London Ambulance Service - Examples of learning

We always look to use any feedback we receive as a chance to learn, and so improve the service we provide to our patients.

We also believe that we need to focus not just on complaints, but the full range of enquiries received from patients and the public, as well as incident reports from other health and social care agencies.

The case examples on this page originated from a range of sources, and were highlighted to us through a number of different contact points. The most important issue from our point of view is that, once they have been received and looked into, we are able to address the causes so that we can better manage similar situations in the future.

For more case studies on how we are caring for frequent callers you can visit our frequent caller section.

You can also find out more about lessons learned around the issue of safeguarding.

Case studies

An 83-year-old patient presented with symptoms that were suggestive of a possible stroke, however they were not fully explored by the call handler who received the 999 call. This led to the call being determined at a lower priority category and it being referred to our clinical telephone advice service. Subsequent 999 calls were not re-triaged and it was only following a fifth call that the position was realised.
The lessons learned included the need to improve awareness of a patient’s symptoms to determine use of the triage stroke protocol (which results in a higher level of priority being made), the importance of the re-triage protocol being completed where further calls are received in relation to the same patient, and increased monitoring and intervention of senior managers where a 999 call is being ‘held’ awaiting dispatch of an ambulance.

A member of the public had received an answer phone message, apparently intended for the patient’s GP, from an elderly patient who was experiencing breathing problems. The patient sounded very breathless, and requested an urgent GP visit. The member of the public was concerned as she had no details of the patient’s phone number, but did have most of the address. We were able to confirm that we had not attended on that day. Our control room was contacted and an ambulance was dispatched to ensure the patient was safe and well. It was subsequently identified that the patient is a frequent caller and action is being taken to establish a care plan approach.

In relation to a complaint against a local authority, a Freedom of Information request was received relating to a specific incident involving the enquirer’s relative. The enquirer was advised that the information would be made available under the Data Protection Act, providing the patient’s consent could be obtained. The enquirer provided an authorisation document, signed by the patient. On further enquiry, it emerged that the incident related to several allegations of abuse made by the enquirer against the patient’s next of kin, with the enquirer being unhappy with the patient’s management by the agencies involved, including our service. As a result, we attended a multi-agency strategy meeting, to which the enquirer had been not been permitted to attend as a consequence of unreasonable behaviour. Detailed information of our involvement was made available which contributed to the outcome of a ‘vulnerable adult’ investigation. The authorisation was deemed invalid as the patient did not have capacity at the time of signing it, but a decision was made to release some of the information requested in the interest of openness and transparency.

A London hospital fracture clinic and the patient’s parents raised concerns that a scheduled ambulance did not arrive to take a child home. It emerged that the hospital’s patient transport service provider had declined to carry out the journey. We had attended, but the patient had already gone home by independent means, at some clinical risk. An explanation was provided and the hospital agreed to review the terms of the contract they hold with their PTS provider.

A ‘vulnerable adult’ referral was completed by a crew regarding a carer. What were considered aggressive messages had been left for the crew on station. The crew was alarmed that the carer in question had obtained their contact details and that this had somehow been ‘leaked’ by our service. The local management team was concerned that this may affect crews and lead them to be hesitant to make referrals, in fear of reprisals. On investigation it emerged that the person who had left messages was in fact the social worker managing the case, who had independently reported being alarmed at being unable to contact the crew. The social worker’s speech impediment appeared to have been misconstrued as aggression. We were able to clarify what had occurred and establish a process by which social work staff can use a central mechanism to access additional information after a vulnerable adult referral has been made. Additional learning focussed on understanding the perspective of people with speech impairments.

We received an account of a patient, a young man, who was placing a significant number of 999 calls. Enquiries were made which identified that the patient has autism and the 999 calls are a feature of dysfunctional behaviour. A care plan is being agreed to enable alternative contact should calls from this patient be received, so that it may be verified if there is an actual emergency.

Concerns were raised by the family of an elderly patient, triaged as a lower priority response after they fell and were left lying on a cold floor for over an hour with a wrist fracture. A comprehensive response was provided, which included data regarding call volumes and availability of ambulances. Information was also provided as to the action we are taking to improve response times. Some shortcomings were also identified in relation to the call management, and a reflective practice exercise was arranged for the staff involved.

