SPSO Individual Decisions

Ms C's brother (Mr A) collapsed at home and an ambulance was called. It took around 45 minutes to arrive and, upon arrival, the crew found Mr A to be in cardiac arrest. He was pronounced dead shortly after. Ms C complained about the failure to send assistance to Mr A sooner, including that a community first responder (CFR) was not used. She also complained that the crew did not carry out cardiopulmonary resuscitation (CPR). The Scottish Ambulance Service (SAS) responded to Ms C's complaint and then carried out their own internal clinical review with the ambulance crew to enable further reflection on the incident. SAS identified that the call had been inappropriately downgraded from a cardiac arrest to chest pain category. It was identified that a satellite navigation failure contributed to the delay in the ambulance arriving. It was also noted that a CFR was not showing as available due to software and systems issues, and was therefore not used. We took independent clinical advice which agreed with some of SAS's findings. We noted that there were differing interpretations of the guidelines on when CPR should or should not be attempted. We found that the crew should have taken steps to establish all the available facts in order to fully inform their decision-making in this regard. Therefore, we upheld the complaint.

A GP practice contacted the Scottish Ambulance Service (SAS) to request that C's grandchild (A) be transferred from a local hospital to a hospital with a paediatric unit after A became unwell with suspected meningitis. The practice prioritised the request as urgent, therefore requiring a response within an hour. SAS contacted the practice to request approval for a delay in responding to the request. The practice agreed to the extension based on the information provided by SAS. C complained that the time taken for A to be transferred to the main hospital was unreasonable for A's suspected ailment. C considered that an air ambulance should have been sent to transfer A to the main hospital. We took independent advice from a consultant paramedic. We found that the SAS failed to provide the practice with accurate clinical information about A on which the practice could base their decision to agree or refuse the extension to the transfer time. As SAS failed to obtain confirmation from the local hospital that A's condition was unchanged, and therefore the practice's decision to agree to the delay was based on incomplete information, we upheld this aspect of the complaint. C also complained that SAS's response to their complaint was unreasonable. We found that the investigation of the complaint did not identify SAS's failure to provide accurate information regarding A's condition to the practice. As a consequence, the complaint response failed to provide an accurate account of how the decision was made to delay the transfer. For this reason we upheld this aspect of the complaint.

Ms C complained about the care provided to her by the Scottish Ambulance Service (SAS) when she experienced an episode of cellulitis (a potentially serious skin infection). She said that SAS failed to identify that she was suffering from sepsis (a serious complication of infection) and take the appropriate action. We took independent advice from an adviser who is experienced in pre-hospital, emergency and unscheduled care. We found that the care and treatment provided by SAS to Ms C was reasonable and in line with relevant guidance. We did not uphold Ms C's complaint. However, during our investigation we identified that SAS had failed to respond to Ms C's complaint within the appropriate timescales and had not kept her updated on the delay. We therefore made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Mr C called an ambulance after finding his wife (Mrs A) in a concerning condition. The ambulance took longer to arrive than Mr C felt was reasonable, and he made further calls to the Scottish Ambulance Service (SAS) before it arrived. When Mr C complained to SAS about this, their investigation concluded that the call had not been handled in line with their protocol and that, had protocol been correctly followed, a higher acuity may have been given to the call and an ambulance diverted from another call to respond. SAS apologised for the delay in the ambulance arriving and took steps to prevent a similar situation recurring. Mr C was dissatisfied and raised his complaints with us. We found that there was an unreasonable delay in the ambulance arriving but found no evidence to determine whether a higher acuity would have been given or an ambulance diverted if the protocol had been followed correctly. We upheld the complaint but made no further recommendations. Related reading View Decision Report 201807508 as a PDF (23.78 KB) Updated: August 21, 2019

Mrs C complained that the Scottish Ambulance Service (SAS) delayed in sending an ambulance for her husband (Mr A). Mr A's GP requested an ambulance within two hours as Mr A was experiencing vomiting and diarrhoea and was delirious. The ambulance did not arrive until almost eight hours later. SAS explained that there was an unexpected increase in the volume of calls that day, and that there was no missed opportunity to allocate an ambulance. SAS acknowledged that their delay in sending an ambulance was unreasonable. We took independent advice from a consultant paramedic. We found that there was no missed opportunity to send an ambulance. However, we found that on one occasion the SAS call handler failed to use the correct interrogation system. We also found that SAS failed to carry out a clinical triage which would have involved Mrs C receiving a call from a clinical adviser who would have assessed Mr A's symptoms in more detail. This failing was acknowledged by SAS and was due to the high demand on the service. We upheld Mrs C's complaint and made a recommendation for learning and improvement.

