appropriately and in a timely manner. We also investigated whether Mr A’s complaint was appropriately investigated, in line with relevance guidance, by both bodies. We found that based on the information provided, Mr A’s calls to the 111 service were appropriately assessed, so did not uphold this complaint against the Trust. We found that while the OOH GP’s decision to wait for a home visit before admitting Ms A to hospital was appropriate, the time taken to contact and then visit Mrs A was significantly in excess of relevant timescales (by up to 12 hours). However this was unlikely to have affected Mrs A’s eventual outcome, although clearly caused distress to Mr & Mrs A. The complaint was therefore partly upheld against the Health Board taking into account the context of the significant pressure on the OOH GP service at the time. We found that the complaint should have been considered jointly, and 1 complaint response issued, and that the error in doing so was due to the Trust, but there were also issues with the accuracy and timeliness of the Health Board’s response. This was an injustice and caused confusion and further distress to Mr A, so this element of the complaint was upheld against both bodies.We investigated a complaint by Mr A about the delay in obtaining an Out of Hours GP visit for his late wife, Mrs A, which was requested via 111. Specifically, we considered whether Mrs A’s symptoms were appropriately assessed by the 111 service, which is provided by the Trust, and then whether the referrals to the OOH GP service (provided by the Health Board) were acted on appropriately and in a ti

Ms Z complained about the appropriateness of the categorisation given by Welsh Ambulance Services NHS Trust (“the Trust”) to an emergency call made by her father in August 2022. Ms Z also complained about the appropriateness of a welfare check made by the Trust, specifically whether further questions should have been asked which may have changed the priority of the call. The investigation found that the categorisation given to the emergency call made by Ms Z’s father was appropriate. In respect of the welfare check it was determined that the correct questions were not asked. The failure to ask the correct questions has caused uncertainty to Ms Z, which is an injustice to her. The Trust agreed to apologise to Ms Z that the correct questions were not asked and for the uncertainty this had caused her. It also agreed to remind all call handlers of the importance of following Trust’s Managing Delayed Responses SOP and asking the questions set out in it.

Mr A complained about the length of time it took an ambulance to arrive after calling 999 and raised concern about information obtained by the Trust’s call takers to determine the call priority. The Ombudsman found the Trust had responded to Mr A’s initial complaint. However, she was concerned to note he was dissatisfied with the Trust’s explanation about how it prioritises and responds to all emergency calls. The Ombudsman took into account that the Trust’s call handling and priority system is complex and decided it would be helpful for Mr A to receive a further explanation. As an alternative to investigating the complaint, the Ombudsman made a recommendation which the Trust agreed to implement. The Trust agreed to contact Mr A within 10 working days to arrange a convenient date when a meeting may be convened, to discuss the call handling and priority system.

A solicitor complained on behalf of Mrs S that Welsh Ambulance Services NHS Trust had failed to conclude a redress investigation within a timely manner. The Ombudsman found that there had been a significant delay in responding to the solicitor and that WAST had failed to provide meaningful updates. She said this caused frustration to Mrs S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained WAST’s agreement to apologise to Mrs S and explain the reasons for the delay. It also agreed that it would issue the investigation response directly to the solicitor within 12 weeks.

Mrs B complained that the Welsh Ambulance Services NHS Trust had failed to respond to a complaint she had made to it in November 2022. The Ombudsman found that the Trust had failed to respond to Mrs B complaint or to regularly provide her with updates during its investigation. The Ombudsman said this caused frustration for Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Trust’s agreement to apologise to Mrs B, provide a response to her complaint, and to offer her a payment of £150 within 4 weeks.

