Summary: There was fault in the Council’s actions as the Council failed to take all the appropriate action when an emergency call was made and did not let Mrs C know that it had called an ambulance for her mother. The Council has agreed to apologise, pay a financial remedy and carry out a service improvement.

The complaint

1. Mrs C complains on behalf of her mother, Mrs D, who has died. Mrs C’s complaint relates to the Council’s emergency alarm response system. Mrs C says Mrs D’s alarm was activated and an ambulance was called but the Council failed to call Mrs C and did not send a responding officer.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

4. I have discussed the complaint with Mrs C. I have considered the information that she and the Council have sent and both sides’ comments on the draft decision.

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What I found

5. Mrs D was an older woman who lived at home. The Council provided her with a personal alarm which meant that Mrs D could press the button of the alarm if she needed help.

The contract

6. Mrs D’s contract for the alarm said the following actions should be taken when Mrs D pressed the alarm button:
• Speak to the customer, identify the reason for the call and the appropriate response.
• Agree with the customer the appropriate action.
• Send a member of the response team or, in the case of an emergency, summon the emergency services.
• Ther service provider reserves the right to contact the customer’s next of kin if there is a concern for the welfare of the customer at any time, although this will depend on the circumstances.
• The service provider agrees to provide a responding support team to attend, following calls that do not immediately require the attendance of the emergency services.

Call handling manual

7. The Council’s call handling manual set out how call advisers should respond to the alarms and said:
• If emergency services are needed then the adviser should put the call on hold while ringing 999 or ring the customer after calling the emergency services. They should re-assure the customer and ask them whether they want them to contact their next of kin.
• If the customer wants the adviser to call their next of kin then the adviser should put the call on hold until after they have spoken to the next of kin, so they can re-assure the customer that their son, daughter, friend is on their way.
• The adviser should pass the call to a responder and they can attend until the contact arrives or until the ambulance arrives.
• The adviser should ring the responder/contact every 30 minutes for an update until the emergency services arrive.

What happened

8. The following is a chronology of what happened when Mrs D pressed the alarm button.
• Time: 23:11. Mrs D activated the alarm. The adviser tried to speak to Mrs D but she did not respond. The adviser said they would ring Mrs D on the landline and, if they could not get through, they would send help.
• Time: 23:12. The adviser rang Mrs D and spoke to her. Mrs D said she felt very ill. The adviser asked whether Mrs D had fallen and Mrs D said she had not. Mrs D said she had pain in her back. The adviser asked whether Mrs D had rung 111. Mrs D said she could not breathe. The adviser asked whether she needed an ambulance. Mrs D initially said she needed a nurse, but then agreed she needed an ambulance. The adviser said Mrs D felt very ill, had a pain in her back and could not breathe so they would ring the ambulance service. The adviser told Mrs D that the ambulance service would ring her so she should pick up the phone when it rang.
• Time: 23:15. The adviser rang the ambulance emergency service and said Mrs D had pain in her back, could not breathe and was really not feeling very well. They gave Mrs D’s details. The ambulance operator asked for Mrs D’s telephone number and said they would ring Mrs D and ask some questions.
• Time: 00:31. The adviser rang the ambulance service for an update. The ambulance service said that an ambulance had not been assigned yet.
• Time: 01:52. The adviser rang the ambulance service for an update. The ambulance service said that an urgent ambulance had been arranged but the ambulance was not on its way yet.
• Time: 03:17. The adviser rang the ambulance service for an update. The ambulance service said the request was still ‘pending’ as there were no ambulances available. There were major delays in the area.
• Time: 05:02. The adviser rang the ambulance service for an update.
• Time: 05:33. The adviser rang the ambulance service for an update. The ambulance service said there were two ‘jobs’ on the same address. They said the ambulance had not arrived yet. The ambulance service said it had been logged as ‘back pain’ but they could not confirm so it ‘went’ as an urgent ambulance response. They said that ‘job’ had been closed and another ‘job’ was registered as high priority at 04:20.
• Time: 06:53. The adviser rang the ambulance service for an update. The ambulance service said the ambulance crew was currently on the scene. No update.
• Time: 07.03. The ambulance service rang Mrs D’s alarm. The ambulance service asked the adviser for the details of the next of kin and the adviser provided the details.
9. When the ambulance crew arrived, Mrs D had already died.