Mrs C complained about the treatment she received from the ambulance service. Mrs C said that she told the paramedic she had chest pains and had vomited a lot of blood. She said the paramedic refused to carry out a proper assessment and returned to their vehicle. Mrs C dialled 999 again and the paramedic returned to the house. The paramedic spoke to Mrs C's GP and it was arranged that she should make an appointment at the practice to discuss her health problems. Mrs  C made a further call to the ambulance service 12 hours later and was then taken to hospital. We took independent advice from a consultant in emergency medicine. We found that there was a difference in recall between the paramedic and Mrs C about the amount of blood she had lost whilst vomiting. The paramedic had recorded that Mrs C had only coughed up a small streak of blood. If the paramedic's recall was the more accurate, then there was no requirement to take her to hospital. However, had she vomited a lot of blood as had described in the later call for assistance then a transfer to hospital was appropriate. While there was some contact between the paramedic and Mrs C's GP, the GP's phone note did not mention any blood loss. On balance, we decided that in view of the record of little blood loss and the facts that the paramedic had made contact with the GP practice, Mrs C did not seek additional medical assistance for a period of 12 hours; and that her symptoms at that time were vastly different from before, that the actions of the paramedic were reasonable. We did not uphold the complaint. Related reading View Decision Report 201804326 as a PDF (24.08 KB) Updated: March 20, 2019

Mr C complained on behalf of his late wife (Mrs A) that an ambulance crew unreasonably failed to take Mrs A to hospital. Mrs A had taken a reaction to medication which had recently been prescribed for her and her blood pressure had dropped to a dangerous level. The crew felt that it was appropriate for Mrs  A to remain at home as she was due to have a visit from a specialist nurse the following day. Mrs A died a short time later. We took independent advice from a professional adviser. We found that the crew had managed to obtain two blood pressure readings from Mrs A and they were both at critically low levels. We considered that the blood pressure readings should have indicated that Mrs A was critically unwell and required assessment and treatment at the hospital which may have prevented her death. Therefore, we upheld Mr C's complaint. We did not make any recommendations in this case as the ambulance service have accepted these failings, apologised and taken appropriate actions to prevent future failings. Related reading View Decision Report 201802571 as a PDF (23.84 KB) Updated: December 19, 2018

Mrs C complained that the ambulance service delayed in sending an ambulance to her daughter (Miss A) when Miss A dislocated her knee. The ambulance took almost an hour to arrive, which the ambulance service acknowledged was much longer than they would have expected. They apologised for the delay and explained it was due to a lack of resource, and the need to prioritise life threatening situations. We took independent advice from a paramedic. We found that the request was assessed and prioritised appropriately. We were satisfied that the ambulance service responded reasonably to the request, and could not have done anything differently with the resources available to them at the time. We did not uphold this complaint. Mrs C also complained about the time taken to respond to her complaint; the lack of interim update which led to her having to chase for a response; and also the adequacy of the response in addressing her concerns. We were content that the response was a reasonable and proportionate response to Mrs C's complaint. However, we were critical that the ambulance service failed to adhere to the NHS Scotland Model Complaints Handling Procedure in that they did not issue their response within 20 working days, and did not proactively contact Mrs C in the interim to explain the delay and agree a revised response timescale. We upheld this complaint.

Mrs C complained on behalf of her father (Mr A) that the ambulance service unreasonably failed to dispatch an emergency ambulance. Mr A collapsed at work with a stroke and two calls were made for an ambulance, which took 50  minutes to arrive. Mrs C felt that the call handler who took the first call had not established sufficient information to determine whether Mr A was conscious or not, and that this affected the priority status of the ambulance response. We took independent advice from a paramedic. We found that both phone calls were graded appropriately in view of the questions asked by the call handlers. However, in the first call it was not clearly established whether Mr A was conscious or not. Good practice would have been for the first call handler to have questioned the caller in more detail, which would have established an accurate consciousness level and may have affected the grading of the ambulance response. We upheld the complaint.