Mr V complained that the Welsh Ambulance Services NHS Trust failed to issue a full response to his complaint concerning his 93-year-old mother waiting 16 hours for an ambulance to arrive. During that time incorrect information was given, arrival times kept changing, and laying on the floor for such a long period of time caused a build-up in toxins in his mother’s kidneys which contributed to her death. The Ombudsman found that whilst the Trust issued a preliminary response, it failed to notify Mr V that it was also undertaking a joint investigation with the Health Board to provide a full response. She said this caused additional frustration and inconvenience to Mr V. The Ombudsman decided to settle the complaint without an investigation and sought the Trust’s agreement to issue its full response within two weeks along with an apology for failing to inform him that a joint investigation was ongoing.

Mr B complained that Welsh Ambulance Services NHS Trust had failed to provide a response to his complaint which he made in December 2022, and that he had not received any updates from the Trust. The Ombudsman decided that the Trust had failed to provide regular and meaningful updates and had not issued a complaint response. She said that this caused frustration and uncertainty to Mr B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Trust’s agreement to apologise to Mr B and provide explanations for the delay and lack of regular updates. The Trust also agreed to offer Mr B redress of £50 and issue a complaint response within 2 weeks.

Ms A complained that her late father, Mr B, not being taken to the local hospital by the first ambulance crew adversely affected his treatment and investigation for a suspected stroke. Ms A said that her father’s condition had deteriorated and the following day he was very confused. He had an episode of urinary incontinence and the lower half of his body was uncovered when the second ambulance crew attended. Ms A complained that her father’s dignity was not respected during the second ambulance crew’s attendance when he was transported to the ambulance. Ms A also felt that Welsh Ambulance Services NHS Trust’s (“WAST”) complaint response was not sufficiently robust in relation to its findings around her father’s stroke. The Ombudsman found that Mr B’s delayed admission to hospital did not impact on his stroke treatment and therefore his clinical outcome. However, it did cause a delay in Mr B’s stroke being investigated. While the Ombudsman concluded that this would not have changed Mr B’s clinical outcome, it might have avoided the sad sequence of events that later occurred due to his deteriorating condition. This had significantly impacted on Mr B, Ms A and her son. It was to this limited extent that the Ombudsman upheld this part of Ms A’s complaint. In relation to the second ambulance crew’s attendance, in the absence of evidence to the contrary, the Ombudsman was satisfied that more could have been done to have maintained, or at least looked at options for minimising the compromise to Mr B’s dignity. She also commented on the inadequacies of the documentation which made no reference to the fact that a carry chair had to be used due to the space restrictions at the property, issues with the blanket used to cover Mr B, or the difficulties posed by Mr B’s weight which had led to Mr B’s grandson assisting with the transfer. This aspect of Ms A’s complaint was upheld to the extent set out in the report. In relation to complaint handling and the robustness of the findi

Mr W complained that Welsh Ambulance Services NHS Trust had failed to respond to the complaint he submitted in July 2022. The Ombudsman decided that there had been a delay in WAST’s response and this had caused inconvenience and frustration for Mr W. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained WAST’s agreement to apologise to Mr W and provide him with a complaint response within 7 weeks.

Mrs A complained that WAST had failed to respond to her follow-up complaint about the 11 hour ambulance delay endured by her father. The Ombudsman decided that there had been a delay by WAST to respond to the follow-up complaint and this had caused inconvenience and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained WAST’s agreement to apologise to Mrs A and offer her a financial payment of £50 in recognition of the delays. WAST also agreed to provide Mrs A with a complaint response within 4 weeks.

Mr C complained to the Ombudsman (with the assistance of his Community Health Council (CHC) advocate) about the Welsh Ambulance Services NHS Trust’s response to his concerns following an accident on 17 June 2022. He had concerns around the Trust’s complaint response, its failure to arrange a face-to-face meeting, its categorisation of the emergency call and the advice of the call handler during the call. The Ombudsman found that the Trust’s complaint response was sufficient and that the categorisation of the emergency call was based on his son’s responses to the call handler’s scripted questions. The Ombudsman also found that the complaint about the advice of the call handler had not previously been raised with the Trust and therefore this was deemed to be premature. However, the Ombudsman was concerned that arrangements for a face-to-face meeting had commenced in August 2022 but had still not taken place. It was acknowledged that the Trust has experienced delays in obtaining comments from Hywel Dda University Health Board. The Ombudsman sought and gained the Trust’s agreement to provide Mr C with an apology and to schedule a confirmed date, time and location for a face-to-face meeting, within 20 working days.