Mrs C’s complaint

10. Mrs C complained to the Council and said:
• The Council’s alarm service failed to inform her that an ambulance had been called for Mrs D and failed to send a responder to Mrs D despite the long delay in the ambulance.
11. The Council responded and set out the actions the adviser had taken. The Council upheld Mrs C’s complaint and said:
• In line with existing operational procedures, the call handler should have made further contact with Mrs D to discuss and agree what additional support she might need. This could have been for a responding officer to visit her or for a family member to be contacted. This did not happen.
• A formal investigation had been started into the actions and lack of actions of the officer concerned but, for reasons of confidentiality, the Council could not give further information.
• The Council said it was extremely sorry that its service fell short of what Mrs D should reasonably expect.
12. Mrs C was not satisfied with the response as she wanted to know why she was not contacted and why Mrs D died alone.
13. The Council responded and said it could not provide her with any further information beyond what it had already said because of the confidential nature of the investigation.

Analysis

14. I note that the adviser initially took the correct action. The adviser rang Mrs D when they received the call. The adviser spoke to Mrs D and decided that Mrs D needed an urgent ambulance. The adviser immediately called the ambulance service.
15. The adviser explained Mrs D’s medical issues to the ambulance service and the ambulance service said it would ring Mrs D. It appears, from the information I have, that the ambulance service made a request for an urgent ambulance response.
16. The adviser acted correctly in that they repeatedly called the ambulance service for an update in the hours that followed. I note that it took almost 8 hours for an urgent ambulance to arrive.
17. However, there was fault in the adviser’s actions as they did not follow the call handler’s manual in several aspects:
• The adviser did not put the call on hold while ringing 999 nor did they ring Mrs D after calling the emergency services. The adviser did not ask Mrs D whether she wanted them to contact her next of kin. I presume that Mrs D would have asked the adviser to ring Mrs C.
• The adviser did not ring Mrs C. The adviser also did not put the call on hold until after they had spoken to Mrs D, so they could re-assure Mrs D that Mrs C was on her way.
• Alternatively, the adviser should have passed the call to a responder and they could attend until the next of kin arrived or until the ambulance arrived. This did not happen.
18. Sadly, this meant that Mrs D was alone while she waited for the ambulance and sadly died alone. Mrs C has said she has been devastated by what had happened. She explained that she was Mrs D’s carer for 10 years and she had only recently decided to start using the Council’s alarm system. Mrs C thought that this would provide Mrs D with extra security in case there was an emergency. Mrs C said that, instead, she had to live with the knowledge that Mrs D was alone while she waited for the ambulance and that she died alone.

Remedy

19. The aim of the Ombudsman’s remedy is to put the person in the position they would have been if the fault had not happened. Sadly, that is impossible in this complaint. However, I do not underestimate the devastating impact the fault had on Mrs C and Mrs D.
20. Mrs C said that her main aim of pursuing the complaint with the Ombudsman was to find out what happened on the night that Mrs D died.
21. The Ombudsman and the Council are restricted in the information we can provide, but the decision statement contains all the information that can be shared with Mrs C so I hope that it answers some of the questions that Mrs C had.
22. I also recommend that the Council apologises to Mrs C and pays her £300 as a symbolic amount.
23. I also recommend that the Council reminds all relevant officers of their duties in contacting family members and responding officers, which are set out in the call handling manual. This will, hopefully, avoid another family experiencing what Mrs C and Mrs D suffered.

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Agreed action

24. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise to Mrs C in writing.
• Pay Mrs C 300.
• Remind relevant officer of their duties in contacting family members and responding officers, which are set out in the call handling manual.

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Final decision

25. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman