SPSO Individual Decisions

C complained on behalf of their friend (A), a care home resident. A became unwell and was in a lot of pain. An Out of Hours GP suspected an internal bleed and arranged for an ambulance to be requested. A call was made to Scottish Ambulance Service (SAS) at 20:20, requesting a ‘one-hour response’ to hospital. The SAS call handler advised that the majority of responses were taking over four hours. An ambulance did not arrive until 02:21, by which time A’s condition had deteriorated and they were too ill to be moved. A was given medication and died in the care home. C complained about the delay in SAS providing an ambulance for A. In their response to the complaint, SAS explained that they operate a priority-based system of dispatch to ensure that emergency ambulances are available to respond to the most serious and life-threatening cases in the first instance. They operate a welfare call back process when timed admission calls are unable to be met within the requested timeframe. Regular welfare calls were made to A’s care home, during which SAS apologised for the delay, checked on A’s condition, and gave worsening advice to call 999 if A’s condition deteriorated. SAS considered that the final welfare call, which was reviewed by a SAS clinician, was appropriately upgraded to an emergency response. We took independent advice from a paramedic adviser. We acknowledged that some of the contributory factors which led to the delay in providing an ambulance for A were beyond SAS’s control. There were significant demands on their service and there were also delays in handovers at the receiving hospital. However, our investigation identified a missed opportunity to escalate the request for an ambulance following an earlier welfare call in which symptoms of faster breathing and agitation were reported, indicating a deterioration in A’s condition. Although it was not possible to say whether the outcome for A may have been different had an ambulance been provided sooner, this may

C complained that the Scottish Ambulance Service (SAS) unreasonably delayed in dispatching an ambulance for their late parent (A) and, as a result, this had an adverse impact on A’s care and treatment. C questioned why an SAS call handler initially advised them that an ambulance was not needed, when a locum GP subsequently arranged for one as soon as they learned of A’s condition. Shortly after arriving at A&E, A died following a cardiac arrest. We took independent advice from a paramedic adviser. We found that the actions of the SAS in relation to the allocation and dispatch of an ambulance for A were reasonable, based on the information, resources, and systems in place at the time. We also found that the project improvement initiatives the SAS are undertaking to mitigate the challenges with the triaging of abdominal pain are reasonable. Therefore, we did not uphold the complaint. We did, however, provide feedback to the SAS that when responding to a complaint, where possible, it would be helpful if they provided the complainant with information and explanation of any improvement initiatives that they are taking to address issues raised within the complaint. Related reading View Decision Report 202304529 as a PDF (24.4 KB) Updated: August 20, 2025

C complained about delays in ambulance response time after their elderly parent (A) had a fall at their care home. Care home staff called 999 and, following triage, the call generated an emergency but non-life-threatening response. A clinical triage call took place shortly after followed by another 999 call by care home staff. A paramedic response unit arrived at A’s location, followed by an ambulance. A arrived at hospital around 5 and a half hours after the first 999 call. Scottish Ambulance Service (SAS) acknowledged that the wait for an ambulance was unreasonable and apologised to C for this. They explained that the delay was due to limited resource and very high demand at that time. C was unhappy with this response and brought their complaint to us. C felt that A was not prioritised fairly following the 999 and clinical triage calls. C considered this to be partly due to A’s age. Although SAS had already acknowledged that there was an unreasonable delay, we carried out an investigation to determine whether the assessment and prioritisation of the calls also contributed to that delay. We took independent advice from a paramedic. We found that the non-clinical call handling was appropriate. We also considered that there was no indication that A was treated differently or unreasonably as a result of their age. Therefore, we did not uphold C’s complaint. However, we did provide feedback to SAS regarding an aspect of the clinical triage call which did not cause or contribute to the delay in an ambulance being provided, but was not in line with relevant national guidance. Related reading View Decision Report 202206802 as a PDF (24.59 KB) Updated: May 22, 2024

