Attachment 3 - East Midlands Ambulance Service NHS Trust

Transcription

Formal Complaint Proforma Ref: FC/022/13
FC/022/13
Section A: To be completed on receipt of Formal Complaint by admin
Date Received: 04 June 2013
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 21 May 2013
Patient Name:
Deceased? No
How Received: Email
Relationship to patient:
Their reference:
Logged by:
Incident Location:
Brief details of the
Non provision to unconscious pt who then suffered a miscarriage.
complaint:
Type of Complaint: Call Management (Timeliness, Activation/Response)
Division/Area: A&E Cont. Lincolnshire. (A/E Control)
Investigation Officer:
(15 working days)
Date for Investigation conclusion: 01 July 2013
(20 working days)
Date to post response letter: 02 July 2013
Section B: To be completed by the Investigation Officer
Staff involved TAS Team
& Station: EOC Lincoln control
Initial grading
& Rationale:
Was the 999 call correctly coded?
Scope of What is the protocol when a call is coded this way?
Investigation What was the timescale of the Clinical Assessment call back?
(must include all
complainant
concerns) :
Was the Clinical Assessment complete?
Was the advice given by the Clinical Assessor correct?
Why was the patient not conveyed?
Contact made with complainant:
Expectations of Complainant: Clarification
Date OSM/PTL/Manager informed: 24/6/13
Staff involved informed:
Immediate actions taken: None
The Investigation Officer’s Report
FC/022/13
Chronology of Events:
Date and Time
21/5/13 04:02
04:17
Events
999 call 5559720 received to a female ’… having a miscarriage yesterday – fallen over’
Crew was immediately assigned to the call but stood down when the call was coded as
a G4
Clinical Assessor (CAT) called back to assess the patient. CAT advised patient saw
GP in morning as the patient did not want to travel.
Evidence Gathered:
999 Call audit
Clinical Assessment Audit
CAD SOE 559720
MP letter
WAV file 999 call
Analysis of Care Management or Service Delivery Issues:
A 999 call was received to a patient who had fallen. Her partner provided information for the
Accredited Medical Priority Dispatch System (AMPS) so that the condition of the patient could be
established. The partner stated that the day previously, 20/5/13, the patient was seen at hospital due
to a miscarriage in progress. That patient had been 10 weeks pregnant at time of loss.
From the information provided, by the partner, the call was coded G4. This is classed as suitable for a
Clinical Assessment to ascertain the best treatment for the patient. The 999 call has been audited and
found to be correct in all actions under the AMPDS system.
A Clinical Assessor (CAT) called back the patient within 15 minutes of the 999 call. This was within
the required 60 minutes for a G4 call. The CAT confirmed patient had been miscarrying for 24-36
hours before the fall.
Audit of the call states ‘…The miscarriage had been on going for the previous 48 hours and the patient
had been seen in hospital…‘ for this. The patient ‘…did not want to go to hospital now and as she
had recovered from her fall..’ The Audit confirmed that advice to rest and seek help from GP in the
morning was correct in these circumstances.
Conclusion:
The call was correctly coded and sent to the CAT team for Clinical Assessment. This complied with
the Protocols for a call coded G4.
The timescale for callback on a G4 call is within the hour. The patient received a call back within 15
minutes.
An audit of the Clinical Assessment confirms that the Clinical Assessor acted correctly, and the advice
given was appropriate. Patient did not want to travel to hospital so advised to see GP in morning
Recommendations:
No recommendations
Sign Off (include dates)
Date report sent to Investigation Manager for approval: 17/7/13
Date feedback given to complainant:
Response letter sent:
Sent to administrator:
Patient or relative willing to be approached for their ‘story’ for
the EMAS board? Have you asked? Why? Why not? What did they say?
FC/023/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 01 June 2013
Deceased? No
How Received: PALS.office
Their reference:
Logged by:
Incident Location:
Amb crew attended a pt in a care home. Another resident followed the
crew into the pt bedroom and the P1 was witnessed physically mancomplaint:
handling the other resident out of the bedroom.
Type of Complaint: Inappropriate Actions (Other)
Division/Area: # A&E Derbyshire (A/E)
(15 working days)
02
July
2013
(20 working days)
Date to post response letter:
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Moderate 6 – Involves crew interaction with a Vulnerable Adult, so safeguarding
concern, unlikely to reoccur
Why did the crew member move the resident?
Were the Crew member’s actions appropriate for the situation?
Was there another option other than crew moving the resident?
What was said after the incident to the patient and staff?
What is EMAS doing to promote awareness of dementia with its crews?
27/7/13
Expectations of Complainant: Awareness of residential home patients
Date OSM/PTL/Manager informed: None
Staff involved informed: 26/7/2013
FC/023/13
Date and Time
1/6/2013 13:52
13:53
13:58
14:34
Events
999 call (CAD 5585795) received to patient semi-conscious and vomiting.
Crew assigned and the call is coded R2, requiring an 8 minute response to scene.
Crew arrive on scene within the 8 minute required response time.
Crew left for hospital with patient.
Evidence Gathered:
CAD SOE
PRF
Record of conversation with Home Manager
Crew email
Case progress sheet
CRT induction training word document
DB advice on Dementia strategy wording
At 13:52 on 1/6/13, a 999 call was received to a female semi-conscious and vomiting. This was coded,
using the Accredited Medical Dispatch System (AMPDS) as a R2 call, requiring attendance within 8
minutes. A crew were assigned, and arrived within the required time.
