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.