Report Date


Case Against

Welsh Ambulance Services NHS Trust


Ambulance Services

Case Reference Number



Upheld in whole or in part

Miss D complained about her late father, Mr D’s, treatment by the Health Board and the Trust. She complained that as her father was at the end of life exceptions should have been made to visitor restrictions that were in place due to Covid-19 to allow family to visit him, that incorrect updates were provided to family about his condition while he was in hospital, that he was prescribed unnecessary pain relief, and was discharged twice in a state of neglect. She also raised concerns about a Do Not Resuscitate (DNACPR) decision made by the Health Board, including if the decision was made and communicated correctly, how the Trust dealt with DNACPR when called to treat her father at home, and the delay caused in transporting her father home due to an inability to locate the DNACPR form. Finally Miss D complained about the use of sub-contracted, non-emergency transport to bring her father home from hospital.

The investigation found that Mr D would not have met the exception for end-of-life visiting, as he was not expected to die imminently while he was in hospital. However it found that contradictory information appeared to have been provided to his family about this, which was an injustice to them, and this complaint was therefore upheld. It did not find sufficient evidence to confirm a contradiction between Mr D’s health, as recorded in his hospital medical records, and information the family were provided with. It found that although Mr D did not suffer from pain, the prescription of painkilling medication in anticipation of the possibility was justified. These complaints were therefore not upheld. The investigation found that Mr D’s nursing, including hygiene, care, was of an acceptable level, but there was little available information to establish the exact state of Mr D’s appearance during his discharges. As the Health Board acknowledged there could have been some issues with this, but was unable to offer an explanation, this complaint was partly upheld.

The investigation found that although the family did not agree with the DNACPR decision, there was no evidence that it had not been properly made. It also found that Mr D’s transport home was suitable as the contracted service had the same equipment and staff training as WAST’s own non-emergency transport options, and these complaints were therefore not upheld. Whilst the investigation found that the paramedic who attended Mr D at home treated him appropriately, it found that the complaint response provided to Miss D by the Trust misrepresented a key element of the interaction, and therefore partly upheld this complaint. It found that the Trust was correct in requiring a DNACPR form to be provided before transporting Mr D home, and that the delay caused by the loss of this form was due to the Health Board. This delay was an injustice to Mr D, and this complaint was therefore upheld against the Health Board (but not against the Trust).

The Ombudsman recommended that both bodies offer an apology to Miss D for the issues identified within the report. She recommended that the Health Board should remind all relevant staff involved in discharging patients and making transport arrangements that if they are requesting transport for an end of life patient a DNACPR form needs to be available, and that it ensures that relevant staff were made aware that end of life visiting exceptions only apply in specific circumstances and are not applicable to all terminal patient sat all stages of their care. She also recommended that the Health Board should consider whether there would be benefit in logging all calls to its Patient Liaison Service. The Ombudsman recommended that the Trust should remind all staff involved in compiling complaint responses of the importance of accurately representing key evidence when summarising it.