SPSO Individual Decisions

Mrs C complained about the treatment that the Scottish Ambulance Service gave to her mother (Mrs A). Mrs A, who suffers from rheumatoid arthritis (an inflammatory disorder that mainly affects the joints), had hurt her leg and was unable to put weight on it. She had been in pain for a number of days and Mrs C phoned 999 for an ambulance. However, the person who took the call assessed it as a non-emergency situation, and decided not to send an emergency ambulance. Our investigation found that this was reasonable in the circumstances, and that it followed the protocol of the medical priority dispatch system. We did note that the call taker had not told Mrs C that there was another route she could use - she could call NHS 24 to see if her mother could be referred to hospital that way. However, as the service had already recognised this omission when investigating Mrs C's complaint, and had taken steps to address it, we made no recommendation about this. Related reading View Decision Report 201201695 as a PDF (11.18 KB) Updated: March 13, 2018

Mrs C complained that when her husband (Mr C) was airlifted to hospital after a heart attack, there was unreasonable delay in transferring him from the air transport into the hospital and in assessing his condition. We upheld both Mrs C's complaints. Our investigation found that there was no ambulance available to transfer Mr C into the hospital. The health board and Scottish Ambulance Service were in the process of finalising a protocol under which patients could be transferred on a trolley in such circumstances. However, when Mr C was taken ill the protocol had not been finally agreed or adopted although the equipment required - such as a trolley and protective clothing and equipment - was available. Our investigation identified that responsibility for a patient remains with the service until the patient is received in hospital. The ambulance staff involved in transporting Mr C were paramedics and provided evidence that they had offered to take clinical responsibility for transferring Mr C on a trolley. However, this offer was declined by a nurse from the hospital who was also there. It was about 40 minutes before an ambulance was available to transfer Mr C. In view of the offer made by the paramedics, we considered that it was unreasonable for Mr C to have had to wait this long. With regard to the assessment of Mr C's condition, our independent adviser noted that she would not necessarily expect to find notes of an assessment made while a patient was the responsibility of another body. However, although we noted that responsibility remained with the service until Mr C was received at the hospital, the board had in fact indicated in their response that the nurse had assessed Mr C's condition. We found no evidence, however, that any such assessment was made.

Mrs C complained about the professionalism of an ambulance crew who had attended her late husband about a year before. She said that the crew refused to allow her husband to take a case with him in the ambulance or to allow a family member to travel with him. The family was also told to wait an hour before attending the hospital. The board explained that due to the time that had elapsed since the incident, the crew could not recall what was actually said. The board, however, accepted that there must have been a failing in the way the crew communicated to the family. As a result the crew had been reminded of their responsibilities and that their actions could be interpreted differently from what they intended. We found that the board had conducted a thorough investigation, including interviewing appropriate staff, and we took the view that it was unlikely that further consideration of the matter would achieve more for Mrs C. Related reading View Decision Report 201203582 as a PDF (11.16 KB) Updated: March 13, 2018

Miss C complained about the time that it took for an ambulance crew to attend to her late father, who had suffered a heart attack. The board explained that on receipt of an emergency 999 phone call, the nearest available ambulance was dispatched. However, when it was thought that the ambulance would be delayed due to road works, a second ambulance was dispatched and the first was stood down. The board then realised that the second ambulance had to negotiate the same road works and as a result arrived one minute after the time estimated for the first ambulance's arrival. The board explained that the first ambulance should not have been stood down and gave an assurance that lessons have been learned. We found that the board had taken the complaint seriously, and that the appropriate staff had been interviewed and reminded of their responsibilities. We took the view that further consideration of the complaint would not achieve more for Miss C. Related reading View Decision Report 201203095 as a PDF (11.13 KB) Updated: March 13, 2018

Mrs C was assaulted, and was taken by ambulance to a hospital accident and emergency department (A&E) with two police officers in attendance. She complained that she was not fully examined and that no tests were done to assess whether or not she had a head injury, which meant that her concussion was undiagnosed. She said that this has caused her ongoing health problems. Mrs C was discharged into the care of the police officers who took her to the police station to make her statement and then took her home. When she later applied for copies of her notes from the incident she took issue with the lack of detail in them. Mrs C complained to the board but was not satisfied with the response she received. She was unhappy that later statements made by the nurse and doctor who saw her on the night indicated that she had been uncooperative and possibly under the influence of alcohol. Our investigation included taking independent advice from one of our medical advisers. We found that there was a disparity between the notes made at the time of the events and the later statements made by the staff who attended Mrs C. The A&E unit is a GP-led unit and on the night in question was staffed by a nurse practitioner (a specially qualified senior nurse) and an on-call GP. We found that the notes made at the time by the nurse and the GP did not record all the injuries Mrs C had suffered, as recorded by the Scottish Ambulance Service staff who took her to hospital. Nor did any of the notes taken at the time refer to Mrs C as being uncooperative or under the influence of alcohol. However, after Mrs C complained to the board, the nurse and GP were asked for statements and both then referred to her as being uncooperative, possibly due to alcohol intake. The GP said that it was because Mrs C was not cooperating that he was unable to conduct a full examination and assessment of her condition. Our adviser found that the lack of information in the notes taken at the time did not giv

