SPSO Individual Decisions

Mrs C's husband (Mr A) suffered a suspected stroke at work. An ambulance was called. Mrs C complained that there was an unreasonable delay in an ambulance attending. She was also unhappy that the caller was not properly informed that there were no ambulances currently available and, later, that there was going to be a delay in the ambulance attending. We took independent advice from a specialist in emergency medicine. The adviser found that the categorisation of the call was reasonable and that, while there was a delay in attending, there are times when demand will exceed capacity and that at these times, it will not be possible to provide a response within an ideal timescale. Therefore, while we accepted that there was a delay, we did not consider that the delay was unreasonable. We also accepted the adviser's view that it was reasonable that initially the caller was told that the ambulance would be there as soon as possible and, in relation to the further call, that it took four minutes before the ambulance arrived, so giving further detail to the caller was not necessary. We therefore did not uphold Mrs C's complaint. Related reading View Decision Report 201601729 as a PDF (11.12 KB) Updated: March 13, 2018

Mr C complained about the time it took for the Scottish Ambulance Service to send an ambulance after he and his wife (Mrs C) were involved in a road traffic collision. It took 40 minutes for the ambulance to arrive and Mr C felt that the ambulance service should have contacted either off-duty staff or trained responders to assist his wife, who was in pain. We found that the ambulance service had acknowledged from the outset that there had been a delay in the ambulance being dispatched. We considered the ambulance service had acted in accordance with their call-out procedures in relation to off-duty staff and trained responders (including GPs) because there was no apparent threat to life. The ambulance service provided information on the action they took as a result of the delay. They have reviewed their shift capacity and put further measures in place including the training of staff and new posts. In terms of the ambulance service's handling of Mr C's complaint, we considered that there was an unreasonable delay of around six months in responding to additional questions Mr C had asked. The ambulance service accepted that there were failings in relation to the time they took to reply to Mr C. Therefore they introduced a pilot method to record contact from individuals as part of their complaints handling.

Ms C's partner (Mr A) collapsed. He was treated by a paramedic and transported to hospital, where he later died. Ms C complained that Mr A's mobile phone went missing. Our investigation focused on the actions taken by the Scottish Ambulance Service to locate the phone or to try to find out what happened to it. Although they did not find the phone, we were satisfied that reasonable efforts were made to investigate this matter. Related reading View Decision Report 201508500 as a PDF (10.77 KB) Updated: March 13, 2018

Miss C complained about the care and treatment provided to her late father (Mr A). Mr A became unwell and an ambulance was called. The ambulance crew examined him and suspected a heart attack. They contacted the coronary care unit at the Royal Infirmary of Edinburgh and it was agreed that Mr A should be brought there. However, Mr A went into cardiac arrest on the way and, despite the ambulance diverting to the nearest hospital at that time, he could not be resuscitated and he died. Miss C complained about the time taken for the ambulance to set off for hospital and also about the decision to take Mr A to Edinburgh rather than his local hospital. The ambulance service noted that the ambulance was present at Mr A's home for a total of 33 minutes. They advised that this included all the patient assessment process, liaison with the Royal Infirmary of Edinburgh, and transferring Mr A to the ambulance. They indicated that the only issue that may have created a slight delay was difficulty in establishing intravenous access (where a thin tube is placed inside a vein to administer or withdraw fluids). We took independent clinical advice from a paramedic. They considered that the ambulance crew had provided appropriate clinical treatment and acted within Mr A's best interests. While they noted that the ambulance was at Mr A's home for 13 minutes more than the optimum recommended time for a coronary case, they considered that the delay was not unreasonable in the circumstances. They advised that it was the correct decision to transfer Mr A to Edinburgh for specialist treatment, right up to the point that he went into cardiac arrest. They informed us that it was accepted practice to bypass nearer hospitals to take patients to the best possible place of treatment and they said it was not certain that Mr A would have survived the cardiac arrest had he been in hospital when it occurred. We accepted this advice and did not uphold the complaint. Related reading View Deci

