Advanced Medical Priority Dispatch System
You said, we did - Advanced Medical Priority Dispatch System (AMPDS) issues. (PE - 28645)
You said
A complaint was received regarding a 90 minute response for an ambulance attendance following a serious fall. An ambulance was requested urgently as the patient was laying outside an experiencing severe pain. Five further calls were made by members of the public with an ambulance arriving 90 minutes later. The patient was taken to hospital where she was diagnosed with multiple fractures and a punctured lung. During treatment in hospital, the patient developed sepsis, causing her oxygen and pulse levels fell to a critical level. This complaint has also been reviewed by the Parliamentary and Health Service Ombudsman.
We did
From the investigation that took place it was highlighted that there were four calls received in relation to the incident. One error was identified on the second call where the incorrect protocol was selected, this was further reviewed to not affect the categorisation (outcome) of the call.
During the Parliamentary and Health Service Ombudsman investigation it was established that there was an error with the Advanced Medical Priority Dispatch System (AMPDS) protocols. This is the system that is used nationally to triage 999 calls for an ambulance response. Protocol 17 (used for falls) should have prompted the Call Handler to ask which part of the body was injured, and follow up questions, including if the patient was having any trouble breathing. The version of the protocol on the main system (called ProQA) did not do that even though the prompt is included on a ‘card copy’ version, which is available as a backup. This investigation highlighted a national system wide issue as the main AMPDS system and backup system questioning differs. It was concluded that had the correct question been prompted under the falls protocols then the calls would resulted in a faster response to the patient.
What this means
Although there were no specific failings, this complaint identified that the Trust had to rely on the AMPDS system. The problem was with the system itself rather than anything the Call Handler did. The issue highlighted in this complaint will be learning on a worldwide scale.
The Parliamentary and Health Service Ombudsman have raised this issue with the International Academy of Emergency Medical Dispatch, the company that created and manages the system worldwide. They have confirmed that they will include a fix in the next global update, which will be completed in July 2021 .The Ombudsman have also raised this with NHS England and Improvement to cascade the issue to all the ambulance services in England.