C complained about the care and treatment that their spouse (A) received from Scottish Ambulance Service (SAS). C called for an ambulance after A fell from a height at home. A was assisted to their feet after an initial check and then walked to the ambulance for further checks. After returning to the house, A became pale and reported a brief loss of sight. It was decided A should be transferred to hospital where they were later diagnosed with a broken pelvis. C said that one of the crew members was rude and dismissive when they had tried to describe the height A had fallen from. C complained that SAS had not fully assessed A, failed to consider the accounts given by eyewitnesses and unreasonably concluded that A could remain at home and take painkillers. A was clear that they did not want to go to hospital, however, C considered the crew failed to recognise A was in shock. In responding to the complaint, SAS advised that a full assessment had been carried out. It was also noted A did not initially wish to be transferred to hospital and had declined to be immobilised on a spinal board. The response advised of actions for learning and improvement which would be taken with the crew in response to C’s complaint. This included actions in relation to the mechanism of injury (in this case a fall from height), moving and handling, consideration of silver trauma (the impact of trauma on older patients), and communication with patients and relatives. C was unhappy with this response and brought their complaint to us. We took independent advice from a senior paramedic adviser. We found that SAS failed to undertake a reasonable assessment of A as they did not act in keeping with the Joint Royal College Ambulance Liaison Committee guidance on Spinal and Spinal cord injury. In particular, there was a failure to immobilise A at the scene given the mechanism of injury. We also considered that SAS failed to reasonably document the incident, consider A’s age and the effects of ‘silve

C contacted the Scottish Ambulance Service (SAS) when they began experiencing abdominal pain. An ambulance attended but did not take C to hospital. The crew provided advice to contact the service again if their symptoms worsened. C contacted the service again the following day. A telephone assessment was completed but no ambulance was sent. C later made their own way to hospital where they required surgery for a perforated bowel. C complained that the SAS failed to recognise the seriousness of their symptoms and failed to provide appropriate care and treatment. C said that as a result, they required more extensive surgery than if they had been taken to hospital sooner. We took independent advice from a paramedic. We found that the ambulance crew had unreasonably failed to carry out an adequate assessment of C. The crew assessed that C had withdrawn consent for further assessment, and did not provide adequate advice on the benefits of assessment or the risks of not completing the assessment. We also found that the telephone assessment the following day was inadequate and was poorly documented. Therefore, we upheld C's complaints.

C complained about the care and treatment provided to A by the Scottish Ambulance Service (SAS). A had a pacemaker fitted and developed a severe headache and rash. A phoned NHS 24 as they were finding it difficult to breathe. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they sought telephone advice from a consultant at the local hospital. The consultant advised that A should take paracetamol and see the GP the following morning. A phoned the GP the next day and was told to go to the COVID-19 hub where A collapsed and was taken to hospital by ambulance. A was admitted to hospital and died the following day from sepsis (blood infection). C complained about the decision not to take A to hospital and is concerned that the paramedics failed to recognise the signs of sepsis and to take the appropriate action. We took independent advice from a registered paramedic. We found that in hindsight it was unreasonable that SAS did not recognise the seriousness of A’s condition, including applying any weighting to past medical history, in particular recent surgery and the fact that the presence of infection could have been the result of sepsis. However, we found that many of the clinical signs and symptoms observed in A would have been present in a patient experiencing COVID-19. Based on the conditions and guidelines SAS were operating to at the time we found that it was reasonable that the paramedics’ working diagnosis was COVID-19. Whilst we considered it was reasonable that A was not taken to hospital, we were critical that there is no evidence that A was informed of the risks and benefits of the option of staying at home, going to hospital or of any alternative options available. We also found that it was unreasonable that key information was not passed to the consultant during a call and that record keeping was unreasonable. Furthermore, we found that it was unreasonable th