Mrs C complained about an ambulance crew who attended her following a fall in her garden. After the fall, Mrs C knew she had damaged her back; she was in severe pain and could not move her legs. The crew attended without carry equipment and pulled her up into a garden chair and gave her gas and air. The crew appeared to be unsure about whether or not to take Mrs C to hospital but eventually did so (after an hour) and she was diagnosed as having fractured three vertebrae. We took independent advice from an A&E consultant and found that, given Mrs C's reported symptoms, the location and severity of her pain, it was highly suggestive that Mrs C had suffered a lumbar (lower back) spinal fracture. As a result, she required a hospital assessment for an x-ray or CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) as required. It was not appropriate for the crew to have attempted an assessment of Mrs C on scene or to have tried to sit her on a chair, and her spine should have been immobilised. We upheld the complaint and noted that the service had already arranged for the Area Service Manager to review the case and allow the crew to reflect on their actions.

Mr C complained about an ambulance crew that attended his wife (Mrs C). After Mrs C was taken to hospital, she was diagnosed with a ruptured abdominal aortic aneurysm (a weak point in a blood vessel), which was a life-threatening condition. Mr C said the crew did not diagnose his wife's condition or provide treatment for it, and did not regard the situation as an emergency. In addition, Mr C was unhappy with the ambulance service's response to his complaint. We took independent advice from an adviser who is a consultant in emergency medicine. Although we would not expect the crew to make a definitive diagnosis of an abdominal aneurysm, we found that they should be able to recognise when a patient is seriously unwell. In this case, the crew assumed that Mrs C's symptoms were due to sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) or muscular back pain, and they failed to recognise that she had a life-threatening condition. We upheld this part of Mr C's complaint. Once the crew decided to take Mrs C to hospital they gave her morphine. In this respect, they provided treatment to Mrs C and so we did not uphold this part of Mr C's complaint. The crew did not use blue lights when taking Mrs C to hospital, which was reasonable as it was the early hours of the morning. However, doing this was another indication that the crew did not recognise Mrs C was seriously unwell, as was their discussion about leaving Mrs C at home for review by her local doctor. We upheld Mr C's complaint that the crew failed to regard the situation as an emergency. In addition, we had concerns about the accuracy of the ambulance service's response to Mr C, and we upheld this aspect of his complaint.

Mr C complained about the care his mother (Mrs A) received from the Scottish Ambulance Service (the ambulance service). Mrs A had a history of vertigo and migraine but she had been recently advised that she had symptoms of having suffered a transient ischaemic attack (TIA, often referred to as a mini-stroke, where blood supply to the brain is interrupted). Mrs A's GP had advised her to stop taking her migraine medication. When Mrs A collapsed, her husband (Mr A) called for an ambulance. The crew arrived, assessed Mrs A's condition and decided against hospital admission. The crew believed Mrs A had suffered a migraine and advised her to take her medication, despite being informed her GP had told her to stop taking it. Six days after this Mrs A suffered a stroke. She died two days later. Mr C complained about the ambulance service's decision not to transport Mrs A to hospital. We took independent advice from a medical adviser who is a GP. They said that there was enough evidence to give suspicion that Mrs A had suffered a further TIA and conclude that she required hospital assessment. The adviser also commented on the crew's advice to Mrs A to take her migraine medication. The adviser said this was unreasonable and outside the scope of their expertise. The adviser said that non-prescribers should not advise patients to take medication without medical advice, particularly medication recently stopped by the patient's own GP. We upheld the complaint and made recommendations. We also identified problems with the way Mr C's complaint was handled. We were not given evidence that the recommendations made by the ambulance service during their own investigation had been carried out. We also noted that when Mr C raised new questions with the contact listed on the ambulance service's final response letter, that person declined to correspond on the complaint further. We did not believe this to be reasonable.