Mrs C complained about the length of time that her mother (Mrs A) had to wait for an ambulance. We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs A be transported to hospital within two hours, and that this was not a request for an emergency 999 response. However, we found that, if a request to be transported goes beyond the agreed timescale, then ambulance service call handlers will carry out urgent welfare call backs to check whether the patient's condition has deteriorated. Where the call handler identifies that the patient's condition has worsened, they should upgrade the call to an emergency response and process it through the medical priority dispatch system. We found that during the first welfare call back Mrs A was reported to be struggling to breath and that during the second welfare call back she had reportedly stopped taking sips of water. We considered that there were failures to appropriately explore possible deteriorations in Mrs A's condition during the first and second welfare call backs. We upheld the complaint.

Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him to a major trauma centre. Mr C subsequently developed fat embolism syndrome (a life-threatening condition where fat particles within the bone are released into the bloodstream) and went into a coma. He considers that this was at least partly due to the ambulance service's delay in sending ambulances to both his home and his local hospital. We took independent advice from a paramedic. We found that a dispatcher in the ambulance control centre had failed to identify a paramedic crewed ambulance that was available at the time of Mr C's 999 call. This had caused an unreasonable delay by the ambulance service in sending an ambulance to Mr C's home. In view of this, we upheld this aspect of Mr and Mrs C's complaint, although we acknowledged that the ambulance service had already apologised for this and had taken some action to try to prevent this happening again. We found that the delay by the ambulance service in sending an ambulance to transfer Mr C from his local hospital to a major trauma centre had not been unreasonable. Mr C was in a place of safety and could have been upgraded to an emergency by the hospital at any time. We did not uphold this aspect of Mr  and Mrs C's complaint. However, we considered that the communication between the ambulance service and clinicians in the hospital could have been better and we provided some feedback to the ambulance service in relation to this. We also provided some feedback to the ambulance service on trauma care and the documentation of this.

Mr C complained about the way in which the ambulance service handled him after he had a seizure and fell at home, injuring his lower back. Mr C was concerned about the lack of assistance he received from the ambulance crew before they took steps to immobilise his spine and transfer him to hospital. It was later established that Mr C had sustained two fractures of his spine. We took independent advice from a consultant in emergency medicine. Given that there had been restricted space in the room that Mr C had fallen, together with a number of factors that made it unlikely that he had sustained such fractures, we considered that it was reasonable of the ambulance crew to have provided spinal immobilisation in an area with greater room to do so. However, we noted that there was no evidence of a clinical assessment of Mr C's back and neurological function, nor evidence of a risk assessment prior to the decision to move Mr C. We considered that the assessment of Mr C was unreasonable and upheld his complaint.

Mrs C complained about the care and treatment provided by the ambulance crew who attended to her husband (Mr A). Mrs C had called an ambulance in the early hours of the morning as her husband was unwell. The crew examined Mr A and told Mrs C that they were not going to take Mr A to hospital, but that she should contact her GP for a home visit when the medical practice opened later that morning. A GP made a home visit and found Mr A to be disorientated and confused, which had been mentioned by Mrs C in her phone call to the ambulance service. The GP arranged for Mr A to be taken to hospital for further assessment and it was later diagnosed that he had suffered a stroke. Mrs C felt Mr A should have been taken to hospital by the ambulance crew. We took independent advice from a clinician involved in the training of paramedics and concluded that the ambulance crew had failed to adequately record Mr A's symptoms and that he should have been transported to hospital for further clinical assessment. We upheld Mrs C's complaint.

Mrs C complained on behalf of her late husband (Mr A) that the ambulance service failed to transfer Mr A to hospital in an appropriately safe manner. Mr A had recently been diagnosed with a cancerous tumour on his femur (thigh bone) and was at risk of fracture. While being admitted to hospital for pain management, Mr A sustained a fractured femur while he transferred himself from a trolley cot to a hospital trolley. Mrs C was also concerned that the ambulance crew did not stay with Mr A in the accident and emergency department until he was attended to by hospital staff and did not complete an incident report regarding the fracture. We took independent advice from a paramedic clinical team leader. We found that good practice should have dictated the use of transfer equipment or, as a minimum, the supporting of Mr A's leg during his efforts to self-mobilise. We also considered that the ambulcance crew should not have left Mr A in hospital without ensuring treatment had commenced and should have completed an incident report regarding the fracture. Therefore, we upheld Mrs C's complaint. Mrs C also complained about how the ambulance service handled her complaint. We found that there was an unreasonable delay in responding to the complaint and a failure to keep her updated. We also noted that Mrs C only received a copy of the internal investigation report document. No formal, personalised complaint response letter was issued and she was not informed of her right to appproach us with her complaint. We upheld Mrs C's complaint.

