Miss B complained about the care and treatment provided to her late son, Mr C, by Welsh Ambulance Services University NHS Trust (“the Trust”) on 10 and 11 December 2022. Specifically, the handling of the 2x 999 calls made and whether a response should have been dispatched sooner, and if it had, whether earlier arrival would likely have affected his outcome.
The Ombudsman found that both emergency calls were correctly triaged and prioritised by the Trust’s Emergency Medical Dispatch call handlers. However, the Trust’s Clinical Support Desk clinicians should have reviewed Mr C’s situation during the first 999 call, identified that he was at serious risk and then escalated the ambulance response category in line with the Trust’s own guidance. This failure to review the call was a serious injustice to Mr C. The time Mr C spent waiting for an ambulance would have been distressing, painful and undignified for him, and extremely upsetting for his father who was present with Mr C. Accordingly, this element of the complaint was upheld.
The Ombudsman found that although an emergency response should have been dispatched sooner, on the balance of probabilities, this delay was unlikely to have changed the outcome for Mr C. That said, his family were left with doubts about the outcome while this matter has been investigated. The impact of the Trust’s failings amounts to an injustice to the family which will have had a lasting impact on them. To that extent, the complaint was upheld.
The Trust accepted the Ombudsman’s recommendations; to offer a meaningful apology for the failings identified and for not identifying the failings during its complaint handling process; to offer financial redress totalling £2,250 for these failings, including having to pursue this complaint to gain answers.
The Trust also accepted recommendations to share the investigation report with: The Trust’s complaint investigation team to review the conduct of its investigation in line with the Duty of Candour. Any learning points and improvements it identifies are to be fed back into its complaints handling procedure and shared with this office; The Trust’s Quality and Patient Safety Committee to consider the findings in relation to the Trust’s Duty of Candour and include it in its Annual Report on the Duty of Candour; All Clinical Support Desk staff and those undertaking triage for manual escalation to the Clinical Support Desk queue, and remind them of the importance of fully reviewing all information provided by callers when conducting clinical reviews of emergency calls.
Finally, the Trust accepted the Ombudsman recommendations to review its processes for ensuring that calls relating to overdose scenarios are appropriately escalated to the Clinical Support Desk queue for review in a timely manner, in line with its Standard Operating Procedure. The Trust agreed to introduce an audit process to assure itself that any process changes are embedded, and any such calls have been appropriately escalated.