Ms C complained on behalf of her father (Mr A) about a delay in transferring him home from hospital. Ms C complained that the ambulance service had not taken reasonable steps to ensure they could transfer Mr A home. The transfer was booked by staff on the hospital ward. They advised the ambulance service that, if there were any steps at Mr A's home, they believed Mr A would be able to move from a stretcher to a wheelchair. When the crew arrived, they found that Mr A would not be able to do this and they cancelled the transfer. We found this was a reasonable decision to have made, ensuring the safety of both the patient and the crew. Therefore, we did not uphold the complaint. Related reading View Decision Report 201502258 as a PDF (10.91 KB) Updated: March 13, 2018

Mr C complained about the care and treatment of his late wife (Mrs C) during an ambulance visit and, in particular, the decision not to take Mrs C to hospital. Mrs C had been recently admitted to hospital. Two days after discharge, Mr C became concerned about Mrs C’s symptoms and called 999. An ambulance crew attended and gave Mrs C oxygen treatment and advice about fluid intake. However, the paramedic decided not to take Mrs C to hospital immediately. Mr C said the decision to leave Mrs C at home was made because the paramedic could not get through to the duty doctor for permission to bring her to hospital. He said Mrs C’s hospital admission later that day was arranged by a community nurse who visited shortly afterwards and raised concerns about Mrs C’s condition with the duty doctor. The ambulance service disagreed with this account. They said the paramedic spoke to the duty doctor and agreed that it would be appropriate to leave Mrs C at home to allow time for Mrs C’s recent insulin injection, and the advice about fluid intake, to take effect. The ambulance service said the paramedic arranged for an unscheduled care nurse to visit in four hours to check whether Mrs C had improved, and this was what prompted Mrs C’s admission later that day. After taking independent advice from a paramedic adviser, we did not uphold Mr C’s complaint. There was evidence that the paramedic did call the duty doctor to discuss Mrs C’s condition and to arrange review. The adviser considered that, in these circumstances, the decision to leave Mrs C at home was reasonable. Related reading View Decision Report 201407184 as a PDF (11.31 KB) Updated: March 13, 2018

Mr C, who is an advice worker, complained to us on behalf of Mr A. He said that Mr A has diabetes and had experienced a number of hypoglycaemic (low blood sugar) episodes. His colleagues had contacted the Scottish Ambulance Service (the service) to request an ambulance when he had another hypoglycaemic episode just before starting work. When the ambulance crew arrived, they carried out a blood glucose test, which showed that Mr A had hyperglycaemia (high blood sugar levels). Mr C complained that the ambulance crew had failed to take the blood glucose reading appropriately. He said that Mr A had spilled a sugary drink on his fingers. He stated that the ambulance crew had failed to clean Mr A's skin before carrying out the blood test and, because of this, the blood tests incorrectly showed that his blood sugar levels were very high. We took independent advice on the complaint from an adviser in emergency medicine. We found that the ambulance crew should have cleaned Mr A's hands, using either soapy water or an alcohol wipe, before taking the blood glucose reading. This was to prevent getting a high reading in error, and also to reduce the chance of infection, which is a particularly high risk for diabetics. The evidence showed that the ambulance crew failed to clean Mr A's hands so we upheld this aspect of Mr C's complaint. Mr C also complained that the ambulance crew then unreasonably took Mr A to the local hospital. However, ambulance crews are required to transport patients with hyperglycaemia to hospital. Although it was likely that the high blood sugar reading was due to the sugary drink on Mr A's skin, we found that the ambulance crew were required to take Mr A to hospital when the blood test showed that he had hyperglycaemia. We did not uphold this aspect of the complaint.

Mrs C complained that the Scottish Ambulance Service (the service) did not have the appropriate equipment or vehicle to take her late husband (Mr C) to hospital for a scan. Mr C was terminally ill with cancer and had widespread pain which severely restricted his mobility. Mrs C was also dissatisfied that the service did not apologise or explain why they delayed in replying to her complaint about the matter. We took independent advice on this case from one of our nursing advisers. We noted that the service had reviewed the way the situation was managed and took appropriate action to prevent a similar situation recurring. We found that there was confusion about what equipment was required to take Mr C downstairs to the vehicle. Whilst the ambulance staff did their best with the equipment and vehicle that was available, there was a lack of communication as to the type of vehicle needed to transport him. As Mr C could not sit for long periods due to his condition, we considered it unreasonable to transport him to hospital in a chair which would have caused him additional pain and distress. We also found that it took the service over three months to respond to Mrs C's complaint, which was well beyond the 20 working day timescale. Additionally, the service did not provide Mrs C with regular updates about the progress of their investigation or the reasons for the delay.