On arrival, crew were taken to the patient (Pt) who was in a general room. Whilst treating the patient, a
resident with dementia, entered the room. The Resident believed that this was his bedroom. The Pt
began to deteriorate, and T1 went to leave the room to get more equipment. T1’s exit was blocked by
the resident who was stood by the door. T1 asked resident to leave the room. The resident did not
appreciate the way in which he was being spoken to, so refused. T1 then physically turned the
resident and moved him into the hallway as patient was deteriorating. T1 explained ‘..what was
happening and why so (they) could continue treating the patient..’ Staff stated the resident looked
unsteady on his feet for a couple of steps after this.
The patient was then taken to the ambulance, and she informed the crew that the resident ‘…would
regularly try and get into her room and she was frightened of him.’ At this point T1 became aware that
the resident had dementia. T1 apologised, twice, to the Resident and staff for taking this action. The
Manager has accepted T1s apology, but would like awareness raising regards to dealing with Care
Home Residents. The Manager would like to thank the crew for attending this patient.
East Midlands Ambulance Service (EMAS) Dementia Agenda 2011/12
EMAS are committed to the Dementia agenda. During 2011/12 we delivered face to face Dementia
education to all staff and this was supported by a communications campaign raising awareness.
EMAS have also recruited a large number of Dignity champions who support the work and
dissemination of the Dementia agenda. Our aim for 2013/14 is to focus on improving the safety and
experience of patients with dementia by facilitating early identification and appropriate referral.
Conclusion:
Why did the crew member move the resident?
The patient was deteriorating and T1 needed to get the stretcher to transport to hospital as soon as
possible. Due to the position of the Resident, T1 had difficulty doing this. T1 did not realise that the
Resident had dementia, and moved him physically when the Resident refused to move. The Resident
was turned and moved into the hallway by T1.
Were the Crew member’s actions appropriate for the situation?
It is never ideal that someone be moved against their will by Ambulance Staff. T1 was concerned for
the patient’s condition and responded to the issue by moving the resident. T1 felt this was a time
sensitive situation, he took the action he deemed appropriate for the well-being of his patient at time.
T1 used no more force than was necessary to move the resident. T1 explained, and apologised for
this action, at the earliest point to those involved.
Was there another option, other than crew moving the resident?
Yes. Using a proactive approach when arriving, the crew could have given guidelines to the staff on
how they wanted the scene managed. The Staff would then have been actively charged with the
resident in question. Staff could then have used their knowledge to convince resident to leave of his
own volition, allowing crew unimpeded access to treat the patient.
What was said after the incident to the patient and staff?
The patient informed the crew that this resident regularly tries to get in her room, that she was
frightened of him. T1 then realised that the Resident had dementia. T1 then ensured he apologised
to the resident and the staff. The Manager has accepted his apology and thanks the crew for
attending the patient.
What is EMAS doing to promote awareness of dementia with its crews?
EMAS has an active, and continuing program of awareness regards to dementia. All staff have
received training and this is supported by a communications campaign raising awareness
Recommendations:
Report to be shared with the attending crew to consider active involvement of Care Home Staff
regards scene management on arrival at a call.
Action: Email copy of report to crew
For: Investigations officer (AD)
Deadline: 5/8/13
Evidence: Copy of Email
Date report sent to Investigation Manager for approval:
FC/024/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 31 March 2013
Patient Name:
Deceased? Yes
How Received: Letter
Their reference:
Logged by:
Incident Location:
Pt with advanced prostate cancer collapsed onto the floor in severe pain.
Family rang 999. Rang 999 again 40 minutes later & was told that the call
Brief details of the had been downgraded & cancelled. Asked again for an amb & was told it
complaint: was bank holiday so all the ambulances were busy. Amb finally arrived
after over 3 hours. Pt never tried to walk again before he died 12 days
later.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
A&E Lincolnshire Control
What were the original codes of calls received?
Scope of What was the patient’s family told during the call?
Investigation Was the call downgraded? If so, why?
(must include all
complainant
concerns) :
What CFR/Fire responders were available at time of call? If so, was call coded as
appropriate for them to attend?
Expectations of Complainant:
Date OSM/PTL/Manager informed:
No – due to timescales investigation commenced to provide
response
Letter of explanation
No
Immediate actions taken:
No
FC/024/13
Date and Time
31/3/2013
15:28
16:16
18:43
19:26
19:28
19:30
20:06
Events
Lincolnshire Occurance Book (RL) notes problems with defibrillators not
adjusting to British Summer Time that day (Easter Sunday). From Midnight
East Midlands Ambulance Service (EMAS) was in stages of Capacity
Management Plan (CMP) ranging from 1 to 4 at stages. CMP is brought into
action when call level outstrips EMAS resources available to attend.
Grimsby Hospital has CT Scanner failure – requiring all patients needing CT
Scanner to be taken to Lincoln resulting in delays for crews to clear such
details. Hospital Liaison officer (HALO) assigned to Grimsby Hospital to
assist Crews clearing at A/E. Grimsby Hospital update EMAS regards staffing
issues. Issue passed to the EMAS Tactical Team regards to divert in place at
Hospital.
CMP 1&2 confirmed as in place. Currently 25 uncovered emergencies and 6
out of time urgents to be reviewed at 17:30.
This requires all G1 and G2 calls be given an additional speech explaining
potential delays. Triage team to call back patients on G4 calls within the hour.
RL notes that Triage Clinician reporting sick – No triage Clinician night shift
Lincoln Control.
999 call received call to an address in ------- to a male who had collapsed with
prostate cancer. This was from Patient’s daughter who was not at the same
address as the patient. CAD 5441017
Call was taken through AMPDS and coded G4 response – 26A07. This
coding requires that the Call Taker (EMD) pass the call to the Clinical Triage
Team and an ambulance is not initially sent.
EMD called patients wife back and went through AMPDS again. Coded for
Triage – EMD advised wife call would be passed to triage; and gave CMP
script to explain delays.
nd
2 999 call for the patient.
