PSOW Individual Decisions

Ms A complained that the Welsh Ambulance Services University NHS Trust failed to respond to the complaint she submitted in May 2025. The Ombudsman found that the Trust failed to formally respond to the complaint and said this caused uncertainty and frustration for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Trust’s agreement to, within 3 weeks, provide the complaint response, apologise for the delay and explain why this happened, and offer a £100 financial redress payment in recognition of the time and trouble.

Mrs A complained that there were repeated failures by Welsh Ambulance Services University NHS Trust (“the Trust”) to appropriately prioritise an emergency response when her husband, Mr A, called 999 after midnight on 30 May 2025, resulting in a significant delay in his receiving appropriate medical care. Mrs A was concerned that the delay led to Mr A experiencing avoidable excruciating pain, and contributed to his premature death. The Ombudsman identified that although Mrs A’s complaint against the Trust had been considered in an investigation by the Health Board in her area, her concerns had not been adequately addressed. The Ombudsman considered that a full and thorough investigation of Mrs A’s complaints by the Trust could potentially resolve her complaint. The Trust agreed to within 1 month initiate a “Putting Things Right” complaints investigation with reference to those aspects of Mrs A’s complaint which related to care provide by the Trust.

Ms L complained, about how the Trust responded to an emergency call from her late mother, Mrs F. The investigation focused on whether the emergency call was triaged appropriately and reasonably and whether an upgraded priority assigned to the call, following failed attempts to contact her by telephone, was appropriate. The Ombudsman found that Mrs F’s emergency call was triaged appropriately and that although there was an error in coding the call, the overall priority was correct which meant there was no effect on the overall ambulance response time. This element of the complaint was not upheld. The Ombudsman found that the upgraded priority assigned to Mrs F’s call following failed attempts to contact her by telephone were not managed in accordance with the Trust’s procedures. This was an injustice to Mrs F and this aspect of the complaint was upheld. The Trust accepted the Ombudsman’s recommendations that it apologise to Ms L for the shortcomings identified and to remind staff to provide robust documentation when deciding whether or not to upgrade a call.

Mr B complained that poor communication and inadequate care from Welsh Ambulance Services Trust caused delays in the assessment and treatment of his wife’s sepsis, when she was taken to hospital by ambulance. The Ombudsman decided that the Trust had not dealt with Mr B’s concerns in accordance with the NHS Concerns, Complaints and Redress arrangements (‘Putting Things Right’). The Trust and the Health Board provided separate responses to Mr B’s complaints, which resulted in inconsistencies and omissions in the findings. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Trust’s agreement to cooperate with the Health Board and provide a joint complaint response within three months.

Ms A complained about care provided to her late partner in November 2024. The Ombudsman investigated whether the Welsh Ambulance Services University NHS Trust (“the Trust”) appropriately prioritised and responded to Ms A’s 999 call and whether it provided appropriate advice to her to safeguard her partner’s wellbeing, including in relation to the advice to find alternative transport to the Emergency Department (“the ED”) at Morriston Hospital. Ms A’s partner very sadly died after suffering a cardiac arrest on the way to hospital. The Ombudsman found that the 999 call was appropriately prioritised by the Trust, but that it was not possible to provide a timely emergency response at the time due to extreme demand on the ambulance service. Accordingly, the first complaint was not upheld. The Ombudsman found that the Emergency Medical Dispatcher (“the EMD”) who answered Ms A’s 999 call, had deviated from the call handling script when advising her to take her partner to the ED. However, it was not possible, with hindsight, to determine whether Ms A’s partner’s outcome would have been any different if the EMD had used the correct wording. Accordingly, the second complaint was not upheld.

Mr A complained about the delay in receiving a response from the Welsh Ambulance Services University NHS Trust (“WAST”) to his complaint which he submitted in February 2025. The Ombudsman found that WAST had failed to respond to Mr A’s complaint in a timely manner. It was decided to settle the complaint without an investigation. The Ombudsman sought and gained WAST’s agreement to within 1 week, issue its response to Mr A’s complaint and provide an apology and explanation for the delay in responding.

Mr X complained that Welsh Ambulance Services University NHS Trust had failed to respond to the complaint he made to it in February 2025. The Ombudsman found there had been a delay in WAST responding to Mr X’s complaint, causing frustration to him. She decided to settle the complaint without a formal investigation. The Ombudsman sought and gained WAST’s agreement to apologise and explain the reasons for the delay and to issue its complaint response to Mr X within 4 weeks.