Mr C complained about the way he was treated by an ambulance crew who attended his home following a fall. He felt that the crew had handled him badly, and said that they did not fit a neck brace or transport him to the ambulance using a stretcher. On arrival at hospital it was established that Mr C had suffered a fracture of the second vertebra. The board explained that the crew had carried out a thorough assessment and could not detect any tenderness to the vertebrae of Mr C's neck or back, and there were no signs of nervous system damage. There was some mild tenderness on the left side of the neck but this was over the soft tissue area. Current UK guidelines say immobilisation is not required if there is no central spinal tenderness. The crew decided there was no requirement for a neck brace based on the symptoms reported, and no detectable signs of spinal injury at the time. We sought independent advice from a medical adviser with experience in the training of paramedics. The adviser had no concerns about the actions of the ambulance crew, and was satisfied that they had acted in accordance with the guidelines concerning the treatment of patients with neck and back injuries. Related reading View Decision Report 201501488 as a PDF (11.19 KB) Updated: March 13, 2018

Mr C phoned the Scottish Ambulance Service (the service) for an emergency ambulance as he was suffering from severe abdominal pains. He described his symptoms to one of the service's clinical advisors who told him to attend his local out-of-hours centre. He attended the centre and was examined by a doctor who immediately phoned for an ambulance and Mr C was taken to hospital where it was diagnosed that he had perforated ulcers. Mr C complained that the service should have sent an ambulance when he originally reported his symptoms. We took independent advice from an adviser, who is a paramedic, and they explained that, although Mr C's condition was not immediately life threatening, the service's clinical advisor failed to ask sufficiently detailed questions about the character of the pain or associated symptoms. As a result, the service's clinical advisor failed to put himself in a position to safely judge whether or not to despatch an ambulance. Although there was not a need to send an immediate ambulance, we upheld the complaint because there was a failure to assess Mr C's symptoms appropriately.

Mr C complained to us about the care and treatment his mother (Mrs A) received from the medical practice after a GP visited Mrs A's home as she had abdominal pain. Mr C told us that the GP examined his mother, gave her a injection for pain and called an ambulance. He said that the GP spent approximately 15 minutes with his mother before leaving. Mr C said that the ambulance arrived two and a half hours later and during this time his mother's pain worsened. He said that the ambulance crew expressed shock at Mrs A's condition and gave her more pain medication before taking her to hospital. When he went to the practice to complain, he felt that the GP was aggressive towards him. He also said that he asked for information on making a complaint and was told there were no specific forms and that each practice is different. The practice said that they provided proper care and treatment. The GP said that as Mrs A had family support and her condition was not considered life threatening, it was appropriate to leave and return to other patients at the surgery. The practice said that Mrs A's family did not call them to say that she was worse. They apologised for confusion about the complaints form and explained that although they do not have such forms they do have a procedure, and complaints can be made in writing. They said that they were not aggressive towards Mr C – they in fact felt that he had been aggressive towards them, and they had sent him a formal warning. We took independent advice from one of our GP advisers, who said that the GP provided reasonable care. Our adviser was of the view that the pain relief given and the decision to request an ambulance within a two hour window were reasonable. The Scottish Ambulance Service provided evidence during our investigation that their crew that day had no recollection of criticising the GP and or of expressing shock at Mrs A's condition. We did not uphold this complaint. We did uphold Mr C's complaint about the

Mr C had a fall at home. An ambulance crew attended and examined him for a possible dislocation of the shoulder. It was decided that he did not need to be admitted to hospital, as there were no indications that his shoulder was dislocated. Three days later Mr C contacted his GP, who came out to see him, and advised that he attend A&E. Mr C did this and was found to have a dislocated shoulder. Mr C complained that he was not given a reasonable assessment by the ambulance crew. He also said that when he had complained, the Scottish Ambulance Service (the service) had told him that a clinical review of his treatment would be carried out. However, he had not heard anything further about this. The service told us that they thought Mr C may have experienced another fall in the intervening days between being seen by the ambulance crew and the visit from his GP. We took independent advice from one of our GP advisers about Mr C's injury and assessment. The adviser said that it was not possible from the medical records to say with certainty when Mr C's dislocation injury occurred. The adviser also said that there was nothing in the ambulance crew's report to suggest the assessment Mr C received was unreasonable so we did not uphold this aspect of Mr C's complaint. We did, however, have concerns about the clinical review that the service said they would carry out. This was conducted nine weeks after the complaint response letter to Mr C and five days after we initially contacted the service about Mr C's complaint. We were concerned that there was no formal procedure and that it may be unclear to complainants whether or not they are still in the complaints process or not. We upheld this complaint and made recommendations.

