Decision Report 201702685

  • Case ref:
  • Date:
    May 2018
  • Body:
    Scottish Ambulance Service
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    admission / discharge / transfer procedures


Mrs C complained that her late husband (Mr A) had been taken to the wrong hospital by the ambulance service. Mrs C explained that, when Mr A became ill, she recognised signs of a stroke and called an ambulance. She said she thought that, according to the protocol in place at the time, Mr A should have been admitted to the Hyper Acute Stroke Unit at a particular hospital. He was taken to a different hospital and Mrs C felt that this had had an impact on the treatment he was given.

We took independent advice from a paramedic. We found that, on the basis of the information given by Mrs C in the emergency call, the ambulance crew should have suspected a stroke and on this basis should have taken Mr A to the stroke unit at the hospital where Mrs C thought he should have gone. We, therefore, upheld this complaint. We noted that the ambulance service had carried out stroke education since the events of this complaint; however we recommended that they carry out an audit to confirm that patients are being taken to the correct hospital. We also noted that the ambulance crew had failed to document a test they carried out, and we made a recommendation on this point.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for unreasonably taking Mr A to the hospital they did, rather than the specialist stroke unit elsewhere.The apology should meet the standards set out in the SPSO guidelines on apology available at

What we said should change to put things right in future:

  • Tests carried out by ambulance crews when attending a patient should be documented.
  • In similar situations, suspected stroke patients should routinely be taken to the Hyper Acute Stroke Unit, as opposed to the local emergency department in line with protocol.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: December 2, 2018