Again coded G4 call 26A07. CAD 5441099. EMD manually upgraded call to
G2 – reason not known and cannot confirm if action correct as no Cybertech
call accessible. This is same code as original call but call now upgraded to a
Blue light response to attend within 30 mins. Not known if CMP speech given
to caller.
nd
The Dispatcher closed down this 2 call as they were now attending the
address on blue light using the original call. The coding of this call was not
suitable for a Community First Responder (CFR) to attend as it was on the
sick person card with no alteration in alertness or breathing problems – as per
EMAS/CFR policies. Additionally, unable to assign Fire Co-Responders as
Fire control require that the call code R1 or 2 only – these are immediately life
threatening calls requiring an 8 minute response.
20:47
Call to patient’s home number from EMAS Clinician extension – call lasted 5
minutes NB. Due to issues with Cybertech the not all calls can be downloaded
or listened to for the investigation file at this time.
Triage clinician called address and took family through a Clinical Telephone
assessment. Clinician authorised further upgrade of call to a G1 response
which puts it as a higher priority call than outstanding G2 calls waiting for
ambulances to be assigned.
21:01
21:06
21:06
21:35
21:45
22.20
23:47
23.48
Reason for upgrade was ‘Fall, been on floor for over 80 mins – in severe
discomfort and pain – has prostate cancer and is cold to touch’. Pt was
reported to be conscious and alert. FRV attending out of time urgent mobile
in Skegness but can only divert to R1 or R2 calls only.
CMP 1 & 2 revoked. Standard operating procedures apply.
Dispatcher presses Res/Alloc button for first time since call had been
upgraded at 20:06. This button allows the Dispatcher to see which crews are
available for allocation for this call and should be pressed regularly to
evidence delays in assistance to a patient. Only vehicle available was within
its meal break window and could not be assigned to a G2 call.
Dispatcher note ‘K0 DCA’ this is a code for no available resources in the area.
Res/alloc show one vehicle available at this time but the RL shows that this
crew was out of order due to a flat tyre.
Double crewed ambulance assigned 21:35 to respond on blue lights
rd
3 999 call received – CAD 5441303. Call now stating patient on floor
having fallen. Call not coded by EMD, not taken through AMPDS so not
known if G2 was still an appropriate response. EMD did not establish
conscious; breathing or alert status. If this had been established and there
were changes in patient condition this information may have resulted in an
opportunity to escalate to a higher priority call
Arrived with patient.
DCA crew call Triage Co-ordinator – ‘spoke with crew – pt does not want to
travel to hospital crew states fall no injs noted ..’ based on observations given
the Co-ordinator agreed with pt request to stay at home.
Called clear
Evidence Gathered:
SOE CAD Call 1
SOE CAD Call 2
SOE CAD Call 3
Cybertech call 1 – unable to download
Cybertech call 2 – unable to download
Cybertech call 3 – downloaded
Daily Performance Review 31/3/2013
CFR attendance categories for Lincolnshire Responders
EMAS Daily performance Review 31/3/2013:
The A8 performance for EMAS, which is for life threatening calls which require an 8 minute response,
should drop no lower than 75%. On this day the EMAS A8 response level had dropped to 63.88%.
These calls should then be supported by a vehicle able to convey the patient within 19 minutes (A19).
This response should not drop below the 95% requirement, on this day EMAS’s A19 level had
dropped to 87.81%.
Regards to non-life threatening calls, classed as G1 (response within 20 minutes) and G2 (response
within 30 minutes), the level had dropped below the required 95% down to 59.69% and 62.64%
respectively.
At 17:41 the Lincoln Control Resource Log (lincs TL) performance update stated: Currently
experiencing high demand with in the division. (Holding unassigned) 2 x R2 Calls; 1 x G1 Upgraded
Urgent; 3 x Urgents – 2 out of time; 999 92% on 1373 calls; A8 74.18%; A19 87.97%.
21:06 after CMP revoked the lincs RL states: CAT A8 73.99% A19 86.99%; 999 calls handled 1673
service level 93%.
(Staff shortfalls):
Grantham DCA 1 x 1400 – 0200
Sleaford DCA 1 x 1830 – 0630 (late start 1900)
Solo (FRV)
East PTL 1 x 1900 – 0700
SE PTL 1 x 1900 – 0700
Grimsby RRV 1 x 1930 – 0730
East
Grimsby 1 DCA x 1300 – 2000
Skegness 1 DCA x 1830 – 0630
Skegness 1 DCA x 1900 – 0700
Louth 2 DCA x 1900 – 0700
Spalding DCA 2 x 1900 – 0700
Control – BBEOC
Dispatcher 1 x 2000 – 0800 – backfilled with Dispatch Trained EMD
Total Grimsby/Skegness and Louth shortfall: 4 x DCA and 2 FRV
The drop in performance relates to an increase in calls coded as R1 or R2 on the day by 12.54% from
the previous week. Due to this, in combination with the problems under review by the Tactical Team
at Grimsby Hospital, and staffing shortfalls in the area, increased the pressure on the available
planned resources for day in question.
Conclusion:
This call was on Easter Sunday where call volume outstripped EMAS resources throughout the day.
From Midnight through to 21:01hours, EMAS was in various stages of its Capacity Management
Plans. This is a staged strategy used by the service to ensure medical attention is prioritised for life
threatening emergencies. The higher the number of calls across EMAS the higher the CMP
instigated. This results in increased restrictions and delays in attending lower graded calls, such as
G1 and G2. At the time of this call, EMAS was in CMP 1&2 requiring EMD’s to notify callers of delays
with a pre-written script.