Mr C complained that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, headaches for the past three weeks, and that he now also had pins and needles in his right hand side. The ambulance service said that Mr C's reported symptoms did not meet the criteria for an emergency ambulance. However, as Mr C had symptoms for a number of weeks, he did require a medical review and it was agreed that Mr C's sister would transport him to hospital. We took independent advice from a paramedic and listened to the audio recordings of the phone calls. We found that Mr C's symptoms did not warrant the dispatch of an emergency ambulance and that it was appropriate to arrange for the clinical adviser to phone him back to obtain further information. We found evidence that a number of assumptions had been made by the clinical adviser. At no time did Mr C state that he had had the pins and needles for two weeks but rather that the problems had just started. We found that the clinical adviser did not adequately question Mr C or his sister about how manageable it would be to transport Mr C to hospital, should he suffer another collapse. We also found that insufficient weight had been taken of the severity of Mr C's headache, the visual disturbances, and neck stiffness. We found that it would have been advisable to have dispatched an ambulance crew who would have carried out a face-to-face assessment in Mr C's home and determined the appropriate way to progress matters. We upheld the complaint.

Mr C complained on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably. Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting for an operation. Mr C said that Mrs A was told to call the emergency services if she experienced certain symptoms. When Mrs A subsequently experienced these symptoms, Mr C called the emergency services and spoke to a call handler who referred Mrs A to NHS 24. Mr C was unhappy that the ambulance service failed to dispatch an ambulance following the emergency call. We took independent advice from a consultant in emergency medicine. We found that the information reported during the emergency call did not confirm that Mrs A had an immediately life-threatening condition, which would have required the dispatch of an ambulance as an emergency. The adviser noted that the decision to refer the call to NHS 24 in order to get a more detailed assessment of the situation by a clinically trained person was reasonable. We found that the decisions taken by the ambulance service were reasonable and therefore, we did not uphold this aspect of Mr C's complaint. In relation to complaints handling, we found that the ambulance service had performed a detailed audit of the emergency call and that the member of staff involved had appropriately reflected on the call. We were satisfied that the complaint investigation carried out was reasonable and that the response to Mr C addressed the points he had raised. We did not uphold this aspect of Mr C's complaint. Related reading View Decision Report 201705035 as a PDF (11.32 KB) Updated: December 2, 2018

Mrs C complained that her late husband (Mr A) had been taken to the wrong hospital by the ambulance service. Mrs C explained that, when Mr A became ill, she recognised signs of a stroke and called an ambulance. She said she thought that, according to the protocol in place at the time, Mr A should have been admitted to the Hyper Acute Stroke Unit at a particular hospital. He was taken to a different hospital and Mrs C felt that this had had an impact on the treatment he was given. We took independent advice from a paramedic. We found that, on the basis of the information given by Mrs C in the emergency call, the ambulance crew should have suspected a stroke and on this basis should have taken Mr A to the stroke unit at the hospital where Mrs C thought he should have gone. We, therefore, upheld this complaint. We noted that the ambulance service had carried out stroke education since the events of this complaint; however we recommended that they carry out an audit to confirm that patients are being taken to the correct hospital. We also noted that the ambulance crew had failed to document a test they carried out, and we made a recommendation on this point.

Ms C complained about the care and treatment provided to her late partner (Mr A) by the ambulance service. She felt that the service should have taken Mr A to hospital when they attended him and he was unwell with diarrhoea, because several days later Mr A was diagnosed with a perforated duodenal ulcer (when the lining of the stomach splits due to a sore). We took independent advice from a consultant in emergency medicine who is involved in the training of paramedics and who works alongside them in the provision of pre-hospital care. We found that the ambulance service appropriately assessed Mr A and reasonably contacted an out-of-hours GP to further assess Mr A. We did not uphold this complaint. Related reading View Decision Report 201704912 as a PDF (10.95 KB) Updated: December 2, 2018

