We launched two investigations after receiving separate complaints about Welsh Ambulance Services University NHS Trust.

Mr B’s case

Mr B complained about care and treatment provided to his late mother, Mrs C (aged 93), after she fell at her home address on 13 September 2022.  An ambulance arrived at Mrs C’s address around 16 hours after the first of 6 emergency calls made by the family.  Mrs C sadly died on 20 September, after being admitted to an ED department.  Mr B complained about how emergency calls about his mother were triaged and prioritised and about advice from Trust staff during those calls.

We found that the Trust’s emergency call handlers correctly triaged and prioritised the emergency calls about Mrs C.  However, a clinician on the Clinical Support Desk (a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category.  If this had happened, an ambulance may have been allocated to Mrs C sooner.  This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her.

It was impossible to be sure whether a quicker ambulance response would have changed Mrs C’s sad outcome.  We decided that this uncertainty amounted to additional injustice to Mr B and his family.

We were very concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after receiving the views of our Paramedic Adviser in April 2024.

The investigation also looked at the actions of Swansea Bay University Health Board after Mrs C was admitted to its Emergency Department.  However, that element of the complaint was not upheld.

Mrs A’s case

Mrs A complained about care and treatment provided to her son, Mr B (aged 35), in December 2022.  Mr B was at home with Mrs A and his brother, when he collapsed and sadly was later pronounced dead by attending paramedics.  Mrs A complained about how the Trust handled two 999 calls, how the attending paramedics kept a record of events and whether Mr B’s outcome would have been different had the ambulance arrived earlier.

We found that the Trust did not properly manage the two 999 calls made after Mr B had collapsed.  The first call was incorrectly downgraded from Red priority to Green 2.  The second call was also not handled appropriately, with incorrect information given to Mrs A about cardio-pulmonary resuscitation.  As a result, the ambulance arrived to the scene 32 minutes late.  Additionally Mrs A and her other son spent 45 minutes attempting to deliver CPR to Mr B without instruction or support.

We found that the attending paramedic did not enter fully accurate information on the patient clinical record.  The recorded information was inconsistent with that obtained from Mr B’s family and based on estimation.  This was an additional injustice to Mr B’s family.

We could not be sure that earlier attendance of an ambulance would have made a difference, because it was not known when exactly Mr B suffered a cardiac arrest.  However, as there was a small possibility of a different outcome for Mr B, we deemed this as further injustice to the family.

We considered that the Trust’s response to Mrs A’s complaint fell well short of what was expected.  There was a lost opportunity during the Trust’s investigation to obtain key evidence about the care provided.  As a result Mrs A was left with unanswered questions about the events leading to the death of her son.  The Trust also failed to provide us with all relevant evidence at the start of our investigation; some significant pieces of evidence were not provided until several months later.

Our recommendations

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

• Apologising and providing an explanation to Mr B and Mrs A about the shortfalls in the investigation processes, and paying them £2,750 each for the distress and uncertainty caused.
• Reviewing its approach to maintaining accurate clinical records to ensure it meets the requirements of The Health and Care Professions Council Standards of Practice.
• Reminding all clinicians about the importance of good communication with those present at calls they attend.
• Sharing the reports with:

1. the Trust’s Complaint Investigation Team to identify learning points
2. the Trust’s Quality and Patient Safety Committee to include its learning from these recommendations in its Annual Report on the Duty of Candour
3. appropriate staff to remind them of the importance of fully reviewing information recorded in the Command & Dispatch system at the time of the call.

Almost a year has passed since the Government submitted a proposal to amend the Ombudsman Act to the Parliament. It has now been sealed with the President's signature. The law will enter into force on 1 July 2025. Thus, the institution of the Children's Ombudsman will be created on that date. Until the election of its representative, the duties will be carried out by the Deputy Ombudsman, Vít Alexander Schorm. The amendment also extends the ombudsman's mandate to include a so-called "National Human Rights Institution" whose aim is to protect and promote human rights in the Czech Republic. 

On the first day of the holiday season, the newly-approved Children's Ombudsman will start work under the roof of the current Ombudsman's headquarters in Brno. His task will be to promote children's rights in individual cases and at a systemic level. Both ombudsmen will work independently. 

Deputy Ombudsman Vít Alexander Schorm explains the changes that the establishment of the Children's Ombudsman will bring. "The Czech Republic will finally have a figure who will consider the rights of children in a comprehensive way. He will therefore have to carry out a whole range of activities - investigating children's complaints, researching and communicating children's views to other institutions. He will be assisted by an advisory body composed of children, which will be an important source of information on the concerns and aspirations of the younger generation. A completely new element is the power of the Children's Ombudsman to initiate or intervene in selected legal proceedings where the rights of a child are at stake".

For example, what will the Children's Ombudsman do?

Investigate children's complaints against the authorities.

Give children quick, effective and clear advice on how to deal with the problem.

Monitor compliance with rights in children's institutions.

Protect children against discrimination.

Monitor the fulfilment of children's rights in different areas of life and to enforce their findings.

Comment on legislation and other documents concerning children.

Initiate legal proceedings if the rights of the child are at stake.

Listen to the younger generation through an advisory body composed of children and pass on their views to other institutions.

Ombudsman Stanislav Křeček points to another important change brought about by the amendment: "In connection with the amendment that has just been signed, there is often talk of a children's ombudsman. Less attention is paid to the fact that the law gives the ombudsman's office new responsibilities in the form of a so-called human rights institution. Until now, the Czech Republic has not had an independent body dealing with human rights in a comprehensive manner. Although the Government Commissioner for Human Rights and a number of non-profit organisations work on this issue, we have so far lacked an institution that would take care of the protection and promotion of human rights in a completely independent manner".

The establishment of a national human rights institution does not entail the creation of a new office. The term refers to the new role of the Ombudsman in protecting and promoting human rights.

What will the National Human Rights Institution (or NHRI) be responsible for?

The main activity of the NHRI will be the protection and independent promotion of human rights. The Czech Republic already has a number of institutions for the protection of rights (courts, authorities, police). The NHRI will complement and strengthen the existing system. 

The NHRI will not be similar to a court, it will not decide on disputes, but will monitor and evaluate the human rights situation and make recommendations on how to further improve the implementation of rights. It will deal with systemic issues. Last but not least, it aims to prevent human rights violations.

The Ombudsman already works in this way in a number of areas. He helps to protect people deprived of their liberty (e.g. in prisons) or dependent on institutional care (e.g. in care home for the elderly) from ill-treatment. He addresses the situation of people with disabilities. He provides methodological assistance in the field of discrimination. 

However, the Ombudsman will now also deal with human rights in areas that were previously excluded from his remit. Examples include victims of crime, human rights related to the development of modern technologies (AI, digital exclusion), homelessness and housing affordability.

The NHRI's mandate also entrusts the Ombudsman with tasks such as human rights awareness and education.

The NHRI will also have an Advisory Council composed of scientific, academic and spiritual experts, representatives of civil society, national minorities and other social groups.

Functioning of National Human Rights institutions (NHRIs) abroad

The specific form of NHRIs varies from country to country. In some countries, there is a human rights commission; in others, a research institution monitors compliance with rights. Very often, even abroad, the functions of the NHRI are entrusted to an ombudsperson. Such a solution combines very well the independence of ombudspersons and their mission to protect human rights with the tasks of the NHRI. Such a solution is also advantageous in terms of financial costs.

Who can become the Children's Ombudsman?

A natural person whose knowledge, experience and moral qualities are a prerequisite for the proper performance of his/her duties may be elected as the Children's Ombudsman.

Other requirements are:

citizenship of the Czech Republic;

legal capacity; 

integrity;

at least 35 years of age;

completed university education with a master's degree in law;

at least 5 years of experience in the field of protection of children's rights in the last 10 years

Children's Ombudsman election

The Children's Ombudsman is elected by the Chamber of Deputies for a term of 6 years. The Chamber chooses from 2 candidates proposed by the President, 2 candidates proposed by the Senate and 2 candidates proposed by a body of university representatives.

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