The initial call received was at 19.26 and a crew were on scene at 22.20; a response time of 2hrs 54
minutes. This call was not assessed as immediately life threatening.
The delay in attending this call was due to excessive calls throughout the day resulting in the
activation in the Capacity Management Policy on a Trust wide perspective. In the ------------- area
additional pressures placed on EMAS with delays at the hospital. An unexpected shortage of 4 double
crewed ambulances and 2 Fast response cars was also a contributing factor to the extended response
time for this call.
What were the original codes of calls received?
Call 1 was coded as Green4 (G4) (Clinical Assessment by phone within 1 hour) at 19.28; Call 2 at
20.06 was also a G4, but upgraded manually by the Emergency Medical Dispatcher (EMD) to G2
(Face to face response within 30 minutes). The Triage Clinician continued to make the assessment
call to the patient following the G4 call coding. The call was further upgraded to G1 (Face to Face
response within 20 minutes) by the Clinician; Call 3 was not coded as the caller was not asked for
information using the Accredited Medical Priority Dispatch System (AMPDS).
Due to the volume in calls received at the time, had this upgrading occurring earlier would not have
affected the arrival time of the crew. Due to the CMP in place at the time, no vehicles were available
for any calls coded G1 or G2 in the area. Staff shortfalls in the area of 4 DCA and 2 FRVs may also
have been a contributing factor for the unavailability of resources at that time.
What was the patient’s family told during the call?
The wife of the patient was informed that EMAS was experiencing high demand and the CMP speech
was given. No mention was made by the daughter, or wife, that the patient had fallen so the call was
dealt with as a collapse. Due to technical issues with the software recording system (Cybertech) at
present it has not been possible to listen to the all the calls. Due to this we are currently unable to
ascertain what was said on Call 2 or the Clinical Assessment call.
Was the call downgraded? If so, why?
The call was not downgraded. All calls were gradually upgraded in priority as additional information
came through from the callers. Unfortunately, as the number of calls exceeding the resources EMAS
had to respond there were delays in attending calls other than R1 and R2, immediately life
threatening.
What CFR/Fire responders were available at time of call? If so, was call coded as appropriate
for them to attend?
CFR area voluntary service and no resources were on duty at the time of the call. It was not a suitable
call for Fire Co-Responders in the area due to the call coding. Fire Co-Responders are only active
where call coding is R1 or R2, and do not attend falls so they would not have been assigned this call
coding either as per agreed protocols.
We cannot say what would have happened on the third call. However, if the call had been suitable for
an upgrade to R2 the EMD would have been able to utilise the fall card. All calls are coded based on
the information provided by the caller.
Recommendations:
1. Consideration should be given to a Dispatch Qualified EMD being utilised during CMP to check
res/alloc on waiting calls.
Action: Identify what support is in existence and review resources available to support
For:
Evidence: Copy of the report
Deadline: 1/9/2013
This includes the resources available to the Dispatchers monitoring such an increase of calls
that need processing.
2. Action: Request that the 2nd and 3rd call receive a call audit.
For:
Evidence: Copy of call audit
Deadline:
Learning Outcome
Additional pressures are placed on EOC staff during times of high demand when insufficient resources
are available to be deployed.
FC/025/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: Email
Their reference:
Logged by:
Incident Location:
Pt found collapsed on the floor. Pt had shallow breathing, fixed eyes &
had bleeding from the back of his head. Family rang 999. Amb took over
complaint:
2 hours to arrive.
Type of Complaint: Delayed Response (Timeliness, Activation/Response)
(15 working days)
(20 working days)
Staff involved Lincoln Control A&E
& Station:
Initial grading
& Rationale:
Scope of
Investigation What was the call graded as?
(must include all
complainant
concerns) :
What is the standard response for this code?
Why was the ambulance delayed?
Expectations of Complainant: Explanation of delay
Date OSM/PTL/Manager informed: n/a
Staff involved informed: n/a
Immediate actions taken: none
FC/025/13
Chronology of Events: 24/3/13
Date and Time
15:59
18:32
19:54
19:55
19:56
20:03
20:30
20:31
20:56
21:06
Events
Division out of (Capacity Management Plan) CMP 3
Service Level reported by Duty Manager (DM):
Clinical Assessment Team (CAT) A8 75%; A19 85.83%
Calls handled 1459
Service Level 92%
999 call received to --- year old male who had fallen.
Patient was unconscious and breathing so call coded Red 1 (R1) 8 minute response
time 20.04.
Community First Responders (CFR) shown as off duty
Crew allocated as patient is noted to be conscious and alert.
Call is recoded as per guidelines to Green2 (G2) for 30 min response for face to face
contact.
nd
2 999 call received coded G2
3rd 999 call received to male fallen – coded G2
Crew diverted to higher priority call
th
4 999 call received – still coded G2
Crew assigned and arrived scene 21:37.
st
Out of performance reasons logged – 1 crew diverted to R2;
nd
2 crew diverted Red backup in Grimsby.
Evidence Gathered:
Call Audit 5424080 – correctly coded
SOE CAD call 1
SOE CAD call 2
SOE CAD call 3
SOE CAD call 4
PRF 5424080
Lincs RL
Daily performance review
Divisional Shortfalls:
8 x Fast Response Vehicles across the County
3 x Double crewed ambulances
Performance
Call volume of all categories showing an overall increase of 5.04% on previous week.
At 19:54, a call was received stating that a --- year old male was unconscious after a fall. Due to this
the call was coded R1. This is the highest coding achievable under the Accredited Priority Dispatch
System (AMPDS). A crew was assigned at 19:56. As the call taker obtained more information
regards to the patient’s condition from the caller who reported that the patient was no longer
unconscious. Due to the responses given the call was downgraded to a G2 call, ambulance response
within 30 minutes. Call audit has shown action by the call taker to be fully correct.
