Questions raised over ambulance response times

THE case of a Gower pensioner who died at home while waiting for an ambulance has again raised questions about how the Welsh Ambulance Service (WAS) responds to calls.

Valerie Roderick’s son Tom and daughter Angela Jones said their mother’s GP had initially arranged an ambulance to take her to Singleton Hospital to be checked out.

They said they made two follow-up calls to the ambulance service as their mother, who had a chest infection and a bad back, was becoming increasingly unwell.

They said nearly five hours after the initial call by the GP their 83-year-old mother died in front of them.

Mrs Jones, who said at one point that she had “begged for help” while speaking to the Welsh Ambulance Service, attempted resuscitation before medical help arrived.

Mr Roderick said: “We accept the inevitability that at some time we will lose our parents but it is the frustration of frantically trying to do the right thing but coming up against a brick wall.”

A review last year into the way calls to the Welsh Ambulance Service are categorised provided insight into what happens when someone phones for an ambulance.

Immediate life-threatening calls are “red”, which should be reached within eight minutes; urgent but non-life threatening calls are “amber”; and non-serious calls are “green”.

Amber is then didvided into amber one for things like recent strokes and chest pain; and amber two for things like falls, and strokes which happened more than four hours previously.

Concerns had been raised that the amber category was too large and that, for some patients, resulted in waits that were far too long.

There are no time targets for amber and green calls.

The Welsh Ambulance Servicehas again offered its sincere condolences to Mrs Roderick’s family and has pledged to investigate the case, but it has not disclosed which category or categories the calls made on the day she died were placed in.

Call handlers at one of three Welsh Ambulance Service contact centres categorise incoming calls based a series of questions, known as protocols.

A second process determines how the ambulance service responds to that particular call.

Calls can be re-categorised if a patient’s symptoms escalate.

Between April 2016 and March 2018, a total of 536,260 calls were classed as amber in Wales.

Of those, 314,112 patients waited less than 20 minutes for an ambulance, and 465,749 waited less than an hour.

However, that left 70,511 patients who waited more than an hour, and of those, 6,017 waited more than five hours.

In January, the family of an 86-year-old Mary Duffy, from Swansea, said they faced a wait of nearly two days for an ambulance after she fell and broke a leg. It is not clear how the initial and then subsequent calls were categorised.

But do longer waiting times inevitably mean a worse outcome?

The review described this relationship as “complex and uncertain”.

It said for people suffering cardiac arrest, there was evidence of a relationship between delay in resuscitation and survival.

But it added none of the evidence available showed a direct relationship, in terms of mortality, between ambulance response times and patient outcome for other conditions – life-threatening or not.

This may seem counterintuitive, although the review did acknowledge a link between timely care and outcome for stroke patients.

A key finding of the review was that the current categorisation system in Wales, which was introduced four years ago, was resulting in paramedics reaching the sickest patients first.

And, while concerns were raised about the process and the long waits experienced by some, it was the resources available to handle the calls and treat the patients that were more problematic.

While Welsh Ambulance Service staff numbers and its budget rose during the two-year review period, so did the number of calls.

But the number of staff available on any given day rarely matched the planned capacity.

Sickness absence was high, there were delays handing over patients at busy hospital emergency departments, and hours were lost in getting ambulances ready in time – for example re-stocking medication – for the next callout.

These factors caused 226,985 hours to be lost over two years.

Contact centre staff interviewed as part of the review wanted to have more clinicians present with them to provide judgement, to give callers an estimation of how long they would have to wait and, where appropriate, to suggest other treatment options.

Staff felt the public didn’t know enough about these other treatment options, with one employee describing minor injury units as “the best kept secrets of the health service”.

Neath Port Talbot Hospital has a minor injury unit. Singleton Hospital’s is temporarily closed.

While the Welsh Ambulance Service’s current system has been credited with focusing on red, life-threatening calls, its staff expressed frustration with the number of alcohol intoxication calls from the public.

They also felt they didn’t know enough to deal with callers in mental distress.

The review made eight recommendations, including that the Welsh Ambulance Service’s planned resources are sufficient to meet demand, that the longest waits reduce, that contact centres have a sufficient number of clinicians, and that health boards reduce emergency department bottlenecks.

It also recommended eight further pieces of work, including three by the chief ambulance services commissioner Stephen Harrhy, who commissioned the review.

When the review was published last autumn, Stroke Association Wales director Llinos Wyn Parry said she believed ambulance crews should have a response target for stroke patients.

“We’re concerned that without a target for getting stroke patients to hospital, we won’t see an improvement in the emergency stroke care received in Wales,” she said.

Back in Gower, the family of Mrs Roderick was one of many in the area who contributed towards a £60,000 target for a fully-equipped 4×4 for the on-call fire station based in Reynoldston – two miles from their Scurlage farm.

Its crew have medical training and can be tasked by the Welsh Ambulance Service to attend red and amber one calls.

Crew members were first to arrive at the scene on the day Mrs Roderick died, but her family wonders why they didn’t appear to have been alerted sooner.

The family has also suggested that further funding could potentially be sought locally to pay for a standby ambulance in Gower.

That should not be necessary, according to Gower councillor Richard Lewis, who said the on-call fire station should be given a bigger role in dealing with appropriate medical emergencies.

“We raised all that money for the new vehicle, and the boys there are wonderfully trained,” he said.

Cllr Lewis praised Welsh Ambulance Service’s paramedics but said that, in his view, the way the system was being managed was to blame for long amber waits.

“It is a huge worry for Gower,” he said.

The Local Democracy Service asked the Welsh Ambulance Service what it had done to implement the recommendations of the review since it was published.

A spokeswoman said it was working closely with the commissioner and the emergency ambulance services committee to address the findings.

“There are a number of actions in train, including a demand and capacity review, which will begin shortly,” she said.

“This will model the precise number and location of ambulances and response cars needed across Wales, ensuring that we have the right resources available to meet the demand with which we are faced, both in relation to the timeliness of our arrival and the quality of care and patient experience that we want to deliver.”

She added: “In the meantime, there is significant work under way to maximise the resources we have available to respond to calls, including refreshing our rosters, introducing new arrangements to tackle long waits for ambulances handing over patients at hospitals and making sure that our people have the right skills to care for more patients at scene.

“In addition, and in line with the recommendations of the review, we have increased the number of clinicians in our clinical contact centres from 33 to 48 in the last six months.”

We also asked commissioner Mr Harrhy if the further pieces of work suggested by the review had got under way, but a spokeswoman was unable to respond at the time of going to press.