Mrs C complained on behalf of her late husband (Mr C) that there was an unreasonable delay in taking him from their home to an ambulance. Mrs C said that the ambulance crew spent too long trying to get her husband to respond to them and should have taken him to the ambulance and conveyed him to hospital straight away. Mrs C also raised concerns that the crew were unable to insert an intravenous line (a plastic tube introduced with a metal needle into a vein to allow the delivery of medications to assist resuscitation). We took independent advice from one of our medical advisers, who is a GP. The adviser said that the time taken at the scene (22 minutes) was not excessive. They explained that as Mr C had 'shut down' (when a patient is in the extremes of a medical crisis and their peripheral veins collapse) it would have been very difficult for the paramedic to have inserted an intravenous line. This was not unusual and in itself did not make the paramedic's actions unreasonable. The adviser explained that, when the insertion of an intravenous line fails, it is reasonable to use an intraosseous needle (a large bore needle pushed into the bone marrow of the shin to allow the introduction of drugs and fluids to assist resuscitation). However, in this case the crew attending Mr C did not have access to such a needle and the adviser said that even had one been available and the conditions appropriate, its use would have been unlikely to have changed the outcome for Mr C. The evidence suggested that the ambulance crew acted appropriately and in accordance with their organisation's and national guidelines in their treatment of Mr C. However, we were concerned that the service told us that use of intraosseous needles was not their custom and practice, given that national guidelines on resuscitation say that if intravenous access cannot be established within the first two minutes of resuscitation, consideration should be given to intraosseous access.

Mr C, who is a doctor, complained about the Scottish Ambulance Service's response to a call he made to them when his wife (Mrs C) awoke one night with an irregular heartbeat. Mr C reviewed her condition and was concerned that her symptoms indicated she needed immediate medical assessment and possibly treatment. He called for an ambulance, but was not happy with the response. He was taken through the standard triage procedures, despite explaining that he was a doctor and was with the patient. After a discussion with a clinical adviser, a non-emergency ambulance was sent, and Mrs C was taken to hospital. The service said that they had a protocol for calls from doctors, but as Mr C was not practicing at the time of the call, they treated him as if he were a member of the public, and took him through the normal triage procedures. They also explained that they were in the process of redesigning their triage process for calls from health professionals, and would take this case into consideration during that process. We obtained independent advice on the complaint from a paramedic, who said that the service should have taken greater account of Mr C's assessment of his wife's condition. This would have enabled the clinical adviser to override normal protocols, and request an emergency ambulance for Mrs C. As they did not do this, we upheld the complaint.

Mr C complained on behalf of his wife (Mrs C) that the Scottish Ambulance Service did not adequately demonstrate that they had taken remedial action in response to his complaint. Mr C told us that his wife was visited at home by her GP, who thought she might have had a stroke. Mr C said that at 11:45, the GP called for an ambulance to arrive within four hours, but that Mrs C had to wait for seven and a half hours before an ambulance arrived. Mr C said he was satisfied that the service had investigated his complaint but, given the seriousness of his wife's condition, he wanted an assurance that the service's procedures and attitudes had changed for the better. We looked at the information provided by Mr C and the service, and took independent advice from one of our medical advisers. We found that the service had taken the remedial action that they outlined in their response to Mr C's complaint. They had reviewed Mrs C's case, including the phone calls made and the relevant electronic records, as well as speaking to the supervisor involved and taking follow-up action with them. We were satisfied that the information in the service's response was reasonable and that they had done what they said they would. Related reading View Decision Report 201401120 as a PDF (11.18 KB) Updated: March 13, 2018