With the downgrade of the call the crew assigned were stood down and diverted to a R2 call. This
was a call assessed as immediately life threatening and takes priority over green calls and this patient.
Three further calls were received for this patient. All calls were coded as G2 as the patient was
conscious, breathing and alert. Community First Responders Desk (CFR) attempted to assign a local
responder to the patient but there were none logged on duty at the time.
During the course of the call, the Dispatcher checked the Resource Allocation (Res/Alloc) button ten
times. The Res/Alloc is a facility the Dispatchers use to ascertain which vehicles are available to
attend this detail. At 20:18 the Dispatcher assigned a vehicle to the call, but again had to divert to a
higher priority call. This conforms with the Dispatch Protocols and was the correct action.
A crew arrived on scene at the call at 21:37 and transported the patient to the hospital. The total time
taken from original call was 1 hour and 43 minutes. This was 1 hour and 13 minutes later than the G2
coding requires.
The Lincolnshire Resource Log (RL) has entries relating to serious weather conditions throughout the
day. They relate to drifting snow and impassable roads resulting low performance for the Lincolnshire
area. Notes also made regards to vehicles getting stuck in snow during the shift.
Conclusion:
The call was originally coded as a R1 (8 minute response) this was then, correctly, recoded to a G2
call when the patient was confirmed as conscious, alert and breathing. All subsequent calls were
coded G2 with no change reported in patient condition. A G2 call is a requirement for an ambulance to
attend the address within 30 minutes. This target time was not met.
The reason for the delay was due to a shortfall of 8 Fast Response Vehicles and 3 Double Crewed
Ambulances across the Lincolnshire area. This was additionally hampered by drifting snow banks;
impassable roads and vehicles getting into difficulties with the snow with a 5% increase in the call
volume received.
Recommendations:
No recommendations,
FC/026/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
GP rang 999 for --- year old pt believed to have sepsis. Waited nearly 2
hours for the amb, ran out of Oxygen and very unhappy that a trained
complaint:
medical professional has to go through the same questions in EOC.
Type of Complaint: Delayed Response (Timeliness, Activation/Response)& Call management
Division/Area: A&E Cont. Nottinghamshire (A/E Control)
(15 working days)
04
July
2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Why was there a delay in responding to this incident?
Is there anything the GP could have done to achieve a higher priority response?
Why is there a need to ask a Medical Professional questions which may not be
deemed appropriate when making a 999 call?
04/07/13 – Dr not available, 12/07/13 Dr not in calling 16/07.
16/07/13 1220hrs spoke with Dr.
Expectations of Complainant: To know what can be done differently.
FC/026/13
Chronology of Events: Taken from calls 5427725, 5427863 and 5427918 received in to the
Emergency Operations Centre (EOC) on 26th March 2013 and the Patient Report Form (PRF) details.
Date and Time
11:15
11:17
11:47
12:12
12:13
12:34
12:36
12:36
12:36
12:50
12:50
13:00
13:14
13:24
13:56
Events
First call received 5427725, -------- year old male had collapsed, possible seizure – Call
was correctly coded 31A03 Green4 (G4) then overridden to Green2 (G2) due to a
Doctor/Health Care Professional (HCP) with patient. Doctor spoke with call taker.
Call sign HCP incorrectly allocated as a resource by Dispatcher to the job.
Resource Allocation (Res/All) accessed and checked by Dispatcher – No resource
available.
Second call received 5427863 – Male passed out. This was correctly coded as 31A03
G4 then overridden to G2 due to HCP with patient. (Call not available for download).
Doctor gave information over telephone. Initial call was from GP receptionist. Call taker
asks if there is a Defibrillator on site.
Resource Allocation (Res/All) accessed and checked by Dispatcher – No resource
available.
Third call received 5427918 – Difficulty in breathing. This was coded correctly as
06D02 Red2 (R2). The Doctor was the caller.
The Dispatcher correctly shuts down call two as a duplicate to the original detail
5427725.
The Dispatcher correctly shuts down call three as a duplicate to the original detail
5427725.
The Dispatcher upgrades the first call 5427725 to Red to match the higher response
gained on call three 5427918.
Resource allocation (res/all) list accessed by Dispatcher and Double Crewed
Ambulance (DCA) call sign 3520 checked for current availability due to returning for
lunch break.
DCA 3520 allocated to attend
DCA 3520 arrives at scene of incident.
DCA 3520 leaves scene of incident and conveys patient to Hospital.
DCA 3520 arrives at Hospital with patient.
DCA 3520 call clear from this detail.
Evidence Gathered:
•
•
•
•
•
•
Sequence of Events (SOE) for Emergency Calls 5427725, 5427863 and 5427918.
Electronic Patient Report Form (ePRF) in relation to call 5427725.
Voice recording of call 5427725 and 5427918. Call 5427863 available for listen only.
Call audits for all calls.
Dispatch Deployment Framework Sec 13.0
Copy of the PDM SOE
The first call was received into the Emergency Operations Centre (EOC) at 11:15hrs. This initially
came from the Doctors Receptionist (GPR). When it became apparent they had no information, the
Doctor (GP) was put on the phone and the call was then processed through the Advanced Medical
Priority Dispatch System (AMPDS) gaining a Green2(G2) 30 minute response.
AMPDS is a set of questions relating to a Chief Complaint used to rule out priority symptoms. Once
questions are answered, AMPDS gives the most appropriate response at that time. These questions
are asked of the Public, Fire, Police and Doctors when making or passing a 999 call.
The Dispatcher allocated the call sign HCP to this detail indicating there is a Defibrillator on site. This
information had not been clarified by the call taker.
