Report Date


Case Against

Welsh Ambulance Services NHS Trust


Ambulance Services

Case Reference Number



Upheld in whole or in part

Ms A complained that her late father, Mr B, not being taken to the local hospital by the first ambulance crew adversely affected his treatment and investigation for a suspected stroke. Ms A said that her father’s condition had deteriorated and the following day he was very confused. He had an episode of urinary incontinence and the lower half of his body was uncovered when the second ambulance crew attended. Ms A complained that her father’s dignity was not respected during the second ambulance crew’s attendance when he was transported to the ambulance. Ms A also felt that Welsh Ambulance Services NHS Trust’s (“WAST”) complaint response was not sufficiently robust in relation to its findings around her father’s stroke.

The Ombudsman found that Mr B’s delayed admission to hospital did not impact on his stroke treatment and therefore his clinical outcome. However, it did cause a delay in Mr B’s stroke being investigated. While the Ombudsman concluded that this would not have changed Mr B’s clinical outcome, it might have avoided the sad sequence of events that later occurred due to his deteriorating condition. This had significantly impacted on Mr B, Ms A and her son. It was to this limited extent that the Ombudsman upheld this part of Ms A’s complaint.

In relation to the second ambulance crew’s attendance, in the absence of evidence to the contrary, the Ombudsman was satisfied that more could have been done to have maintained, or at least looked at options for minimising the compromise to Mr B’s dignity. She also commented on the inadequacies of the documentation which made no reference to the fact that a carry chair had to be used due to the space restrictions at the property, issues with the blanket used to cover Mr B, or the difficulties posed by Mr B’s weight which had led to Mr B’s grandson assisting with the transfer. This aspect of Ms A’s complaint was upheld to the extent set out in the report.

In relation to complaint handling and the robustness of the findings, the Ombudsman felt that whilst there were elements of WAST’s investigation that were broadly robust, there were areas for improvement and learning that had not been identified, particularly in relation to the second ambulance crew’s attendance. This part of Ms A’s complaint was to this extent upheld.

The Ombudsman’s recommendations included WAST apologising to Ms A and taking forward or evidencing points of learning around the assessment of strokes in patients deemed non-compliant, maintenance of patient dignity and risk assessment and care episode documentation.