Miss C complained about the care and treatment provided by the ambulance service to her mother (Mrs A). Miss C raised concerns that the ambulance crew did not handle Mrs A's transfer to hospital appropriately. In particular, that she had been dropped in the vehicle and that she had bruising on her back. Miss C also complained that the ambulance services' investigation and response to her complaint were unreasonable. We took independent advice from a registered nurse who is experienced in moving and handling issues. We found that based on the paramedic records, staff undertook the handling and transfer of Mrs A appropriately. Therefore, we did not uphold this aspect of Miss C's complaint. In relation to complaints handling, we found that there was no evidence of factual inaccuracy in the complaints response from the ambulance service, and that they had apologised for the delay in providing the response. Therefore, we did not uphold this complaint. Related reading View Decision Report 201701357 as a PDF (11.03 KB) Updated: December 2, 2018

Mr C complained about the care and treatment the ambulance service provided to his late mother (Mrs A). Mrs A suffered a number of background conditions and she became unwell. The ambulance service received a phone call and paramedics attended. The paramedics assessed Mrs A as likely being medically unwell, with possible sepsis (a blood infection). There were difficulties moving Mrs A, and a second ambulance attended to assist paramedics. Mrs A was taken to hospital where her condition deteriorated and she died. Mr C raised concerns about the actions of staff, including the time they took to move Mrs A, and the way they moved her. The ambulance service considered that the care and treatment provided to Mrs A was appropriate. They considered that staff performed a thorough assessment, and acted reasonably in the circumstances. We took independent advice from a paramedic. We found evidence that all relevant observations and examinations were undertaken. Regarding the time taken to move Mrs A, we found that it was appropriate for paramedics to request a second ambulance to assist them in moving her and we found that the delay was not excessive in the circumstances. We found no evidence that Mrs A was incorrectly moved. We did not uphold Mr C's complaint. Related reading View Decision Report 201703520 as a PDF (11.17 KB) Updated: March 13, 2018

Mr C called 999 when his wife (Mrs A) became very unwell. A paramedic arrived five minutes later, and told Mr C that an ambulance would be on its way. However, the ambulance did not arrive for about half an hour, and only after the paramedic called to request back-up. During this time, Mrs A stopped breathing. The paramedic assisted her breathing and she recovered to some extent. However, after the ambulance arrived, Mrs A suffered a cardiac arrest. Staff carried out cardio-pulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops), which was successful at restoring her pulse. Staff transferred Mrs A to the ambulance and took her to hospital. While in the ambulance, Mrs A suffered a second cardiac arrest. Staff again began CPR, and this was continued until Mrs A was handed over to hospital staff. Hospital staff continued the CPR, but this was unsuccessful and Mrs A died in hospital shortly after her arrival. Mr C complained about the delay in the ambulance arriving and the lack of communication from ambulance service staff, including the way they handled his complaints. The ambulance service upheld Mr C's complaints and apologised. They said there were opportunities to send an ambulance earlier, but these were missed. The ambulance service said they would discuss the communication complaint with the staff involved and senior managers would review their procedures to ensure that ambulance support is provided earlier in future. Mr C was dissatisfied with this response, and he brought his complaint to us. We took independent advice from a consultant in emergency medicine. We found the delay in sending an ambulance was unreasonable, and a lack of clarity in the ambulance service's policies had contributed to this. However, we noted that the ambulance service have now updated their policies and adopted a new response model, which should prevent a recurrence of the failings in this case. We found the treatment of Mrs A's re

Ms C complained to us that the Scottish Ambulance Service (the ambulance service) had delayed in responding to an alarm call made by her late mother (Mrs A). Mrs A lived in an assisted living complex and had made an alarm call to an alarm receiving centre (this was a private company that was not part of the ambulance service). She did not respond when the alarm receiving centre answered the call and they contacted the ambulance service. An emergency ambulance was dispatched to Mrs A's home, but it was then decided that this should be stood down and that another non-emergency ambulance would attend. On arrival at Mrs A's home paramedics found that she had died. We took independent advice from a medical adviser, who is involved in the training of paramedics and who regularly works alongside them in the provision of pre-hospital care. We found that it had been reasonable for the ambulance service to cancel the emergency ambulance and to respond to the call using a non-emergency ambulance. This was in line with the agreed protocol and, as there was no information at that time to confirm that there was an urgent threat to life, we found that the time taken by the ambulance service to respond had been reasonable. The advice we received was that the risk of ambulances responding to calls using emergency blue light driving conditions for calls which turned out not to be life-threatening emergencies had to be taken into account. We did not uphold the complaint. Related reading View Decision Report 201606751 as a PDF (11.28 KB) Updated: March 13, 2018