Mrs D complained about the Welsh Ambulance Service NHS Trust’s handling of her complaint about the care provided to her late mother-in-law. The Ombudsman decided that the Trust had failed to provide regular and meaningful updates, and had not issued a complaint response to Mrs D. She said that this caused frustration and uncertainty to Mrs D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Trust’s agreement to apologise to Mrs D, provide an explanation for the failure, offer her redress of £50, and issue a complaint response within 5 weeks.

The investigation considered whether the appropriate responders/response vehicles were dispatched to Mr A (who was categorised as Amber 1) in an appropriate timeframe and whether the decision to travel at normal speed to hospital (not using sirens and blue lights) was appropriate. The investigation found that Mr A was correctly categorised as Amber 1. Whilst there is no defined response target time for an Amber 1 category, WAST aim to respond “as soon as possible”. The investigation found that appropriate responders and vehicles were sent to Mr A. An Emergency Ambulance should have reached Mr A sooner however one was allocated as soon as a resource became available. The investigation could not determine whether an earlier allocation of an Emergency Ambulance would have altered the clinical outcome for Mr A as he endured a lengthy wait outside the hospital before admission. The investigation found that the decision to travel at normal speed to the hospital was appropriate. The complaint was not upheld.

Ms X complained that she had submitted a complaint to the Trust in May 2022regarding a delayed Ambulance. The Ambulance did not arrive for 43 minutes, and her husband suffered a cardiac arrest and sadly died at home. Despite receiving 2 holding letters from the Trust, Ms X was yet to receive a full response to her complaint from the Trust. The Ombudsman was concerned about the delays Ms X had experienced in receiving a complaint response and had been inconvenienced by the Trust’s actions. The Ombudsman therefore contacted the Trust and it agreed to provide Ms X with an apology, an explanation for the delay and provide a full complaint response or a proposal in relation to taking the case forward, in settlement of Ms X’s complaint and as an alternative to an investigation. The Trust agreed to carry out these actions within 3 weeks of the date of the Complex Case Panel.

Mrs X complained about the adequacy of the clinical assessment by a Community First Responder (“CFR”, a volunteer who is approved by the Trust to attend certain types of emergency calls in their local community) on 9 September 2020 when the CFR attended her father, Mr Y, following a 999 call. Mrs X was also concerned that there was a delay in sending an ambulance based on the recorded observations of the CFR who indicated Mr Y’s condition was “stable”; Mrs X said that the recorded observations were not suggestive of a “stable” patient. The Ombudsman found, taking into account the advice received from her professional adviser, that based on the information received during the 999 call, it was appropriate to send a CFR. The call was one that was pre-approved for a CFR to attend, and the assessment carried out was within the scope of the CFR’s competence and within the bounds of acceptable practice. The Ombudsman also found that the fact that the CFR attended the call did not result in the ambulance call being downgraded: there was no change in Mr Y’s priority. The CFR’s attendance and observations (which were generally indicative of a stable patient) which she reported to the contact centre did not contribute to or result in a delay in sending an ambulance. The Ombudsman did not uphold the complaints.

Mr X complained that he had not received a date for a meeting with the Trust regarding his outstanding concerns about the delay in an ambulance attending to his late mother. The Ombudsman found that although the Trust had explained the reasons for the delay, the Trust had not set a date for a meeting with Mr X. The Trust agreed to make the necessary arrangements to hold a meeting to discuss Mr X’s outstanding concerns within 4 weeks, as an alternative to the Ombudsman investigating it.

