Mistakes between two organisations delayed ambulance

What happened

When Mr G was taken ill at home, his son dialled 999 for an ambulance. The ambulance service wrongly passed the call to NHS Direct. Mr G remained in pain and a second 999 call shortly after was again passed to NHS Direct. Mr G's son then called NHS Direct himself and after he spoke to an adviser, an ambulance was sent. The ambulance arrived to take Mr G to hospital an hour after his son had made the first 999 call.

Mr G needed emergency surgery to clear a blood clot affecting the blood supply to both of his legs. Very sadly, he died during the operation.

What we found

Mr G's symptoms did not match the criteria for passing the call to NHS Direct. The ambulance service should have put the call through to one of the clinician advisers in its control centre for further assessment. The ambulance service therefore did not follow the nationally agreed process when it transferred the two 999 calls to NHS Direct. It also spelt Mr G's name differently on each referral, so NHS Direct did not realise that a second referral had been made.

NHS Direct should have identified sooner that the calls did not meet its criteria. As a result, it took too long to send an ambulance to Mr G. However we found no evidence that the delay was a contributory factor in Mr G's death.

When Mrs W complained, NHS Direct's investigation was thorough and transparent. It identified and apologised for the mistakes that had occurred. We did not uphold the complaint about it.

The ambulance service's investigation did not identify the mistakes. We therefore partly upheld the complaint about it.

Putting it right

The ambulance service apologised to Mrs W and asked for and made changes to its electronic coding system to prevent similar mistakes happening again.