C’s elderly parent (A) had recently been discharged from hospital where they had been treated with antibiotics for a urinary tract infection. However, A continued to experience nausea and vomiting along with hallucinations and A’s GP requested an ambulance be provided for A within one hour. Although the Scottish Ambulance Service (SAS) made a number of calls to A’s home to check on them, no ambulance attended. A’s condition deteriorated throughout the day and C called to request an ambulance again. However, no ambulance attended and an out of hours GP subsequently requested an urgent ambulance for A. An ambulance later arrived and A was assessed as having had a possible heart attack and received treatment from the ambulance crew before being taken to hospital. C complained about the length of time it took for an ambulance to attend A. C considered that SAS did not recognise the severity of A’s condition or the damage to A’s heart and that they failed to appropriately prioritise an ambulance for A, unreasonably delaying their treatment. SAS acknowledged that the delay to an ambulance being provided for A had been unreasonable, explained the particular challenges that they had faced on the specific day in relation to frontline staffing, service demand and hospital admission capacity, outlined the steps they were taking to prevent recurrence and apologised for A’s experience. We took independent advice from a paramedic adviser. We found that there was opportunity for the board to take further steps to prevent recurrence. The information the board provided in response to this indicated that improvements are taking place. After careful consideration, we upheld the complaint given the delay that the board have already accepted and apologised for. The steps that the board had taken and are taking since are reasonable and we made no further recommendations. Related reading View Decision Report 202102932 as a PDF (24.76 KB) Updated: September 20, 2023

C complained that their spouse (A) was not properly assessed by Scottish Ambulance Service (SAS) paramedics and should have been conveyed to hospital, as they had a high temperature, was struggling to breathe, had a fever, a cough and a NEWS2 score of 5 (the system used to identify acutely ill patients). C felt paramedics dismissed A's high temperature due to the temperature in the room and that A should have been given oxygen. C also complained about SAS's handling of their complaint. SAS considered the assessment by paramedics was reasonable. We took independent clinical advice from a paramedic. We found that while it was reasonable that paramedics did not administer oxygen, the paramedics did not follow the advice provided in the SAS Clinical Guidance for COVID-19 v5.0 guidelines, as A met the criteria for a referral to the Covid Hub and this was not considered by paramedics. We found paramedics did not appear to have considered or acted on warning signs for sepsis and there was no documented rationale for the decision to downgrade the NEWS2 score. We also found that the initial investigation and complaint response was lacking in detail and explanation. As such, we upheld C's complaints.

C complained that their sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream). C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable. We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics. However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

C complained about Scottish Ambulance Service (SAS) on behalf of A for whom they hold welfare Power of Attorney. A waited for an ambulance for nearly 21 hours. A has multiple sclerosis (a disease that affects central nervous system), lives in a care home and usually has a catheter (a thin tube used to drain and collect urine from the bladder). The catheter was not working and there was concern that A had an infection. C was unhappy with the delay as A had a known history of sepsis (blood infection) as a result of urinary infections. C also said that A’s case had been incorrectly prioritised, that they had received only two calls from SAS during the wait, and that the overall time waiting for the ambulance had been unreasonable. We found that A’s case had been correctly triaged and prioritised by SAS clinical support desk paramedics, however, we noted that SAS did not meet their own standards for the frequency of welfare calls but recognised that the service was under extreme pressure at the time. We upheld the complaint that the ambulance response time was unreasonable as it had taken nearly 21 hours to attend the patient, which significantly breached the 60-minute target for cases like A’s. We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set. Related reading View Decision Report 202102737 as a PDF (24.52 KB) Updated: December 21, 2022

C's spouse (A) became unwell with severe lower abdominal pain and vomiting. C phoned for an ambulance and was told by the Scottish Ambulance Service (SAS) that A's symptoms did not warrant an emergency attendance and transferred the call to NHS 24. A's condition worsened over the next couple of days and A was taken to hospital, where they were found to have a perforated bowel (hole in the bowel) and kidney failure. A was given palliative care and died in hospital shortly afterwards. C complained about the SAS decision not to dispatch an ambulance to A and considered that the call out system failed to save A's life. We took independent advice from a paramedic. We found that the telephone assessment conducted was reasonable and that appropriate questions were asked. From the responses provided, it was reasonably determined that there were no immediately life threatening symptoms that required dispatch of an emergency ambulance at that time. On this occasion, it was reasonable to transfer the call to NHS 24 for secondary triage to allow a more in depth line of questioning to be carried out to try to understand more about presentation of A's complaint. We, therefore, did not uphold the complaint. Related reading View Decision Report 202006236 as a PDF (24.35 KB) Updated: August 24, 2022