Mrs A complained about the late arrival of an ambulance, which led to the sad death of her daughter, Mrs B, at her home. She was also concerned about the attitude of the attending paramedic and the Trust’s failure to respond to her concerns about that in its complaint response. The Trust had accepted that it had incorrectly prioritised an emergency call. However, it concluded that the sad outcome would have been the same even if the call had been prioritised correctly and a rapid response vehicle had arrived sooner, given the specialist treatment that Mrs B had required for her condition. The Ombudsman decided, having obtained clinical advice, not to investigate that issue, as the earlier arrival of the rapid response vehicle would not have affected the sad outcome. The Ombudsman determined that the Trust had failed to respond to Mrs A’s concerns about the paramedic’s attitude. The Ombudsman sought and obtained the Trust’s agreement to provide Mrs A with a formal written response to those concerns within 3 months.

Mr B complained about the treatment that his wife, Mrs B, received from the Trust after she suffered severe injuries in August 2020, specifically, the use of morphine to treat Mrs B, her transport from the boat she was on to an ambulance, and the accuracy of the complaint response. The investigation found that the use of morphine and the method of transport to the ambulance were appropriate in the circumstances, and these complaints were therefore not upheld. It found that as Mr B’s and the Trust’s accounts of the incident differed significantly, there were several elements that it would never be able to establish definitively. However there were some elements where the Trust’s complaint response was established to be incorrect, or where relevant documentation had not been completed in sufficient detail, resulting in a lack of clarification about some elements of Mrs B’s treatment. This element of the complaint was therefore partly upheld. The Ombudsman recommended that the Trust should apologise to Mr B for the failures identified in the report, offer Mr B a payment of £250 in recognition of the distress caused by the errors involved in complaint handling, and remind all staff of the importance of completing all relevant fields on supporting documentation. The Trust agreed to these recommendations.

Mr D complained that following his father, Mr F, having developed signs of a stroke, requiring an urgent 999 call, the Trust took over 3 hours to dispatch an ambulance to him. Mr D was specifically concerned that given the time-critical need for treatment following a suspected stroke, his father’s call should have been afforded Red status as opposed to the Amber 1 status that was assigned1. Mr D also considered that as a result of the delay in arrival at hospital, an opportunity was missed to administer thrombolysis (medication that functions to dissolve a blood clot) and therefore his father’s chances of survival was compromised. The Ombudsman’s investigation was informed by advice from a highly experienced a Paramedic/Operational Senior Training Manager for Emergency Control Centres (“the Adviser”). Having reviewed all relevant evidence relating to the incident the Adviser was of the opinion that the Amber 1 status of the call was correct and that it would not have been appropriate to escalate the status of the call to Red status. The Adviser also found, having reviewed vehicle availability logs, that were no missed opportunities to have deployed a resource sooner than it did. Having considered the Adviser’s comments, the Ombudsman concluded that Mr F’s arrival at hospital outside the optimal timeframe for him to receive thrombolysis, could not be attributed to any avoidable failing of service on the part of the Trust, and accordingly it would not have been appropriate to review the impact of any delay in Mr F arriving at hospital. Accordingly, the Ombudsman did not uphold the complaint.

Miss D complained about her late father, Mr D’s, treatment by the Health Board and the Trust. She complained that as her father was at the end of life exceptions should have been made to visitor restrictions that were in place due to Covid-19 to allow family to visit him, that incorrect updates were provided to family about his condition while he was in hospital, that he was prescribed unnecessary pain relief, and was discharged twice in a state of neglect. She also raised concerns about a Do Not Resuscitate (DNACPR) decision made by the Health Board, including if the decision was made and communicated correctly, how the Trust dealt with DNACPR when called to treat her father at home, and the delay caused in transporting her father home due to an inability to locate the DNACPR form. Finally Miss D complained about the use of sub-contracted, non-emergency transport to bring her father home from hospital. The investigation found that Mr D would not have met the exception for end-of-life visiting, as he was not expected to die imminently while he was in hospital. However it found that contradictory information appeared to have been provided to his family about this, which was an injustice to them, and this complaint was therefore upheld. It did not find sufficient evidence to confirm a contradiction between Mr D’s health, as recorded in his hospital medical records, and information the family were provided with. It found that although Mr D did not suffer from pain, the prescription of painkilling medication in anticipation of the possibility was justified. These complaints were therefore not upheld. The investigation found that Mr D’s nursing, including hygiene, care, was of an acceptable level, but there was little available information to establish the exact state of Mr D’s appearance during his discharges. As the Health Board acknowledged there could have been some issues with this, but was unable to offer an explanation, this complaint was partly upheld. The invest