Mr C complained about the board's actions in relation to his elderly father (Mr A). He said that his father had been admitted to hospital late in the evening. After being examined and declared fit, he was sent home in the early hours of the morning by car, with a relative. Mr C said the relative was not entirely happy with this but, nevertheless, complied. When Mr A reached home, a neighbour had to be recruited to help him get into the house. Mr C said that his father should not have been discharged, particularly because he was elderly, disabled and had memory problems. We investigated the complaint taking all the relevant information, including all the complaints correspondence, the relevant clinical records and the board's discharge policy, into account. We also obtained independent advice from one of our advisers, who is a nurse. In responding to the complaint, the board had confirmed that Mr A was considered fit for discharge and was keen to go home. There was, therefore, in their view, no clinical reason to keep him in hospital. They pointed out that the Scottish Ambulance Service did not provide out-of-hours transport and, as there was a relative available and willing to take Mr A home, they had asked him to do so. They said that if this had not been the case, they would have had to consider whether a taxi was appropriate. Our nursing adviser reviewed the files and confirmed that the information in them indicated that Mr A was fit to go home. She also confirmed that Mr A was not in fact admitted to hospital, and so the board's discharge policy would not apply in his case. She said that in all the circumstances, it was not unreasonable for Mr A to return home with a relative, given that an emergency department was not an ideal place for an elderly and frail person. Taking all the information into account, we did not uphold the complaint as we found that, while not ideal, in all the circumstances it was not unreasonable for the board to discharge Mr A

Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. Mr A had acute appendicitis (sudden inflammation of the appendix). His appendix was removed that afternoon. He was discharged from hospital seven days later. Mrs C complained that the service failed to attend when she called them for Mr A, and did not deal with her complaints appropriately. We did not uphold Mrs C's complaint that an ambulance was not sent. We took advice from one of our medical advisers, who said that Mr A's condition was not detrimentally affected by not being taken to hospital by ambulance, and that the decision not to send an ambulance was correct in terms of the service's protocol. We listened to the telephone call and reviewed the service's records and procedures together with information provided by Mrs C. We decided that although the emergency medical dispatcher's communication with Mrs C was not as helpful as it could have been, the decision not to send an ambulance was reasonable in the circumstances. We upheld Mrs C's other complaint. We found that she received a response to her complaint after eight weeks, which was longer than the 20 working days the service aimed to work to, and she was not updated with an explanation of why there was a delay. We found evidence that service staff disagreed on who was responsible for sending the update. Our adviser thought that because the service's review of Mrs C's call focused on technical aspects, rather than taking a holistic view that included Mrs C's experience, it lacked any real empathy with her situation. Their investigation report recommended that Mrs C be given a more detailed explanation of the reasons for not sending an ambulance, but we noted that this was not provided.

Ms C complained about the Scottish Ambulance Service’s (the service) investigation into the circumstances where her late partner's wallet went missing when an ambulance attended to him following a serious accident. We found that initially it was reasonable for the service to wait for the result of a police investigation into the missing wallet (which concluded that it had most likely been disposed of as clinical waste). However, after receiving the police report it was 40 days before the service wrote to Ms C with this information. This was despite Ms C telephoning during that period asking for updates. We, therefore, upheld her complaint and made recommendations to address these failures. The service also told us that they did not at that time have a lost property procedure but would develop one, so we made no recommendation in respect of this.

Mrs C complained about the way an ambulance crew treated her mother (Mrs A) who had fainted and had been slipping in and out of consciousness. Mrs C said that the crew had shouted at her mother, handled her roughly and treated her as if she was drunk. Mrs C also complained about the time the Scottish Ambulance Service (the service) took to respond to her complaint. We did not consider the specific complaint about the crew's manner as this was subject to the differing interpretations of those involved. Having taken advice from one of our medical advisers, we found that the crew carried out an appropriate assessment of Mrs A's clinical condition and that it was correct for them to decide to take her to hospital. We also found, however, that the board took too long to formally respond to the complaint.

Ms C complained about an accident she had while being transported by the Scottish Ambulance Service (the service) to a clinic appointment. Ms C said that the driver had taken his finger from the remote-control button operating a stair-lift while Ms C was sitting on it in a wheelchair. The lift stopped suddenly and the driver fell against Ms C, who was thrown forward and to the right. She was injured by a bar at the front of the stair-lift. Ms C said that the driver was speaking to someone else, lost concentration and took his finger off the button. The driver, however, said that he had slipped on the stairs. There was no doubt that the driver's finger came off the button but as there was no objective evidence to explain exactly how this happened, we could not uphold this complaint. Ms C also complained that the driver then left her at the clinic reception and did not report the incident. She had to report it herself. The evidence confirmed that although the driver reported the incident to his own management, he did not report it to the clinic staff or any other hospital staff member. He apologised to Ms C and asked how she was, but did not take any action to ensure that someone attended to her. We upheld this complaint. We noted, however, that the service had provided evidence that the driver's line manager had addressed this and reminded him of his responsibilities in dealing with such incidents in the future. We, therefore, made no recommendations. Ms C's final complaint was that the response she received from the service was inaccurate as it referred to the driver slipping on the stair and also that he had reported the incident to the clinic reception. There was no conclusive evidence to establish whether or not the driver slipped, but the service acknowledged that the driver had not reported the incident to hospital staff. We, therefore, upheld this complaint and made a recommendation. Recommendation We recommended that the service: • apologise to Ms C for the f

Mr C had problems with his hip and used a walking aid. He fell while walking with a friend in the city centre. The police, who attended to Mr C first, called an ambulance. Mr C complained that the ambulance crew did not provide adequate care and treatment to him. Specifically Mr C said that the ambulance crew did not give him pain relief despite his requests; did not properly assess the injury to his leg; and did not take him to hospital despite his requests. Four days after falling in the city centre, Mr C fell at home and was taken to hospital, where he was diagnosed with a broken leg. Mr C felt that the break happened when he fell in the city centre. We found from looking at the records, and taking advice from one of our professional medical advisers, that there was anecdotal evidence that Mr C did ask for pain relief. However, our adviser said it would not have been appropriate to administer it in the specific circumstances. We also found that the ambulance crew's record of the assessment of Mr C was inadequate and, given subsequent events, appeared to have been deficient. There was anecdotal evidence that Mr C did ask to be taken to hospital. We found the decision not to take Mr C to hospital was correct, based on the assessment carried out by the ambulance crew. However, given that the assessment was deficient, that decision could be questioned. Therefore, given the failings identified, we concluded that the ambulance crew did not provide adequate care and treatment to Mr C, and we upheld his complaint.

Mr C complained that the Scottish Ambulance Service (the Service) transported his wife from their shower room to their bedroom by dragging her there on a blanket. Mr C said this was an unreasonable way to have moved her. Mr C also said that the lifting equipment which the Service brought with them was faulty. Our investigation took into account all relevant documentation and we also sought advice from one of our medical advisers. The Service told us that the ambulance crew initially planned to use lifting equipment to move Mr C's wife, who was acutely ill. Given the restricted access in the shower room, however, they decided in consultation with the attending doctor that it would not be appropriate to use the equipment. With the help of the doctor and his driver, the crew, therefore, used a blanket to move Mr C's wife from the shower room to the bedroom. They explained that it was felt that this would be a quicker way of getting Mr C's wife into a more comfortable position before taking her to hospital. Taking account of all the information provided, we took the view that this decision appeared to have been reasonable based on the situation at the time and taking into account the best interests of Mr C's wife. The Service were clear in their view that the lifting equipment was not faulty, but it was not possible for us to prove this one way or the other. We could not, therefore, say whether there had been a failing by the Service in this respect. Related reading View Decision Report 201102718 as a PDF (17.08 KB) Updated: March 13, 2018

Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and was told that someone (apparently the lead nurse of the clinic) would come to see her. This did not happen before Ms C was collected again by the Service for transport home. Ms C also complained that despite being in pain from her injuries no hospital staff came to check her over. She also said that when the board responded to her complaints the letters contained inaccurate information, including referring to her injuries being caused when she was 'putting her aunt onto the stair lift' and that she had been 'walking with the consultant' within the clinic. Ms C was in fact in a wheelchair the whole time she was in the clinic on this day. We upheld all of Ms C's complaints and made relevant recommendations. The board acknowledged that the incident had occurred (while Ms C was in the care of the Service) and that Ms C had made hospital staff aware that it had happened. Although a member of staff checked with the Service that they knew about the matter, no action was taken to report it within the hospital's own policy on accidents. The board had not referred in their response to the failure of the lead nurse to come to speak to Ms C while she was in the clinic. On the matter of Ms C not being checked over, the board said that the consultant that Ms C was there to see recalled Ms C mentioning that she had had an accident but not that she had been injured and/or was in pain. They also said that none of the other staff had any recollection either of Ms C saying she was in pain or that she seemed to be in pain. Although there was no conclusive evidence to support either version of events, we found that although aware that there had been an accident, there was little evidence to sug

