East of England Ambulance Service NHS Trust (P-001014)

  • 1.	This report sets out our final view on this case. 
    2.	We are upholding Person A’s complaint as we have seen a paramedic inappropriately directed Person C to the out of hours service which caused Person C unnecessary pain and Person C and Person A distress. We have not been able to say that Person C’s death was avoidable, but we have seen a missed opportunity for further clinical consideration of possible surgical intervention. 
  • 3.	Person A says that Person C was in excruciating pain when they rang the Trust on 25 October 2018 and an ambulance did not arrive for five hours. 
    4.	Person C died at hospital later the same day and Person A would like to know if the delays in the ambulance contributed to their death.
    5.	Person A feels guilty that they were not able to help Person C and keeps wondering if they could have done more.
    6.	Person A would like service improvements, so the same thing does not happen to other service users.
  • 7.	Person A rang for an ambulance at 3.03am on 25 October 2018 as Person C had stomach pains. Despite two subsequent calls an ambulance did not arrive until 8.19am. Unfortunately, Person C died later the same morning in hospital. 
  • 8.	We have used the evidence provided by Person A including letters sent and received by the Trust. We have also used documents provided by the Trust including reports and audits on the calls involved in the case. 
    9.	We obtained advice from a Paramedic who has 40 years of experience working for an NHS Ambulance Service as both a Paramedic and an Operational Manager. Referred to in the report as Paramedic Adviser.
    10.	Furthermore, we also took advice from a Vascular Surgeon who has 24 years of experience. Referred to in the report as Vascular Adviser.
    11.	We use related or relevant law, policy, guidance, and standards to inform our thinking. This allows us to consider what should have happened. In this case we have referred to the following standards.
    12.	We refer to the following Guidelines and Procedures during the report:
    •	Advanced Medical Priority Dispatch System (AMPDS) – used by the Trust to triage 999 calls. 
    •	LOWCODE nurse triage system used by the Trust to triage calls.
    •	Regarding Aortic Aneurysm- https://www.vsqip.org.uk/content/uploads/2019/12/NVR-2019-Annual-Report.pdf
  • 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.
    Outbound call 
    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.
    Further call
    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.
  • 43.	As we are upholding this complaint, these are the recommendations we are making to the Trust.
    44.	In considering recommendations, we have referred to our Principles for Remedy. These state that where maladministration or poor service has led to injustice or hardship, the public body responsible should take steps to provide an appropriate and proportionate remedy.
    45.	Our Principles also say public organisations should seek continuous improvement. They should use the lessons learnt from complaints to ensure maladministration or poor service is not repeated.
    46.	We note that Person A explained to us when they approached us with their complaint that they would like service improvements. We have seen the Trust have identified something went wrong in this case and they have apologised for it, however we are not satisfied that they have fully recognised the impact that this error had on the complainants.
    47.	As such, within three months of the date of this final report, the Trust should write to Person A detailing the following:
    •	A further apology from the Trust for not recognising the impact that the miscategorised call at 4.41am had on Person A and Person C.
    •	information for Person A regarding the Trust’s response to this error and details of any training that has been put in place to ensure that the same issues do not arise again in future. 
    48.	We will look for the Trust to write to both us and Person A within three months of the date of our final report to explain how it will achieve the recommendations set out in paragraphs 42 to 45 of this report.
    49.	This concludes our report.