C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in their home was poor; that there was a delay in transporting A to the hospital; that C was asked to commence cardiopulmonary resuscitation (CPR) on A whilst on route to hospital and that C was not assisted by the ambulance technician and that they alone performed CPR on A until they arrived at hospital. C was dissatisfied with the way in which their complaint was investigated. It was initially investigated by the SAS, however, when contacted by SPSO, SAS requested to reinvestigate the complaint in light of an error that they identified in their initial response. C remained unhappy after receiving the SAS's further response and asked us to consider the matter. We took independent advice from an emergency and retrieval medicine adviser. We found that the way in which the dispatch of the ambulance was handled was unreasonable, that the initial care provided to A in their home was reasonable, nevertheless it should have been clear to the ambulance crew that A was seriously unwell and that the time spent on scene was unreasonable and that the decision to ask C to perform CPR in the ambulance was not reasonable. We found that the initial investigation was not sufficient, although we acknowledged the proactive steps taken by SAS to address this issue and acknowledge failings, including asking C to commence CPR. We also found that in this case the full crew should have been interviewed. We upheld C's complaints.

C's late partner (A) tested positive for COVID-19. A's condition worsened over time and C called 111 as they were concerned A's breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. Once connected, the call lasted around 30 minutes. The call handler contacted the Scottish Ambulance Service (SAS) and said that they were 'looking to arrange an immediate response for a patient'. A's condition deteriorated further and C made a 999 call around ten minutes after ending the call to 111, as assistance had not yet arrived. However, by the time paramedics arrived, A had stopped breathing and could not be resuscitated. C complained about the length of time it took for an ambulance to arrive. They complained that paramedics did not arrive in personal protective equipment (PPE), and considered that they wasted time getting dressed outside when it was an emergency call. C also queried whether a defibrillator (an electronic device that applies an electric shock to restore the rhythm of a fibrillating heart) had been used as they could not hear any shock being administered. We took independent advice from a paramedic. With regard to the initial call from NHS 24, we found that this had been dealt with appropriately. The call taker had assigned the request for an ambulance the correct level of priority, in terms of the SAS coding system in place at the time. Therefore, we did not uphold this aspect of the complaint. However, we noted weaknesses in the NHS 24-SAS service interaction and suggested that SAS review the process and consider making improvements if necessary. We found that the response to the 999 call was reasonable, proportionate and timely. We noted that it would not have been appropriate to provide shock to A, given their clinical condition. We also accepted SAS' explanation as to why crew required to put on PPE when they arrived at the scene, which was necessary for infection control. We did not uphold this complai

C complained about the Scottish Ambulance Service (SAS) after calling an ambulance for their spouse (A). The ambulance crew that initially attended C diagnosed that A's condition was not sufficiently serious to require hospital attendance and instead requested that a GP attend instead. C considered that this was unreasonable as, when the GP did later attend, they requested a further ambulance to take A to hospital. C was also concerned about the SAS' handling of their subsequent complaints. We took independent advice from an emergency medicine clinician. We found that the original ambulance crew had carried out a detailed diagnostic investigation and reasonably concluded that requesting a doctor to attend the home was the best option. Therefore, we did not uphold C's complaints in that respect. However, our investigation did raise concerns about the SAS' complaints handling. We found that there were unexplained inaccuracies in their response and also that they had failed to clarify the nature of C's complaints when this was not clear from the complaint correspondence, leading to a misunderstanding of the nature of the complaint. We upheld this aspect of C's complaint.