Mr X, with the support of his MP, complained that the complaint he made in January 2025 to the Welsh Ambulance Services University NHS Trust had not received a response. The Ombudsman found that there had been a delay in the Trust responding to Mr X’s complaint, which she said caused frustration to him. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Trust’s agreement to apologise to Mr X for the delay and offer him a £100 redress payment within 4 weeks, and to aim to issue its complaint response within 12 weeks. If the complaint response cannot be issued within 12 weeks, the Trust must update Mr X on a monthly basis until it is issued.

Miss B complained about the care and treatment provided to her late son, Mr C, by Welsh Ambulance Services University NHS Trust (“the Trust”) on 10 and 11 December 2022. Specifically, the handling of the 2x 999 calls made and whether a response should have been dispatched sooner, and if it had, whether earlier arrival would likely have affected his outcome. The Ombudsman found that both emergency calls were correctly triaged and prioritised by the Trust’s Emergency Medical Dispatch call handlers. However, the Trust’s Clinical Support Desk clinicians should have reviewed Mr C’s situation during the first 999 call, identified that he was at serious risk and then escalated the ambulance response category in line with the Trust’s own guidance. This failure to review the call was a serious injustice to Mr C. The time Mr C spent waiting for an ambulance would have been distressing, painful and undignified for him, and extremely upsetting for his father who was present with Mr C. Accordingly, this element of the complaint was upheld. The Ombudsman found that although an emergency response should have been dispatched sooner, on the balance of probabilities, this delay was unlikely to have changed the outcome for Mr C. That said, his family were left with doubts about the outcome while this matter has been investigated. The impact of the Trust’s failings amounts to an injustice to the family which will have had a lasting impact on them. To that extent, the complaint was upheld. The Trust accepted the Ombudsman’s recommendations; to offer a meaningful apology for the failings identified and for not identifying the failings during its complaint handling process; to offer financial redress totalling £2,250 for these failings, including having to pursue this complaint to gain answers. The Trust also accepted recommendations to share the investigation report with: The Trust’s complaint investigation team to review the conduct of its investigation in line with the Duty of Candour.

Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, and the priority they were allocated by the Trust, was reasonable and appropriate. The investigation also considered whether the advice provided by Trust staff during the calls was reasonable and appropriate. Finally, the investigation considered whether Mrs C was appropriately assessed and managed by the Health Board following her arrival at the Emergency Department of Morriston Hospital on 15 September. The Ombudsman found that the emergency calls were correctly triaged and prioritised by the Trust’s emergency call handlers. However, a clinician on the Clinical Support Desk (“CSD” – a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category. If this had happened, an ambulance may have been allocated to Mrs C sooner. This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her. This complaint against the Trust was upheld. The Ombudsman was concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after she shared the views of her Paramedic Adviser in April 2024. The Ombudsman considered that this raised serious concerns about the robustness of the Trust’s investigations of the complaints it receives, particularly as this was not the only case in which she had identified deficiencies in the Trust’s complaints investigation process. In respect of the advice provided by the Trust’s staff, particularly the advice not to move Mrs C, the Ombudsman

Mrs A complained about a lack of care and treatment by the Welsh Ambulance Services University NHS Trust (“the Trust”) for her son, Mr B, on 14 December 2022. The Ombudsman’s investigation considered the handling of 2 999 calls, the standard of record keeping by the attending paramedic, and whether the earlier arrival of Trust staff would likely have affected Mr B’s outcome. The Ombudsman found a failure to properly manage the 2 999 calls made in respect of Mr B. The First Call was incorrectly downgraded from “Red” priority to “Green 2”. This meant a delay of 32 minutes in an ambulance attending Mr B. The Second Call was also not handled appropriately, with incorrect information given to Mrs A about cardio-pulmonary resuscitation. As a result, Mr B did not receive timely medical attention. Additionally, there was injustice to Mrs A and Mr B’s brother, Mr C, as they spent 45 minutes attempting to deliver CPR to Mr B, without instruction or support. In respect of the standard of record keeping by the attending paramedic, the Ombudsman found that fully accurate information was not entered on the patient clinical record particularly that the information was based on estimation. There was inconsistent reporting by the attending paramedic of what information was obtained from Mr B’s family. This lack of clarity about the events of 14 December constituted an injustice to Mr B’s family. In terms of whether earlier attendance by Trust staff could have affected Mr B’s outcome, the Ombudsman could not conclude with certainty that the earlier arrival of an ambulance would have made a difference. There was information that was not known, including the point at which Mr B suffered a cardiac arrest. As there was a small possibility of a different outcome for Mr B, this is an injustice to Mrs A and the family. Whilst the Ombudsman’s investigation did not set out to consider the Trust’s handling of Mrs A’s complaint, information came to light which highlighted concerns about the rob

Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, and the priority they were allocated by the Trust, was reasonable and appropriate. The investigation also considered whether the advice provided by Trust staff during the calls was reasonable and appropriate. Finally, the investigation considered whether Mrs C was appropriately assessed and managed by the Health Board following her arrival at the Emergency Department of Morriston Hospital on 15 September. The Ombudsman found that the emergency calls were correctly triaged and prioritised by the Trust’s emergency call handlers. However, a clinician on the Clinical Support Desk (“CSD” – a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category. If this had happened, an ambulance may have been allocated to Mrs C sooner. This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her. This complaint against the Trust was upheld. The Ombudsman was concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after she shared the views of her Paramedic Adviser in April 2024. The Ombudsman considered that this raised serious concerns about the robustness of the Trust’s investigations of the complaints it receives, particularly as this was not the only case in which she had identified deficiencies in the Trust’s complaints investigation process. In respect of the advice provided by the Trust’s staff, particularly the advice not to move Mrs C, the Ombudsman

Mrs C complained about the care her late husband, Mr C, received from Welsh Ambulance Services University NHS Trust (“the Trust”) on18 December 2022. The investigation considered whether Mr C was appropriately triaged and prioritised during the first and subsequent calls to 999. It also considered whether sufficient and accurate updates were provided to Mr C’s family while he awaited an ambulance, including whether the “welfare call” was sufficient. The Ombudsman found that Mr C was appropriately triaged and prioritised during the first and subsequent 999 calls. Although regular updates were not provided, this was due to the high call volumes the Trust was experiencing that day. The Trust’s policies confirm that welfare calls are not compulsory and that it may not be feasible to make such calls at time of escalated demand upon its services. The Ombudsman did not uphold Mrs C’s complaints.

Mrs D complained about the care and treatment provided to her mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”). The investigation considered whether failings in the Trust’s assessment of Mrs C led to delay in her receiving treatment which could have potentially avoided her death from sepsis (when the body overreacts to an infection and damages the organs and tissue). The Trust’s investigation into Mrs D’s complaint had identified several failings in the assessment and care it provided to Mrs C, but it said that on the balance of probability, the identified failings had not caused Mrs C harm. The Ombudsman found that it was unlikely that earlier treatment would have prevented her death from sepsis. As no injustice was identified, Mrs D’s complaint was not upheld.

Ms A complained that her father waited over 3 hours for an ambulance to transfer him following a suspected stroke. The call was categorised as an Amber 1 (second highest priority). She said that the Trust’s investigation identified a potential error in the processing of the emergency call. The Ombudsman found that whilst Ms A complaint was investigated in accordance with the complaint process Putting Things Right Regulations(PTR), the Trust had not considered the issue of harm (qualifying liability) as required by PTR. The Trust agreed to do the following as an early resolution/settlement • apologise to Ms A for the shortcomings in its complaint handling process; as well as providing a PTR complaint response which addressed qualifying liability and in the interim, keep the family updated on progress.

Ms A complained about the way the Welsh Ambulance Services University NHS Trust responded to emergency calls made regarding her late brother, Mr B. The investigation found that the emergency calls were given the correct prioritisation and that the delay in an ambulance arriving to Mr B was due to demand outstripping the Trust’s available resources at that time. However, the investigation also found that there were potentially missed opportunities to carry out a clinical telephone assessment of Mr B’s condition. It is not possible to say what the outcome of this assessment would have been had it taken place, but this uncertainty is an injustice to Ms A. To this extent, Ms A’s complaint was upheld. The Trust agreed to apologise to Ms A for the failings identified during the investigation. It also agreed, that if it had not done so already, to provide feedback to the clinician that attempted to carry out the telephone assessment on the correct process for managing failed contact attempts. The Trust also agreed to conclude a policy review that it had undertaken and consider the inclusion of an action to verify the most appropriate contact number when 999 calls are made from a care or nursing home.