A second call was received at 12:12hrs stating a --- year old male had passed out. Initially the caller
was the GPR, the phone was then passed to the GP. This call was processed through AMPDS and
received the same response as the first call G2. The GP was asked if there was a Defibrillator at the
Surgery. At this point the GP was not happy over the time being taken to send an Emergency
Ambulance to her patient.
The Dispatcher tried to allocate a vehicle response to the call at 11:47hrs, there were none available.
At 11:50hrs, there were 6 G2 calls in the area waiting to be allocated a crew.
At 12:34hrs, a third call was received into the EOC. The patient was now having difficulty breathing.
The information given was provided by the GP and an upgraded response of Red2, an 8 minute
response was now required.
By 12:38hrs, a note had been made in the Duty Manager’s Sequence of Events (SOE) that in the area
of this call, the Trust were waiting to assign crews to 2 x R2 calls and 9xG2 calls.
The Dispatcher accessed the Res/all function at 12:50hrs and assigned this job to a crew who were
travelling back to base for their rest period.
At 13:00hrs the crew arrived at the surgery.
The patient was taken to Hospital at 13:14hrs and the crew became clear from this detail at 13:56hrs.
Conclusion:
Allocating the call sign HCP to a Green2 call does not stop the clock in relation to response times. The
call sign HCP does not act as a conveying response so 30 minutes after the first call was received, we
would have needed a crew on scene in order to arrive within our intended time limits.
There was a delay in responding to the calls due to all other resources being fully committed in
attending to, or being diverted to higher priority emergencies/backups.
The calls were prioritised as appropriate. When calls are received into the Emergency Operations
Centre (EOC), they are coded using a nationally defined set of priorities based upon the information
given over the telephone. The calls are assessed and prioritised in order of clinical need. At the time
we received the first two calls into the EOC, the information given did not require an immediate 8
minute Ambulance response and instead, was allocated as a 30 minute response.
Once the call was upgraded to a Red2 (R2) 8 minute response, the next available crew was allocated
to attend.
Although the patient has been assessed by a Medical Professional; when taking a call on the 999 line,
we always re-assess the patient to ensure the most appropriate response is being given.
Calls are prioritised using the Advance Medical Priority Dispatch System. AMPDS is a set of questions
relating to a Chief Complaint used to rule out priority symptoms. Once questions are answered,
AMPDS gives the most appropriate response at that time ensuring more immediate life threatening or
time critical patients are responded to first.
When a call is received into the EOC on the 999 line, the call handler will ask a series of questions
about the Patient to establish the priority of the response that is required.
The series of questions asked will be dependent upon various factors including the Chief Complaint of
the patient, age, sex etc.
In order to send the most suitable response, it would have been appropriate to ensure all of the
patients’ Chief Complaints including Difficulty in Breathing, were presented at the time of making the
999 call.
By providing facts and information about the patient, they will receive the correct response from the
outset.
Recommendations:
3. Dispatchers to be reminded when to allocate HCP.
Action: Communicate to all Dispatch Staff that HCP should only be allocated once it’s
confirmed there is a Defibrillator on scene with a trained person to use it.
For:
Deadline: 15/08/13
4. Call Handlers to be reminded to ask if there is a Defibrillator and trained staff when
appropriate.
Action: Communicate to all Call Handlers of the importance of asking the Defibrillator question.
For:
Deadline: 15/08/13
5. Surgery staff to be invited to EOC to see how calls are prioritised and dispatched upon.
Action: Communication with Surgery to invite them to attend the EOC.
For:
Deadline: 15/08/13
Date report sent to Investigation Manager for approval: 22 July 2013
FC/027/13
Date Received:
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident:
Patient Name:
How Received:
Logged by:
Incident Location:
complaint:
06 June 2013
24 February 2013
Deceased? No
Email
Their reference:
2 hour delayed response to elderly man who stumbled down the stairs &
broke his foot.
Delayed Response (Timeliness, Activation/Response) and inappropriate
Type of Complaint:
advice given by call taker
Division/Area: A&E Cont. Leics & Rutland (A/E Control)
(15 working days)
04
July
2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Why was the caller asked to get the patient up?
What caused the delay in getting to the patient?
Did the call handler give the appropriate advice?
19/07/13
Expectations of Complainant: As above
FC/027/13
Chronology of Events : Taken from call 5315495 received in to the Emergency Operations Centre
(EOC) on 24 February 2013 and the Patient Report Form (PRF) details.
Date and Time
00:17
00:17
00:19
00:35
01:24
02:01
02:03
02:17
02:37
02:53
03:16
Events
Call 5351495 received into the Emergency Operations Centre (EOC).
Established patient had fallen injury to ankle.
Dispatcher accesses Resource Allocation (Res/All) list to check resources available to
send. No resource assigned.
Call Handler incorrectly codes as 17O01 Green4 (G4) and sends to Clinical
Assessment: doesn’t override due to patient’s age to Green 2(G2).
Clinical Assessment Team (CAT) makes assessment.
Call upgraded to G2 30 minute response.
Resource Log states --------------------- holding 3 x G2 calls.
CAT calls back and assesses patient. Worsening advice given.
Res/All accessed. 4817 Double Crewed Ambulance (DCA) assigned to attend.
DCA arrives on scene.
DCA convey patient to Hospital
DCA arrives at Hospital.
DCA becomes clear from this detail.
Evidence Gathered:
•
•
•
•
Sequence of Events (SOE) for Emergency Call 5351495.
Electronic Patient Report Form (ePRF) in relation to call 5545630
Voice recordings of call received into the EOC.
Resource Logs from available vehicles at the time of the call being received.
