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Investigation Report 200901107

  • Report no:
    200901107
  • Date:
    May 2011
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health

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.

Updated: December 11, 2018