Ambulance delay added to new mum's anxiety and distress after home birth complications

What happened

Ms W gave birth at home. Everything was fine at first, however later that day she bled heavily and was uncomfortable. Her midwife visited and thought she had a prolapsed uterus. The midwife called 999 at 19.47 and again at 20.14, because an ambulance had not arrived. A clinical co–ordinator contacted the midwife at 20.24 and sent a paramedic in a rapid response vehicle to help until the ambulance arrived. The rapid response vehicle arrived at 20.51 and the ambulance arrived at 21.03 – one hour and 16 minutes later. Ms W was taken to hospital where she immediately had surgery. This was successful.

Ms W complained about the time it took for an ambulance to arrive, even though her midwife had made the seriousness of the situation clear in her 999 calls. Ms W was also concerned that the ambulance crew did not know where the hospital was.

The Trust responded to the complaint and carried out a serious incident investigation. It produced a root cause analysis report, which it shared with Ms W.

The Trust apologised to Ms W for what happened. It gave feedback to ambulance call handling staff regarding the errors they had made and the impact these had had. The clinical co–ordinator revised his approach to dealing with this type of call. In future, he will either talk to the healthcare professional sooner or will immediately upgrade the priority level of the call.

The serious incident investigation report made recommendations to address call handling errors and other issues, and the Trust acted on the recommendations.

What we found

We did not uphold Ms W's complaint because we consider that the Trust had fully acknowledged and apologised for what went wrong. We were satisfied that it had taken reasonable steps to put things right.

The Trust carried out a robust investigation and accurately identified the causes of the delay. It gave a reasonable explanation of why the crew were unsure of the best route to the hospital and how this was managed. It could have given additional assurance that crews have access to satellite navigation technology and can ask for support from the emergency operations centre if they need to.

The Trust did not realise that Ms W wanted compensation as one of the outcomes when it responded to her complaint. It therefore did not have the opportunity to consider this outcome. It agreed to consider compensation when it became aware of this and agreed to pay Ms W £350, the sum we identified as reasonable during our investigation.

Putting it right

The Trust paid Ms W compensation of £350.