Decision Report 201507449

Summary

Mr C complained that the Scottish Ambulance Service (the ambulance service) did not ensure that someone attended his home to make sure he was safe after he took an overdose of paracetamol. When the ambulance crew arrived, they could not or did not gain access and left the house without taking further action. Mr C was later helped by a neighbour to attend A&E. Mr C said he was in a vulnerable situation and that the failings by the ambulance service were potentially life-threatening.

Mr C also complained about the way the ambulance service handled his complaint, including the time it took them to respond.

We took independent advice from a specialist in the training and supervision of healthcare professionals including paramedics. We found inconsistencies in the accounts of the staff involved and it is not clear why contact was not made with Mr C. The ambulance service failed to record their findings and action taken at the time. The evidence indicated a communication breakdown between the ambulance crew and ambulance control centre. We found that the ambulance service should have escalated the situation to the police in order to gain more information and access to the property.

In relation to the handling of Mr C's complaint, we found evidence indicating confusion amongst staff about who should deal with the complaint and how it should be dealt with. We were critical that Mr C's complaint to the ambulance service was initially managed as a concern and that it took over three months for the ambulance service to start an investigation. We also found that complaint staff did not reasonably inform Mr C about the delays and the reasons for these.

Recommendations

We recommended that the ambulance service:

• raise the failings identified with relevant staff;
• confirm that the guidelines being developed for dealing with similar incidents have been implemented and communicated to all staff;
• ensure ambulance crews record adequate information on patient report forms;
• provide an update on the actions taken to improve complaints handling; and
• apologise to Mr C for the complaints handling failures.