An MSP complained on behalf of Mrs A about the Scottish Ambulance Service (SAS). Mrs C's husband (Mr A) suffered a heart attack and the SAS were asked to dispatch an ambulance. The ambulance crew gave Mr A aspirin and carried out an ECG (electrocardiograph). It is normal practice for ECG results to be transmitted to the Golden Jubilee Hospital, which provides specialist emergency treatment for heart attack patients. However, on this occasion, the ambulance crew were unable to transmit the results. The paramedic who attended Mr A phoned the Golden Jubilee for advice, as per the protocol for such situations. He was advised that he could take Mr A to the Golden Jubilee if he was having a heart attack, otherwise he should be redirected to a local Accident and Emergency unit. The paramedic understood that the correct procedure at that time was to take patients to the Vale of Leven Hospital for initial assessment. He did this, but, upon confirmation that Mr A was having a heart attack, staff at the Vale of Leven redirected him to the Golden Jubilee. By the time Mr A arrived at the Golden Jubilee, another patient had arrived and was treated before him. Mr A did not recover from his heart attack and died three weeks later. We found that the equipment provided in the ambulance was not properly configured and prevented the ambulance crew from transmitting Mr A's ECG results to the Golden Jubilee. The protocol in place at the time of this incident required ambulance crews to take patients showing signs of a heart attack to the Golden Jubilee in the first instance. We found that the paramedic was not aware of the correct protocol and incorrectly decided to take Mr A to the Vale of Leven, delaying his treatment.

Mr C had been experiencing abdominal pain since around 05:00 on a day in June 2010. He became unwell and his pain increased in severity around 22:00. He telephoned the Scottish Ambulance Service (SAS). They did not consider his case to be an emergency and transferred his call to NHS 24. Mr C’s conversation with NHS 24 lasted around 40 minutes, during which time he repeatedly asked for an ambulance to be dispatched to his home. The NHS 24 call handler sought details of his symptoms and ultimately decided to arrange for a duty doctor to call him back within one hour. Mr C was not satisfied with this outcome and arranged for a neighbour to assist him to phone the SAS again. Following this call, a paramedic was dispatched and, following an examination, an ambulance was called. Mr C was found to have a burst appendix. Mr C complained that NHS 24 should have dispatched an ambulance given the nature of his symptoms. He felt that the number and nature of the questions put to him by the call handler was repetitive, unreasonable and inappropriate. He also complained that it was inappropriate and unreasonable for NHS 24 to suggest that a doctor phone him ‘within an hour’ for further assessment when he was clearly in considerable pain and distress. We were satisfied with the nature of the questions asked by NHS 24 and found that, whilst there was some duplication, this was kept to a minimum. The evidence that we were presented with showed that there were some communication issues between Mr C and the call-handler and we considered that these contributed to the length of the call more than the NHS 24 call procedure. Our professional medical adviser shared an opinion expressed by NHS 24 that Mr C’s symptoms indicated a need for a physical examination. Mr C had advised the call-handler that he was unable to make his own way to hospital, so we considered it unreasonable for the physical examination to be delayed further by arranging for a doctor to telephone him. We considered that

Mrs C complained that when her late husband (Mr C) was being transferred from Ninewells Hospital to his local community hospital his clinical records were not passed on and staff could not administer medication until they received them which was later in the day. We established that Mr C's records were left in the ambulance and that responsibility for the safekeeping of the records rested with the ambulance service. Our report stated that medical records are important documents and have to be available should clinicians need to review them to obtain details of a patients medical history, medication etc. We were satisfied that in this case the delay was caused by human error. It was discovered shortly after Mr C's arrival that the records were missing and contact was made with the service. They located the records immediately and made arrangements for them to be picked up later in the day and delivered to the hospital. The hospital was content with this arrangement and stated that Mr C was not disadvantaged by the missing records and that he did not require his prescribed medication until after the records had arrived. They also explained that should Mr C have required assistance in the interim period then he would have been assessed by a clinician who would have prescribed appropriate medication if required.