Two initial calls
13. During the morning of 25 October 2018, Person A and Person E made three separate calls to the Emergency call centre (ECAT) at the Trust.
14. Person A initially rang at 3.03am telling the Trust that Person C had stomach pains. Person E then rang again at 3.59 am. The Trust use the AMPDS system to triage calls.
15. The Trust triaged both calls using the AMPDS system as a Category 3 call which the Trust say in their response targets a response time of 120 minutes for nine out ten patients. This response can be an ambulance but can also be a telephone assessment by a clinician, as was the case with these calls.
16. We have seen that the Trust’s internal audit of the calls was satisfied that both calls were dealt with in a good way by the call handler and Category 3 was acceptable.
17. The Trust explained in their responses that Category 3 coded calls are for patients who have potentially urgent conditions that are not life threatening but do require treatment. They noted that Person C was fully alert on both calls and the descriptions given of the pain they were suffering given by Person A did not trigger a higher coding.
18. In their complaint, Person A asked if their own difficulties with osteoporosis should have been considered when assessing whether the call should attract a higher coding.
19. The Trust responded to this by stating that the triage of the call was focused on Person C’s presenting condition rather than the caller’s circumstances.
20. The Paramedic adviser reviewed both calls and was satisfied that the call handler had acceptably triaged the calls. They were satisfied that on both occasions the call handler recognised that Person C was suffering from abdominal pains which attracts a Category 3 code. They explained that on the first call they used the code 01C03 which covers abdominal pain / problems with fainting or near fainting and requires a category 3 response.
21. On the second call, the Paramedic adviser said that the patient’s condition had not changed from the first call, and as such the call would not attract a higher coding. We appreciate this was the second call within an hour which clearly indicates the level of concern Person A and Person C were experiencing but this did not change the clinical response considered necessary.
22. Furthermore, the Paramedic adviser also said that it was not common policy for Trusts to consider the condition of the caller, unless the caller was also saying that they were suffering from illness or injury that they were requiring help from them for. As such, it was acceptable that the Trust did not upgrade the call coding based on Person C’s condition.
23. As such, we have seen no failings in the actions of the Trust for the two calls at 3.03am and 3.59am.
24. A paramedic contacted Person A at 4.41am in response to their previous contact. This call back occurred within the appropriate 120-minute target. This 22-minute call was processed using the LOWCODE triage system and the paramedic decided that an ambulance response was not required and that a referral to an out of hours GP was more appropriate. At 5.29am the 111 service was contacted on behalf of Person C.
25. The Trust has accepted that this call did not meet the requirements of what should have happened. They have explained the paramedic did not fully address some priority symptoms, and although it is clear from the recording that Person C was reluctant to go to A&E, the Trust concluded that an ambulance was an appropriate response at this time.
26. The paramedic adviser said it was possible that as Person C was adamant that they did not want to go A&E that this may have influenced the decision of the paramedic to refer to the out of hours GP (OOH GP). Nevertheless, the adviser maintained an ambulance response was appropriate given Person C was describing some back pain, which they had not mentioned on previous calls
27. As such, we have seen failings in this call and the paramedic’s response to it.
28. Person A rang the Trust again at 6.29am. On this occasion, Person C was reported as feeling faint and the call was coded as Category 2, which the Trust explained was for patients whose condition is potentially serious and aims to respond to nine out of ten patients within 40 minutes.
29. The Trust audited this call and were satisfied that the Category 2 response was appropriate due to the change in some of the symptoms that Person A was describing.
30. The paramedic adviser explained this change in categorisation was appropriate. They noted that the change in Person C’s clinical presentation which included the further reference to back pain meant it was correct to change the seriousness of the call.
31. The Trust explained that there were no emergency vehicles available at that time so a Rapid Response Vehicle (RRV) was sent and arrived at 7.31am. If the 40-minute target had been reached this would have arrived by 7.09am. The RRV attempted to treat Person C but soon decided that they needed the backup of an ambulance, which was called at 8.16am, and arrived at 8.19am.
32. As such, we have seen failings in the Trust response to this call, however as Person C was receiving treatment from the RRV crew, we find that this mitigates the late arrival of the ambulance and do not uphold this head of complaint.
33. We have seen that the Trust correctly triaged the three calls that Person A and Person E made to them on 25 October 2018. However, we have found a failing in the call that the Paramedic made at 4.41am, which lasted for 22 minutes, therefore ending at 5.03am. At that time, the paramedic incorrectly redirected Person C to an OOH GP, rather than arranging an ambulance for them. We therefore need to understand whether this failing on the part of the paramedic had an impact for Person C and Person A.
34. We have established that in the call made at 4.41am, Person C was exhibiting similar symptoms to those in the next call that Person A made at 6.29am, specifically relating to back pain as well as stomach pains. As we know, Person A’s later call was categorized at Category 2 which attracts a target of 40 minutes. We therefore can expect that if the correct decision had been made on the call at 4.41am, an ambulance would have been arranged at the end of the call, being about 5.03am. The Trust have accepted that this should have been done.
35. If an ambulance had been booked at 5.03am, in category 2, Trust figures tell us that 9 out of 10 arrive within 40 mins. Even if it took over an hour (as it did when the later call took place), Person C could reasonably expect an ambulance by around 6am. Sticking to the timescales we know from above, Person C could expect to be in hospital by approximately 7am, or 2 hours earlier than they did arrive. To further measure the impact this would have had on Person C; we took clinical advice from a vascular adviser.
36. The vascular adviser explained that if a person can get to hospital whilst the bleed from an abdominal aneurysm is small and contained, they may be considered for surgery. They said that if they were considered appropriate for surgery they would be transferred to theatre as soon as they arrived for an emergency repair of the aneurysm.
37. The adviser explained there are two methods of repairing such an aneurysm. Either by open surgery through an incision in the abdomen. or a keyhole type procedure through the groin. If the aneurysm is suitable, and the procedure successful, the mortality is approximately 30%. The mortality is higher for open surgery.
38. They told us that unfortunately, by the time Person C reached the hospital, they were in an extreme condition as they had deteriorated whilst being transferred to hospital. As we know, Person C died within 30 minutes after arriving at the emergency ward.
39. However, if Person C had arrived at hospital a couple of hours earlier then we can say it is likely Person C’s condition would not have deteriorated as much as it had by the time they actually arrived at hospital.
40. However, it is impossible for us to say now whether they would have been considered fit enough for surgery, and whether even if they had been considered eligible for surgery, that surgery would have meant their death could have been avoided.
41. This is because we cannot say now what condition they would have been in at the earlier point, whether a clinical decision would have been made that they were fit for surgery at that time, or even if they were, that they would have survived surgery. As we have seen above the mortality levels are relatively significant even where surgery is possible.
42. It is not possible to say with certainty that Person C would have survived if they had arrived at hospital earlier, and as such we cannot say their death was avoidable. However, we are persuaded that because of the wrongly categorized call at 4.41am, there was a missed opportunity for further clinical consideration and the possibility of surgical intervention.