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August 2019

Date: 17 September 2019

  • Details:

    The patient has incurable brain cancer, was fragile and receiving palliative care. She fell at home and injured her right arm, wrist and leg to such an extent she could not use her arm, wrist and could barely use her leg. The complainant dialled 999 for an ambulance.  The patient lay on the floor for one hour thirty minutes until a neighbour came to help and lift the patient up onto a chair. The patient waited over 10 hours for an ambulance to attend.  The complainant was not happy with how adversely the ambulance delay affected the patient.

  • Findings:

    As part of the investigation, the investigating manager reviewed the notes on the Computer Aided Dispatch (CAD) record and the 999 call was by the Trust’s internal audit team.

    The investigating manager could see that the first 999 call was received in the control room at 17:46 hours, from the information provided this was coded as a Category 3 response. Due to the significant pressures that the Trust was experiencing the call handlers were advised to inform callers of the possible waiting times for Category 3 calls. There were no ambulances to assign and at 22:28 hours a clinical coordinator called to assess the patient’s condition.  At this point the clinical coordinator was satisfied that the patient was stable and no upgrade was required.

    At 01:18 hours, a second 999 call was received. This call was also coded as a Category 3 response. The Auditor has noted that the incorrect set of questions was asked by the call handler during this call. It was not possible to identify if the correct set of questions were asked whether or not an equal or higher coding would have been established.

    Unfortunately, it was not until 04:27 hours that an ambulance became available and arrived on scene with the patient at 05:05 hours. This is well outside the time frame expected for the ninetieth percentile of this type of incident.  Sincere apologies and an explanation were provided.

  • Lesson learnt / action taken:

    Due to the investigating officer finding out that the wrong set of question were asked, he has made sure that the call handler was managed in accordance with the Trust internal procedures. This will include call handler reviewing the call with their line manager and reflecting on what questions should have been asked in order to correctly complete the call and get the best possible response for the patient.

  • Date:
    01 August 2019