C complained about Scottish Ambulance Service's (SAS) failure to take appropriate action in response to patient A's symptoms. A had been ill for approximately two days with a high temperature, fever, followed by diarrhoea, trouble passing urine, extreme pain, breathlessness and struggling with mobility. When the SAS crew attended to A at home, an assessment was carried out and senior clinical advice was sought from the out-of-hours GP. It was decided that A did not require to be admitted at that time. The following day A was admitted to hospital and later died from sepsis (blood infection). C complained that the SAS crew failed to recognise the signs of sepsis and to take the appropriate action in response to their symptoms. As part of our investigation, we reviewed the relevant records and sought independent advice from a registered paramedic. We found that the SAS crew carried out an appropriate assessment of A's condition and that there was sufficient evidence that the possibility of sepsis was considered. We found that the SAS took the appropriate action in response to A's symptoms and we did not uphold the complaint. Related reading View Decision Report 202104233 as a PDF (24.27 KB) Updated: February 16, 2022

C’s late partner (A) tested positive for COVID-19. A week after testing positive, A called 111 as they were still feeling very ill. They explained that they had had a fever for a few days and were having difficulty regulating their temperature. A was advised by a nurse practitioner to remain hydrated, continue taking paracetamol, and to continue to self-isolate until they had no fever for 48 hours. They were also advised to call back if they had any further concerns about their symptoms. C called 111 again a few days later as they were concerned A’s breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. During the call, the call handler repeatedly asked to speak to A to take information directly from them, even though C kept answering for A as A was confused. The call lasted around 30 minutes. The call handler contacted Scottish Ambulance Service and requested an ambulance on an emergency basis, but by the time paramedics arrived A had stopped breathing and could not be resuscitated. C complained about the clinical assessments of A’s condition on both instances. We took advice from an advanced nurse practitioner with experience of assessing patients with similar presentations. We found the assessment on the first instance to be reasonable, and we therefore did not uphold this complaint. We considered it unreasonable for the second call to have lasted 30 minutes before an ambulance was called. We noted that the call handler was following the protocol correctly, but were of the view that if the protocol took 30 minutes to establish that an emergency response was required, it was not fit for purpose. We considered that rigid following of the protocol led to a delay in obtaining medical attention for A. Therefore, we upheld this complaint.

C complained on behalf of their parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was delayed and would attend as soon as possible. C later called 999 and advised that A's condition had deteriorated. This resulted in a higher priority ambulance being assigned. C complained to the ambulance service about the failure to respond to the requests for an ambulance. In response, the ambulance service acknowledged they failed to meet the initial one-hour response requested, but explained that one-hour ambulance responses are not automatically upgraded. They said that in these circumstances they call back to explain the delay, ask if there is a change in the patient's condition and advise patients to call 999 if there is a change. C complained to our office that the ambulance service had failed to take account of A's diagnosis provided by the GP, and had therefore not attributed the correct level of priority to the response. C also considered that there was no attempt by the ambulance service to undertake clinical triage of A, resulting in the response level not being upgraded as it should have been. C was unhappy with the investigation and response to their complaint and believed the ambulance service's response to the complaint was not plausible. We found that whilst there was a significant delay in the ambulance attending to A, this was attributable not to failings on the part of the ambulance service in prioritising the request for an ambulance, but on the lack of available resources at the time. However, we found that during the welfare call back, the ambulance service should have sought to clarify whether C considered A's condition had deteriorated before continuing with the call. On this basis, we upheld the complaint with respect to unreasonably failing to respond to the request for an a

C's adult child (A) had anxiety and a functional neurological illness (a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts). One morning A was found to be anxious and unwell. A's other parent (B) thought it appeared different to A's previous episodes and called the GP who visited A at home. The GP believed that A should be admitted to hospital and called 999. An ambulance crew attended the scene. There was some discussion between the GP and the hospital about which department A should be admitted to; the Mental Health Unit or the Clinical Assessment Unit. The ambulance crew transported A to hospital where they were quickly assessed and taken to the Intensive Care Unit. A died later that day. C complained that the Scottish Ambulance Service (SAS) crew did not take A's observations, failed to follow normal protocols and failed to transfer A to the Clinical Assessment Unit straight away. We took independent advice from a paramedic. We found that the ambulance crew attended promptly and appropriately transferred A to hospital. However, during their time at A's address they did not carry out or document a thorough patient assessment. There were multiple assessment tools (F.A.S.T; blood oxygen saturation levels) which could have been used and were not. When A's breathing rate was abnormally high, further action was not taken as it should have been. We found that the SAS had not responded to the complaint reasonably and failed to clearly identify errors and what would be done to remedy them going forward. We, therefore, upheld the complaint.