Concerns were raised at the delay in accessing a patient and the fact that no one at the care home was aware that the family had contacted us. The care home have since prepared a written procedure for out of hours with a designated coordinator who will liaise with other agencies, and have initiated an End of Life Programme to include the details of other family members etc.

A patient was unhappy with the service he received from the attending ambulance staff. It was identified that the patient was frequently calling 999. After enlisting the assistance of the patient’s GP, who was unaware of the number of 999 calls, the patient’s community care package was reviewed to increase the level of support provided by carers and install a hoist. The patient has subsequently not placed any further 999 calls.

A patient raised concerns about the attitude of the attending crew, who responded to what they considered to be a lower priority call than it had been designated. A quality assurance review concluded that the call had indeed been over-prioritised and could have been referred for clinical telephone advice. An explanation of our triage and priority systems was made available. Reflective practice exercises were arranged for all the staff involved, in particular in relation to patients’ perception of what constitutes an emergency and de-escalation practice.

The caller was a first aider of 30 years experience who felt that it had not been made clear whether an ambulance was being sent, which lead to an altercation with the call handler. The quality assurance report concluded that the call handler could have better explained the procedure. We were able to clarify the systems used. The caller welcomed this explanation and advised that he would share this information with first–aider networks so as to increase awareness of the call management process.

A patient’s family was unhappy with the care provided and at the apparent lack of urgency of the attending staff, particularly at the time the crew were on scene; the family were concerned that the patient’s condition, later identified as severe bleeding in the brain, could have been alleviated if the crew had acted appropriately. A comprehensive response was provided explaining the clinical care provided and that the on–scene time was reasonable in the circumstances. The learning point was the need to better communicate with relatives so as to enable improved understanding of the care and treatment provided.

A dispute occurred when a crew attended a patient where a district nurse was already on scene. The ambulance staff considered that the patient was presenting with primarily social care issues, rather than a clinical emergency. The inter-professional dispute left the patient’s relative with an impression that the ambulance staff were being unhelpful. A comprehensive explanation was provided and an apology offered. The learning point was the need for both the involved agencies to work closely together to enable a patient-centred approach, in keeping with the clinical leadership model.

A diabetic patient felt that the attending ambulance crew had displayed a hostile attitude. It became apparent that the crew had not appreciated an understanding of the patient’s perspective and there had been a breakdown in communication which had only caused matters to become heightened. The case was put forward for inclusion in the ‘Excellence in Patient Communication’ training programme and a recommendation was made to our Education & Development department to invite input from specialist agencies who work with particular patient groups to contribute to care management protocols etc.

A patient under the care of a mental health unit was on ‘home leave’ and became unwell; the attending crew was unable to convey the patient to the unit, as there was no direct care pathway agreement in place. The crew offered to take the patient to the local A&E but the patient’s mother felt this was totally inappropriate and chose to arrange for the patient to be taken another destination. As an outcome following review, the local ambulance manager agreed to ensure ambulance complex staff were familiar with referral guidelines with the local Mental Health Assessment Team and to raise this incident at a liaison meeting with the local mental health provider Trust, to achieve an improved care pathway.

An ambulance was called to baby who was experiencing noisy breathing, although conveyance to hospital as a precaution was declined. Sadly, the baby died later that day. A comprehensive review concluded that it was impossible to know whether the baby would have survived if he had been conveyed earlier. The incident has however prompted a review, lead by the Medical Directorate, of consent procedures in relation to non-conveyance. The case also proved the benefit of inter-agency liaison, involving obtaining information from the Coroner’s Officer and the acute Trust concerned so as to enable an informed clinical view of the care provided.

Following an approach from a care home, we provided records relating to a specific incident. This lead to clarification of our practice and procedure in relation to Recognition of Life Extinct and the requirement for an emergency response in such situations. We later arranged for two paramedic staff to take part in a reflective practice exercise, also including the care home provider and the local authority. The outcome actions involved the care home provider introducing a number of measures to improve end of life and emergency management across all their care homes.

Examples of learning

Case studies

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