Overview
The complainant (Ms C) raised concerns on behalf of her client (Mrs B) that a Scottish Ambulance Service crew failed to recognise the seriousness of her daughter (Ms A's) condition when they responded to Mrs B's emergency telephone call. This resulted in a delay in transferring Ms A from Mrs B's home to the hospital with fatal results. Ms C was also dissatisfied with how the Scottish Ambulance Service (the Service) had dealt with this complaint.
Specific complaints and conclusions
The complaints which have been investigated are that the Service:
- (a) failed to provide appropriate care and treatment to Mrs B's daughter (upheld); and
- (b) delayed in investigating the matter and failed to keep Mrs B updated (upheld).
Redress and recommendations
The Ombudsman recommends that the Service:
- (i) review the protocol for ambulance crews to ensure it gives clear guidance to staff about the relative roles of different crew members in the assessment of patients;
- (ii) assess this protocol to demonstrate and evaluate that it is properly understood by ambulance crew;
- (iii) ensure that measures are undertaken to feedback the learning from this incident to avoid similar situations recurring;
- (iv) review their methods for learning from complaints and introduce comprehensive, dated action plans for follow-up action specific to each complaint;
- (v) introduce a method of ensuring that any wider learning from complaints is fully integrated into the governance structure of the Service; and
- (vi) issue Ms C and Mrs B with a formal written apology for the failures identified in this report.
The Service have accepted the recommendations and will act on them accordingly.