C complained about the care and treatment provided to their late spouse (A) by the board in relation to the diagnosis, treatment, and management of A's cancer, especially regarding a delay in A receiving a Positron Emission Tomography scan (PET, a scan that produces detailed 3D images of the inside of the body). We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that A's cancer pathway took 17 months, which was significantly longer than it should have taken. We found that the most significant issue for the delay in the process was the error which resulted in the PET scan not being booked, as requested by the multi-disciplinary team (MDT). Additionally, the PET scan should have been requested on a suspected cancer pathway and we were critical that this was not the case. We found that the delay in A's diagnosis was unreasonable and on balance, due to the increase in size of A's tumour during the delay, it is likely this negatively impacted on their outcome. We considered that the care and treatment A received from the board was unreasonable and upheld this aspect of C's complaint. C also complained about the out-of-hours service (OOHS). A developed a postoperative wound infection, and was admitted to hospital. C complained that the OOHS, who saw A prior to admission, requested a non-life-threatening response from the Scottish Ambulance Service (SAS), rather than a life-threatening ambulance. We took independent advice from a GP. We found that the OOHS GP requested the ambulance in line with the SAS guidance, and any delays in the ambulance attending were outwith the GP's control. Therefore, we did not uphold this aspect of C's complaint.

C complained about the actions of Scottish Ambulance Service (SAS) staff when they attended to their adult child (A) following an epileptic seizure (bursts of electrical activity in the brain that temporarily affect how it works and can cause a wide range of symptoms). A was moved onto a chair to be taken out of the house to an ambulance. When A arrived at hospital they were found to have broken vertebrae (individual bones that interlock with each other to form the spinal column). C complained about the manner in which staff had transferred A and about their clinical assessment of A. SAS said that staff carried out a risk assessment on how to get A to the ambulance; the moving and handling skills applied were based on the clinical assessment of A and access difficulties at the scene. We took independent advice from a paramedic. We found that the history assessment and energy involved with A's mechanism of injury made it extremely unlikely to cause a significant spinal injury. Given the age and medical history obtained, there were no risk factors which would lead the paramedic to suspect spinal injury. This, coupled with the restricted space within which they were working, made the use of a carry chair a reasonable means of transferring the patient. Therefore, we did not uphold this complaint. In relation to the clinical assessment, we found that while A complained of back pain, this was not considered to be a spinal injury. We considered the assessment and management were reasonable for a patient suffering a 'seizure now stopped'. We noted that the paramedic used the finding of motor, sensation and circulation of lower limbs in their risk assessment to help rule out/in spinal injury. Given the history and assessment findings, we considered the care provided was reasonable. As such, we did not uphold this complaint. We noted there had been complaints handling issues, but SAS had taken appropriate steps to address this and had apologised to C. Related readi

C complained that the Scottish Ambulance Service made the decision that their headache was due to a less serious cause (rather than the serious diagnosis that was later identified), which did not require urgent assessment at A&E. C was also concerned that they were taken to the out-of-hours GP rather than to A&E. We found that the there was no evidence in the records that the ambulance crew made any decisions about the cause of C's headache. The records indicate that the crew considered the symptoms C was experiencing required hospital assessment. The records also indicated that a handover was given to a nurse within A&E at the hospital and that the nurse was advised that C had a two day history of headaches. It appeared that the decision to transfer C to the out-of-hours service was made by staff within the A&E department, rather than by the ambulance crew. We did not uphold C's complaint. Related reading View Decision Report 201911093 as a PDF (24.11 KB) Updated: May 19, 2021