A call was received into the Emergency Operations Centre (EOC) at 00:17hrs to say the Patient had
fallen with an injury to their ankle.
At 00:17hrs the Dispatcher accesses the Resource Allocation (Res/All) function to see what vehicles
are available. Two vehicles have become clear at this point however, both are assigned within the
next minute to Red2 (R2) Emergency Calls.
By 00:19, the call handler has correctly coded the call but sent this to the wrong disposition meaning a
clinician would call back; as opposed to an Ambulance being sent with a Green 2(G2) 30 minute
response.
The Clinical Assessment Team (CAT) upgrade the call to G2 at 00:35hrs. An Ambulance is now due
with the patient no later than 01:05hrs.
Resource logs left by Leicester Desk state G2 calls were being held in ---------------------- area with no
crews available to respond to them. At this point, all crews were on higher priority emergencies or
providing ‘hot’ back up requests.
At 02:01hrs a CAT member calls back the patient as a courtesy call and to assess their current
condition. Worsening advice was given to call back if anything changes.
The Dispatcher accesses the Res/All function at 02:03hrs and assigns a Double Crewed Ambulance
(DCA) 4817 to this detail. They arrive on scene with the patient 14 minutes later at 02:17hrs.
Once assessed, the Patient is conveyed to the Hospital and the crew become clear from this detail at
03:16hrs.
Conclusion:
The caller was not asked on the inbound 999 call or the outbound Clinical Assessments calls to lift the
patient. The caller stated unprompted that she could not get him up due to her own conditions so had
left the patient on the floor.
There was a delay in responding to the G2 upgraded call due all other resources being fully
committed in attending to, or being diverted to higher priority emergencies/backups.
The Dispatch desk was aware of the waiting G2 calls and logged that there were three waiting to be
attended to. There were no crews available at that time.
Due to the delay and not being able to respond in a timely manner, the CAT clinician made another
call to check on the welfare of the patient. At this time a crew were also assigned to attend the detail.
The crew arrived on scene two hours after the initial call was made.
The call was processed through the Advanced Medical Priority Dispatch System (AMPDS). The
disposition incorrectly gained was for a member of the Clinical Assessment team (CAT) to call back.
The information given to the caller at that time was to wait for the CAT to call back. When CAT
accessed the call, they automatically upgraded this due the Patient’s age and mechanism of injury.
The correct disposition was then given.
A courtesy call was made by the CAT due to the time the patient had waited, at no point was
inappropriate advice given to move the patient.
Recommendations:
1. Action: Dispatch desks to be aware of and use the Res/Allocate function more frequently to
ensure checking of available resources whilst calls are waiting to be assigned.
For:
Deadline: 28/08/13
Date report sent to Investigation Manager for approval: 25/07/2013 approved 26/07/2013
FC/028/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 15 December 2012
Patient Name:
Deceased? Yes
How Received: Telephone
Their reference:
Logged by:
Incident Location:
Brief details of the Delayed response to elderly patient that then died before the ambulance
complaint: arrived.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
Scope of
Investigation
(must include all
complainant
concerns) :
Leicester City Dispatch Desk
Call Taker (DG)
Major/Rare
Was the call appropriately coded?
If not, what was the cause of the incorrect coding?
Was there a delay in responding?
Explanation and understanding
n/a
n/a
none
FC/028/13
Chronology of Events: 15/06/2013 and 16/06/2013
Date and Time
22:07
22:07
23:55
16/7/13
00:17
00:39
00:41
01:03
Events
Note in Delivery Manager’s Resource Log (RL)
Capacity Management Plan (OCP) 1 & 2 in place.
RL notes EMAS holding the following calls:
9 x Green 1 20 minute response G1
16 x Green 2 30 minute response G2
5 x Urgent agreed with Dr 2 or 4 hour collection
CAD 5174717. Call received from Out of Hours (OOH) Doctors to ---- year old male
with orbital swelling on left side. This was coded Green4 G4 for Clinical Assessment
call back. As this was a GP, the call was automatically upgraded to G2 – ambulance
attendance required within 30 minutes. OOH was on scene but did not want to stay on
scene with patient till ambulance arrived.
CAD 5174775. Call received from OOH stating that the patient was now vomiting
blood. Patient was conscious breathing, but reported to be drowsy, heavy bleeding
with a blood disorder reported. This call was coded G2 but should have been
manually upgraded to a Red 2. No res/alloc check completed by Dispatcher.
Ambulance assigned and arrived on scene 00:47.
This was 52 minutes after the OOH call.
rd
CAD 5174812. 3 call received from OOH.
Patient coughing up blood. Nurse with patient. Patient deteriorating fast.
Crew update dispatch that patient had died.
There was a valid DNAR in place and that the OOH Dr was on scene
Evidence Gathered:
CAD SOE
Call audit
Call WAV file
PHSO details
Upgrade response from CT Mentor
Team Leader email on upgrade
Performance Analysis (excel sheet format)
PDM Resource Log
AMPDS V13 upgrade confirmation email
At 23:55, a call was received from the Doctor’s Out of Hours Service (OOH) to a ---- year old male with
‘orbital swelling’. The Call Taker was not able to ascertain what caused the swelling. The call was
taken through the Accredited Medical Dispatch System (AMPDS) to ascertain whether the patient’s
condition was life threatening. OOH confirmed that the patient was alert and breathing. The call was
coded G2 for a 30 minute ambulance response, and has been audited as correct.
Second call was received, at 00:17 on the 16th, stating that the patient was now vomiting blood. The
call was taken through the AMPDS but incorrectly coded as G2. The Call Taker failed to select an
upgrade option that would have graded this as a R2, within 8 minute response.