Mr A complained that there was an unacceptable 11 hour delay by the Welsh Ambulance Services NHS Trust (“WAST”) in an ambulance attending his late mother, Mrs M, on 3 and 4 November 2019. He also complained about WAST’s handling of his complaint. The Ombudsman’s predecessor decided to use his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the existing investigation into WAST to include the actions of Aneurin Bevan University Health Board (“the Health Board”) in accordance with the Ombudsman’s criteria for commencing such an investigation. The Ombudsman extended the investigation to consider whether there was any maladministration or service failure on the part of the Health Board which contributed to the time Mrs M had to wait for an ambulance and to be seen in the Emergency Department (“ED”), once the ambulance arrived at the Royal Gwent Hospital (“the Hospital”). The Ombudsman’s investigation concluded that the calls to WAST were correctly categorised and appropriate searches were made to try to source an emergency ambulance to attend the calls. It was evident that delays transferring patients into the care of the Health Board seriously affected WAST’s ability to respond on this occasion. The Ombudsman was also satisfied that WAST’s complaint response was reasonable, and did not uphold Mr A’s complaint. The Ombudsman was satisfied that care provided to Mrs M on 3/4 November was broadly reasonable in the circumstances and the delay did not adversely affect Mrs M. However, she noted that the delays must have been distressing for both Mr A and his mother. Please Note: Summaries are prepared for all reports issued by the Ombudsman. This summary may be displayed on the Ombudsman’s website and may be included in publications issued by the Ombudsman and/or in other media. If you wish to discuss the use of this summary please contact the Ombudsman’s office. The Ombudsman was satisfied that the ED was under

Mr A complained that there was an unacceptable 11 hour delay by the Welsh Ambulance Services NHS Trust (“WAST”) in an ambulance attending his late mother, Mrs M, on 3 and 4 November 2019. He also complained about WAST’s handling of his complaint. The Ombudsman’s predecessor decided to use his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the existing investigation into WAST to include the actions of Aneurin Bevan University Health Board (“the Health Board”) in accordance with the Ombudsman’s criteria for commencing such an investigation. The Ombudsman extended the investigation to consider whether there was any maladministration or service failure on the part of the Health Board which contributed to the time Mrs M had to wait for an ambulance and to be seen in the Emergency Department (“ED”), once the ambulance arrived at the Royal Gwent Hospital (“the Hospital”). The Ombudsman’s investigation concluded that the calls to WAST were correctly categorised and appropriate searches were made to try to source an emergency ambulance to attend the calls. It was evident that delays transferring patients into the care of the Health Board seriously affected WAST’s ability to respond on this occasion. The Ombudsman was also satisfied that WAST’s complaint response was reasonable, and did not uphold Mr A’s complaint. The Ombudsman was satisfied that care provided to Mrs M on 3/4 November was broadly reasonable in the circumstances and the delay did not adversely affect Mrs M. However, she noted that the delays must have been distressing for both Mr A and his mother. Please Note: Summaries are prepared for all reports issued by the Ombudsman. This summary may be displayed on the Ombudsman’s website and may be included in publications issued by the Ombudsman and/or in other media. If you wish to discuss the use of this summary please contact the Ombudsman’s office. The Ombudsman was satisfied that the ED was under