C complained about the care and treatment provided to them by Scottish Ambulance Service (SAS) when they called for an ambulance after they had bleeding following the removal of a lesion earlier that day. We took independent advice from an appropriately qualified adviser. We found that the care and treatment provided to C by SAS was of a reasonable standard. C was given appropriate advice from the call handler, the ambulance was dispatched and arrived with C in a timely manner. We also found that the ambulance crew's assessment of C's wound was reasonable. Therefore, we did not uphold C's complaint. Related reading View Decision Report 202000080 as a PDF (23.96 KB) Updated: October 21, 2020

C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an ambulance from their late relative (A). C also complained about the way their complaint to SAS about the matter was handled. Through its own investigation, SAS found that the second call from A was not handled appropriately because medical priority despatch system was not utilised to assess A's symptoms and the level of response required. In addition, the first crew to attend A's home did not follow clinical practice guidelines and policy in relation to consent. The crew felt A did not want any help. SAS also found that information on the patient report form was limited and did not meet the expected standards of clinical reporting. We took independent advice from a paramedic. We found that SAS took reasonable corrective action in response to failings highlighted through its investigation. However, we noted that there was a missed opportunity for interaction between the ambulance control centre (ACC) clinical advisor, who had spoken with A, and the clinician who attended A's home. This may have afforded the attending clinician the necessary information to prompt a more comprehensive clinical assessment of A. There was also an opportunity for the attending clinician to seek clarifying information and question the ACC on the requirement to send a frontline ambulance to A. This would have stimulated discussion and provided an opportunity to share both information and the decision-making responsibility prior to ending the engagement with A. Finally, having listened to the recordings available, a call made from the ACC to A was not ended properly. We upheld this complaint. In relation to complaints handling, we found that C was not kept reasonably informed about what was happening with the complaint and the investigation itself took a long time. We upheld this complaint.

C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an emergency ambulance service for their child (A). C expressed concern about the overall time taken for A to be taken to hospital; which was approximately two hours from the original call being made requesting an emergency ambulance, to A arriving at hospital and being reviewed by a doctor. C also complained about how SAS responded to their complaint about that matter. SAS upheld C's complaint on the basis of a longer wait than would have been expected for this category of call and offered an apology for that wait. They explained that this was a very busy time for the service but confirmed that a call audit had concluded that the call was handled very well and was of high compliance with their dispatch system. We took independent advice from a paramedic. We found that there were concerns with SAS's response for an emergency ambulance, including: The delay in elevating the response level which relied on the subjective opinion of a non-clinical call handler. The lack of clinical advisor input into the call which could have negated the limitations of the system and possibly changed the level of acuity, and as such the response time and time taken for A to reach hospital. The decision of the original ambulance crew to wait on the second responding crew to transport A. Therefore, we upheld the complaint that SAS failed to respond reasonably to the request for an emergency ambulance to attend to A. In relation to complaint handling, we found that SAS's response to C's complaint was appropriate. We also noted that their apology was in line with SPSO guidance. Therefore, we considered that SAS reasonably responded to C's complaint and we did not uphold this complaint.

Mr A fell at home and a 999 call was made to the Scottish Ambulance Service (SAS) to attend. The call was prioritised as an emergency response where an ambulance would be dispatched as soon as one became available. An ambulance arrived with Mr A approximately four hours after the initial call. Mr A was later diagnosed with a broken hip. During Mr A's rehabilitation in hospital, there were concerns that he had sepsis. Staff at the hospital called for an ambulance and requested an emergency response to transfer Mr A to another hospital for treatment. The ambulance arrived over two hours after the initial request. Mr A's daughter (Mrs C) complained that the time taken for an ambulance to attend on both occasions was unreasonable and that Mr A's condition, on both occasions, should have resulted in an emergency response. We took independent advice from an appropriately qualified adviser. We found that on each occasion the delay in an ambulance attending was not attributable to failings on the part of SAS assessing and prioritising the requests for an ambulance, or not appropriately allocating its resources. The delays were a result of a lack of availability of resources at the times in question and ambulances attending to higher priority calls. Whilst there was a significant delay in the ambulance attending to Mr A on each occasion, this was not attributable to failings on the part of SAS handling the calls. We did not uphold the complaint. Related reading View Decision Report 201903349 as a PDF (24.41 KB) Updated: July 22, 2020