Action taken after West Midlands patient died ‘alone, unnecessarily’ while waiting five hours for ambulance

The man’s sister had told an ombudsman that “her brother died alone, unnecessarily, due to these failings”.

“This has caused her and family considerable distress.”

But the Parliamentary and Health Service Ombudsman has found that West Midlands Ambulance Service (WMAS) had correctly triaged the man’s case as category 3 (urgent but not immediately life-threatening).

But the ombudsman found that WMAS did not have the resources to respond to a 15-20 per cent ‘surge’ in calls when the man, referred to only as 'Mr N' in its report, called 999 at 10.36pm on July 18, 2024.

“WMAS explained that at the time of Mr N’s call and wait for an ambulance, it had approximately 250 calls awaiting ambulance response,” reads the ombudsman’s report.

At the time “many of its ambulances were waiting multiple hours to hand over patients to hospital”.

The report adds that “WMAS records show the longest at-hospital wait at the time in question was over four hours".

A national target in the NHS standard contact is for handover within 15 minutes.

This all pushed the waiting time expected for category 3 calls from the expected two hours.

“At the time of Mr N’s call, WMAS reported that they were responding to 90 per cent of category 3 incidents within 304 minutes, just over five hours.”

Sadly the paramedic found Mr N deceased at his home when the professional arrived five hours and 10 minutes after a 999 call.

Officials had listened to a recording of Mr N’s 999 call.

“On the call, Mr N told the call handler it was his sixth day of receiving radiotherapy for cancer.

“He said his concern was anxiety and breathing, that he was breathing slightly harder than usual, explaining that when he gets anxious his breathing is worse.”

But the ombudsman found that throughout the seven-minute call Mr N spoke clearly and calmly, in a normal tone and manner.

“There is no audible or verbal suggestion from him at any time that he was struggling to breathe,” the ombudsman found.

The ombudsman recorded that the call handler gave advice and Mr N had “said he felt better just talking with the call handler, that he thought he was just panicking”.

“The call handler assured Mr N and gave him advice to call back if his symptoms worsened.”

Mr N’s sister, Miss N, had had also complained that WMAS should have called her brother to check. She had asked for a financial remedy.

The ombudsman recorded: “Miss N says her brother died alone, unnecessarily, due to these failings.

“This has caused her and family considerable distress.”

The ombudsman said that WMAS should have called Mr N back but could not say that it would have changed the “sad course of events”.

“We do think WMAS should have called Mr N back. We cannot say if not for this, it would have changed the sad course of events,” the ombudsman wrote.

“We know how much Miss N has been affected by her brother’s sad death, and how important her complaint is to her. We thank her for sharing her experience with us and hope this statement clearly explains our decision.”

Overall the ombudsman ruled that it “did not find any indication this was due to any failure by WMAS".

“We would not criticise WMAS for factors outside of its control.

“Records show it was unable to get an ambulance to Mr N sooner, essentially as it did not have the resources available to do so.

“The evidence available to us shows WMAS was managing the resources it had appropriately.

“In the circumstances, we cannot see that WMAS had anything else they could do to reach Mr N sooner, and we consider the explanation for the delay reasonable. We do not see any indication of service failure on WMAS’ part here.”

The ombudsman recorded that WMAS had acknowledged it should have called Mr N back, and “sincerely apologised to Miss N for this”.

It has also reviewed what happened and has taken a number of actions.

The ombudsman concluded: “In our view, the response is proportionate to what went wrong and the actions already taken go far enough to remedy the impact of the distress caused to Miss N.

“We do not find there is anything left to remedy, and we consider this matter resolved by the response given and actions already taken.”

A WMAS spokesperson said its “thoughts remain with Ms N and her family and the sad death of her brother”.

“We would never want to see such a long response to a patient, but as the ombudsman report highlights, we were dealing with extensive handover delays at the time.

“If our ambulance crews are held outside hospital with a patient on board, they cannot get to patients in the community as fast as we would want, which may impact on the condition of those waiting for our attendance.

“As a trust we have also boosted the number of experienced paramedics and nurses in our control room who deal with patients over the phone.”