Ms C complained that there had been a delay in transferring her mother (Mrs A) from Uist and Barra Hospital to Western Isles Hospital. Mrs A had a stroke and after the emergency services were called, she was taken by ambulance to Uist and Barra Hospital. The Scottish Ambulance Service had been called prior to her admission, and a plane to transfer Mrs A to Western Isles Hospital then left the mainland. Because of adverse weather, the plane was unable to land at the nearby airport and as a result, the transfer could not take place that evening. In response to Ms C's complaint, the board explained that there is a four and a half hour window to assess a patient who is suspected of having had a stroke and judge the potential benefit of thrombolysis (clot busting) treatment. The board said that the delay in transfer was caused by bad weather, which meant that the cut-off time for potential treatment with thrombolysis medication had passed. We took independent advice from a specialist in emergency medicine. They did not find evidence of a delay in contacting the ambulance service regarding air transfer and said that the decision whether it was safe to fly or not, and the assessment of the likelihood of being able to land, rested with the aircraft captain. The adviser said that once it became apparent that the plane was unable to land, the opportunity to get Mrs A to Western Isles Hospital, complete a CT scan and consider the possibility of thrombolysis in under four and a half hours had passed. Whilst the adviser considered that the care surrounding the transfer was reasonable, they considered that the doctor's records should have been more detailed. We did not uphold this complaint, but we made a recommendation. Ms C also raised concern about the communication during the transfer process. We found that the board had apologised for any upset and distress Ms C's family experienced. Having considered the evidence available, the adviser concluded that the communica

Mr C complained about the care and treatment his late wife (Mrs A) received from the Scottish Ambulance Service. Mrs A collapsed at home and Mr C phoned the ambulance service. Mrs A was taken to hospital and died shortly after arrival. Mr C said the ambulance service did not provide a reasonable standard of care and treatment for his wife and that there was an unreasonable delay in transferring his wife to hospital. He also said the ambulance service did not reasonably investigate and respond to his complaint. We obtained independent medical advice on the case from a consultant in emergency medicine. The adviser said that after obtaining a first electrocardiogram (ECG) tracing (a test used to check heart rhythm and electrical activity), which was of adequate quality, the crew then spent 21 minutes obtaining a further five ECG tracings, the reason for which was unclear given that the first reading was adequate. The adviser also said the ambulance crew's clinical assessment of Mrs A was unreasonably minimal, especially with regards to regularly measuring her vital signs. For these reasons, we upheld this part of the complaint. The adviser said that the time spent trying to obtain an ECG and communicate with the intended receiving hospital was unjustifiably prolonged. He said this was especially the case as Mrs A was only a ten minute drive from the hospital that she was eventually taken to, and because she was so critically unwell. The adviser said that when it became clear that obtaining the ECG and transmitting it to the first intended hospital was becoming problematic, the ambulance crew should have urgently taken Mrs A to the second hospital, which was the closer hospital, for medical assistance. From there a decision could have been made about Mrs A's onward transportation to the first intended hospital. We upheld this part of the complaint. We also considered that the ambulance service did not reasonably investigate and respond to Mr C's complaint and

Mr C complained that the Scottish Ambulance Service (the ambulance service) did not ensure that someone attended his home to make sure he was safe after he took an overdose of paracetamol. When the ambulance crew arrived, they could not or did not gain access and left the house without taking further action. Mr C was later helped by a neighbour to attend A&E. Mr C said he was in a vulnerable situation and that the failings by the ambulance service were potentially life-threatening. Mr C also complained about the way the ambulance service handled his complaint, including the time it took them to respond. We took independent advice from a specialist in the training and supervision of healthcare professionals including paramedics. We found inconsistencies in the accounts of the staff involved and it is not clear why contact was not made with Mr C. The ambulance service failed to record their findings and action taken at the time. The evidence indicated a communication breakdown between the ambulance crew and ambulance control centre. We found that the ambulance service should have escalated the situation to the police in order to gain more information and access to the property. In relation to the handling of Mr C's complaint, we found evidence indicating confusion amongst staff about who should deal with the complaint and how it should be dealt with. We were critical that Mr C's complaint to the ambulance service was initially managed as a concern and that it took over three months for the ambulance service to start an investigation. We also found that complaint staff did not reasonably inform Mr C about the delays and the reasons for these.