Summary

Mrs A complained about a lack of care and treatment by the Welsh Ambulance Services University NHS Trust (“the Trust”) for her son, Mr B, on 14 December 2022. The Ombudsman’s investigation considered the handling of 2x 999 calls, the standard of record keeping by the attending paramedic, and whether the earlier arrival of Trust staff would likely have affected Mr B’s outcome.

The Ombudsman found a failure to properly manage the 2x 999 calls made in respect of Mr B. The First Call was incorrectly downgraded from “Red” priority to “Green 2”. This meant a delay of 32 minutes in an ambulance attending Mr B. The Second Call was also not handled appropriately, with incorrect information given to Mrs A about cardio-pulmonary resuscitation. As a result, Mr B did not receive timely medical attention. Additionally, there was injustice to Mrs A and Mr B’s brother, Mr C, as they spent 45 minutes attempting to deliver CPR to Mr B, without instruction or support.

In respect of the standard of record keeping by the attending paramedic, the Ombudsman found that fully accurate information was not entered on the patient clinical record particularly that the information was based on estimation. There was inconsistent reporting by the attending paramedic of what information was obtained from Mr B’s family. This lack of clarity about the events of 14 December constituted an injustice to Mr B’s family.

In terms of whether earlier attendance by Trust staff could have affected Mr B’s outcome, the Ombudsman could not conclude with certainty that the earlier arrival of an ambulance would have made a difference. There was information that was not known, including the point at which Mr B suffered a cardiac arrest. As there was a small possibility of a different outcome for Mr B, this is an injustice to Mrs A and the family.

Whilst the Ombudsman’s investigation did not set out to consider the Trust’s handling of Mrs A’s complaint, information came to light which highlighted concerns about the robustness of the Trust’s investigation of the complaints it receives, particularly as this was not the only investigation she had seen which revealed deficiencies in the Trust’s complaints investigation process. Failures in the investigation process have meant Mrs A has unanswered questions about the care provided to Mr B which have left her with deep concerns.

The Ombudsman made a number of recommendations, which the Trust accepted. These included:

• An apology to Mrs A, an explanation about the shortfalls in the investigation process and payments totaling £2,750 for the distress and uncertainty caused and for Mrs A having to pursue her complaint.
• To review its approach to maintaining accurate clinical records to ensure it meets the requirements of The Health and Care Professions Council Standards of Practice.
• To remind all clinicians about the importance of good communication with those present at calls they attend.
• To share the report with the Trust’s complaint investigation team to review the conduct of its investigation in line with the Duty of Candour and identify learning points to ensure that similar failings are not missed in the future.
• To share the report with the Trust’s Quality and Patient Safety Committee to consider the findings and include its learning from these recommendations in its Annual Duty of Candour report.