Mr C, who is a doctor, complained on behalf of his friend (Mr A). Mr A had phoned Mr C because he had pain in his chest and arm. Mr C was concerned that his friend was having a heart attack, so he phoned for an ambulance. The crew assessed Mr A, including carrying out an electrocardiograph (ECG - a test that records the electrical activity of the heart). They found no indicators of a heart attack, and Mr A decided not to go to hospital. When Mr C heard this, he was very concerned and phoned for another ambulance. At this point his call was transferred to NHS 24, who went on to speak to Mr A before sending another ambulance. Mr A was taken to hospital and was found to have had a heart attack. Mr C then complained that the first crew did not assess Mr A properly and take him to hospital. The Scottish Ambulance Service said that Mr A had not been taken to hospital in the first ambulance at his own request. However, they also noted that the crew did not make sufficiently thorough records of the tests they carried out and their visit. We sought independent advice from a paramedic, who said that the first call was taken and prioritised appropriately, and that the service appropriately sent an emergency ambulance. He also considered that, given the finding of the tests when they assessed Mr A, it was reasonable for the crew's assessment to override Mr C's phone assessment. Mr C's second phone call was also appropriately handled, given the evidence available. We did not uphold the complaint, as although we found that the first crew were not told that a doctor had assessed Mr A by phone, and did not keep sufficient records of their interaction with Mr A, we were satisfied that they appropriately assessed his condition. We also noted that the service had reminded ambulance crews that they should make sure they evidence all of their clinical actions, particularly where a patient is not being taken to hospital. Related reading View Decision Report 201303126 as a PD

Mrs C's husband (Mr C) cut his hand in an accident at home. She dialled 999 and asked for an ambulance. The ambulance service's call handler took details of Mr C's injury but concluded that an ambulance was not necessary. Mrs C had to ask neighbours to help transport Mr C to hospital, where his injury needed surgery. Mrs C complained that the ambulance service's refusal to dispatch an ambulance was unreasonable, and was dissatisfied with their handling of her subsequent complaint. We took independent advice from one of our medical advisers, who is a paramedic, and after considering their advice we upheld Mrs C's complaints. Our investigation found that the call handler used a nationally recognised system of scripts to obtain information about the severity of Mr C's injury. During the call, they also asked for help from a clinical adviser, who could ask questions that were not included on the script to obtain additional information. An appropriate script was chosen and largely followed, which determined that no ambulance was required. However, we considered that the decision-making process was skewed because the call handler input inaccurate information. Assumptions were made about the severity of the bleeding and the clinical adviser asked questions that demonstrated a lack of knowledge of hand injuries. Furthermore, changes in Mr C's condition during the course of the call were not acted upon appropriately. We concluded that an ambulance should have been dispatched to take Mr C to hospital. We found that the ambulance service's handling of Mrs C's complaint was generally reasonable. However, they failed to follow their own complaints procedure as they did not contact her to advise that their decision would be slightly delayed.

After Mr C's daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but rising. He concluded that she had had a vasovagal episode (a temporary loss of blood to the brain) but was improving. Mrs A had further collapses over the following days. An ambulance was called on one occasion, but was cancelled when Mrs A became more alert. However, an ambulance was again called later that day after Mrs A collapsed for a second time. The ambulance crew reportedly helped her into bed, but said that there was not much more that could be done at that point, even if they took her to hospital. Mrs A continued to struggle with her breathing the next day and, in the early hours of the following morning, an ambulance crew attended and took her to hospital. Shortly after arriving there, Mrs A collapsed and, despite attempts to revive her, she died. Mrs A was found to have had a pulmonary embolism (a blockage in the artery that transports blood to the lungs). Mr C felt that Mrs A might have survived had an ambulance crew taken her to hospital after the first attendance, or had the crew that did eventually take her to hospital acted with more urgency. We were satisfied that the ambulance crews obtained relevant information about Mrs A's recent symptoms and carried out thorough examinations during both attendances. We took independent advice from one of our medical advisers, who said that Mrs A was displaying two symptoms that could indicate pulmonary embolism, but that these were also consistent with other more common illnesses, including viral infection. We concluded that although with hindsight it was evident that Mrs A's symptoms were related to a serious underlying condition, this would not have been apparent to the ambulance crews when they attended. Although the c

