Ombudsman finds series of failures after two Welsh Ambulance Service complaints

Two new public interest reports have been released after serious concerns were raised about the robustness of the Welsh Ambulance Services University NHS Trust’s responses to complaints.

The Public Services Ombudsman for Wales has today issued its findings after launching two separate investigations into the Trust after it was accused of failing in its duty of care and treatment.

In both cases reviewed by the Ombudsman, complaints had been made by families about the length of time their loved ones had spent waiting for an ambulance and a lack of support from the Trust.

Sadly the two individuals at the heart of the complaints passed away.

However there is uncertainty over whether the outcome(s) would have been different if the ambulance response times had been quicker.

In today’s reports the Ombudsman identified a series of service failures and serious concerns about the Trust’s responses to complaints.

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.

The Ombudsman 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 should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category.

The Ombudsman concluded that if this had happened, an ambulance may have been allocated to Mrs C sooner; reducing 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.

However he Ombudsman decided that this uncertainty amounted to additional injustice to Mr B and his family.

The Ombudsman was very concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after receiving the views of the Ombudsman’s 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.

The Ombudsman 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.

The Ombudsman 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.

The Ombudsman 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, the Ombudsman deemed this as further injustice to the family.

The Ombudsman 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 the Ombudsman with all relevant evidence at the start of her investigation; some significant pieces of evidence were not provided until several months later.

Ombudsman conclusion

“I would like to extend my sincerest condolences to both families for their sad losses,” said Public Services Ombudsman for Wales, Michelle Morris.

“The failures revealed in these reports raise serious concerns about how emergency calls were handled and triaged by the Trust.

“The failings led to serious injustice for both families and had correct actions been taken then the treatment and outcomes for both patients could have been different.

“I am also concerned about the robustness of the Trust’s investigations of the complaints it receives.”

“The Putting Things Right Regulations, under which the Trust responded to the complaints, places an obligation upon it to investigate concerns properly, efficiently and openly.

“Furthermore the Duty of Candour is now a statutory requirement placed on health boards.”

“The responses provided by the Trust to both complainants fell well short of what the Putting Things Right Regulations and the NHS Wales Duty of Candour promote and are intended to achieve.”

“I have made a number of recommendations, accepted by the Trust, to address the failures identified in both investigations.

“In the future, the Trust also needs to ensure that it responds openly and honestly to complaints, and that staff involved in the response also need to reflect on both the duty, and their own professional standards obligations when doing so.”

The Ombudsman’s recommendations

The Ombudsman has put forward several recommendations, which the Trust has accepted. These include:

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