When Mrs C’s husband (Mr C) was taken to hospital by ambulance, the crew could not get the ambulance doors open, and there was a delay getting him to the hospital. Mr C passed away the following month and Mrs C then complained that the Scottish Ambulance Service (the service) had never apologised for the incident. When looking into the complaint, the service were unable to trace any details of the ambulance journey or crew involved. However, they formally apologised to Mrs C for the incident and assured her that steps had been taken to avoid a similar future problem. Mrs C complained to us that the service had been unable to trace details of having transported her husband to hospital. The service told us what they had done to try and trace the journey. They said that no incident report was completed on the day in question and they received no reports of a vehicle with faulty doors. We were satisfied that they had fully investigated Mrs C’s complaint and gone to considerable effort in trying to trace the ambulance and crew involved. We also recognised that, despite not having traced the incident, they had apologised. However, we did not consider that they had taken appropriate action to try to avoid this happening again. We, therefore, made a recommendation.

Mrs C is 88 years old and has a number of health issues, including osteoarthritis (the most common form of arthritis that affects the joints). After she attended hospital for investigation of a breathing problem, she complained that service staff treated her unreasonably when assisting her to and from their patient transport vehicle. Mrs C also complained that there was an delay in the vehicle arriving to take her home from hospital, and that the service’s handling of her complaint was unreasonable. As there was no independent evidence of what occurred when Mrs C arrived at the hospital, or when she was returned home, we could not say for certain what happened. However, we noted that the service upheld her complaint about patient transport crew walking her to and from their vehicle when they should have used a wheelchair, and that the methods they used to assist her caused her pain. They also acknowledged that Mrs C was left waiting for a considerable time for transport home from the hospital, and we found that the records in fact showed that she had to wait for almost two and a half hours from when the service logged her as ready for transport. In relation to complaints handling, we saw evidence that the service had taken Mrs C’s complaint seriously, but had accepted that there were delays in their investigation. We upheld all Mrs C's complaints, but as the service had already taken action by apologising, speaking to the staff involved, and amending their records to show the correct type of transport she needs in future, we made only one recommendation.

Mrs C said that her husband (Mr C) experienced a seizure while driving his taxi, and an ambulance was called. After Mr C was assisted out of the taxi and into the ambulance, Mrs C alleged that the ambulance staff used unreasonable restraint, which resulted in a compression fracture (when the bones of the spine become compressed due to trauma). She said that her husband could no longer work or enjoy the quality of life he had enjoyed previously. When Mrs C complained about what had happened, the paramedics involved denied that any unreasonable restraint had been used and the Scottish Ambulance Service said that his back injury was likely to have occurred as a result of his seizure. They said that this was not unusual. As part of our investigation of the complaint, we took independent advice from one of our medical advisers. We took all the available information into account, including complaints correspondence, staff statements and patient report forms. Our investigation found that Mr C had had a tonic-clonic seizure (a seizure which affects all of the brain) and, as such, the adviser said that Mr C was likely to have been confused and disorientated. They said that a person suffering such events was not likely to remember what happened. This was confirmed by Mr C, who said that his recollection of events, in part, was unclear. The adviser also said that Mr C had suffered a compression fracture but that this was not, in his view, consistent with pressure exerted in a downward direction when a patient was lying on his back. The adviser confirmed that it was most unlikely that Mr C's injury had been caused in the way Mrs C alleged, and that it had likely occurred during his seizure. Related reading View Decision Report 201203148 as a PDF (11.47 KB) Updated: March 13, 2018

Mrs C's husband collapsed at home and an emergency ambulance was called. Although Mrs C lives near an ambulance station and a hospital, the ambulance sent was not the nearest one at the time, and there was a delay before it arrived. Mrs C's husband later died from a heart attack. The service explained to her that the nearest ambulance was already involved with a patient, and so the next available vehicle was despatched. Mrs C complained to us that the service had not conducted a thorough investigation into what had happened, and that, after she complained to them, it was five months before she received a final response. Our investigation found that the service had completed a thorough investigation, so we did not uphold that complaint. We did, however, uphold her complaint about the complaints handling, as the board had not sent her regular updates on the progress of the investigation or told her that she could contact us, when the response to her complaint was delayed. We also established that they incorrectly told Mrs C that the investigation was nearing completion, when in fact it had been concluded.