AMPDS is a system that automatically codes a call, and assigns a response level, based on the
information given. Within the current system there are 10 criteria where the Call Taker has to
manually override the system and re-grade to a higher priority. This is indicated by a Sun Icon, in the
right hand side of the screen, flashing. The Call Taker failed to select the Flashing Sun icon and a
Qualified Call Taker Mentor was asked to review what had happened.
The Mentor stated ‘The upgrade icon is not in the immediate eye line of the call taker, easy to miss as
it is in the top right of the screen…’ That ‘…If the call taker is using the keyboard to navigate the call it
is easier to miss, not needing to move the mouse pointer up to near where the icon is’. Control Room
Team Leader stated ‘… in times of high demand/ Overcapacity this (Sun Icon) can be missed…’
Confirmation has been received from the Training Team that a new version of the AMPDS system is
expected for the end of the year. The manually upgrade of these codes should not be required on the
new version.
The Dispatcher did not perform a Resource Allocation check for the second call. Due to this it is not
possible to ascertain if a vehicle could have been available or diverted to this patient. When Call 3
was upgraded to a Red 2 call, no vehicle was able to arrive on scene for 22 minutes. This would still
have been outside the 8 minute response requirement.
At the time of calls the East Midlands Ambulance Service (EMAS) was underperforming with only
61.97% (target is 75%) of life threatening calls receiving a vehicle within 8 minutes. The Capacity
Management Plan (OCP/CMP) was noted in the Delivery Manager’s Resource Log as being Level
1&2. This means, that volume of calls were outstripping the number of resources available to
respond.
Conclusion:
Three of the four calls received for the patient were correctly coded. During the second call, the Call
Taker failed to manually upgrade the call to a Red 2. As no Resource Allocation check was performed
by the Dispatcher, it is not possible to state whether a vehicle would have been available to attend
sooner.
On the current version of AMPDS, Call Takers are required to manually upgrade certain calls. In
times of high demand failures to complete this upgrade occur. A new AMPDS program is expected to
be in place in October 2013. This will remove the need for the Call Takers to do this.
There was a delay in attending this patient, taking 1 hour and 8 minutes for an ambulance to arrive on
scene.
The reason for the delay was the number of calls to EMAS outstripped the services ability to respond.
Recommendations:
No recommendations.
Manual Upgrade requirement will not be a feature of the new version of AMPDS.
FC/029/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: Email
Their reference:
Logged by:
Incident Location:
Brief details of the Delayed response and concerned about lack of crew knowledge.
complaint: Upgraded from PALS - fed back verbally and he was not at all happy
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Lincolnshire Control Room
Why did the ambulance take so long to attend your address?
Scope of What was the clinical skill level of the crew attending?
Investigation Why was there such a difference in timings between the ambulance transport on
(must include all the 11/5/2013 and 19/5/2013?
complainant
Why were there no ‘Priority Ambulances’ available at the time?
concerns) :
Phone call; email –
Expectations of Complainant: Explanation of delay and why no ambulances available
Date OSM/PATIENTL/Manager
5/7/13
informed:
Immediate actions taken: N/A
FC/029/13
Chronology and analysis of Events:
Date and Time
11/5/2013
12:00 approx
13:15
13:19
13:24
To 13:48
14:04
14:15
14:41
19/5/2013 20:54
21:22
Events
Patient made contact with 111 and requested advice regards severe
abdominal pain and burst wound. 111 assessed his condition over the phone
and put in a request for a non-blue light ambulance to attend the patient’s
address within 1 hour to transport patient to hospital. This was sent via an
automated system to East Midlands Ambulance Trust (EMAS) at 12:15.
Call waiting for allocation of a vehicle; 1 hour timescale given by 111 service
elapses; system automatically upgrades the call to a G2 response. This
means an ambulance should be with patient within 30 minutes.
Dispatcher checks Resource Allocation button (Res/Alloc) – this shows all
vehicles in the area and whether they are available to the waiting call.
Res/Alloc checked twice in couple of minutes. Fast Response Vehicles were
available but not suitable for this detail as a conveying unit and this was a
transport only request from 111.
Patient calls 999 and duplicate call created and was Coded G4. In standard
circumstance this would have been sent to the Clinician team for triage. As a
call was already awaiting assignment to this patient it was upgraded to G2 as
per the EMAS policy. This upgrade was not done based on patient condition.
Dispatcher checked Res/Alloc another 4 times and marks that the Division is
‘K0 (no available resources) throughout the call’ – Dispatcher states will
resource when crew available. ‘No … DCA – Due to Paramedic shortfall’.
The K0 message relates to DCA’s not Fast Response Cars (FRV). Originally
a 111 booking for transport to hospital so awaiting Crew available to transport
Patient to hospital. At points throughout the Res/Alloc process there were
DCA’s available, but these were in meal break window so under EMAS policy
were not available for allocation to G2 calls.
Dispatcher completes 25 checks on Res/Alloc during timescale of this call.
Detail still unallocated so Clinical Triage asked to welfare check Patient as per
procedure.
Clinical triage completes assessment of Patient condition over the phone.
Patient pain level established as 5-6 (moderate) and authorises a Nonqualified (Patient transport only) crew attend to transport the Patient.
Continuing checking of Res/Alloc continued until VAS (Patient transport level
only crew) becomes available. Arrived scene 15:00 and arrived Peterborough
City Hospital AE at 15:54.
Total time elapsed – 3.5hrs; 2.5 hours over 111 originally requested time
scale.
999 call received from pt. This was coded 21B01 which is a G4 calls. This
means ambulance not dispatched, instead patient is called back by an EMAS
clinician for triage.
EMAS Clinician upgrades this call to a G2 response. Crew assigned at 21:23
and arrive scene 21:44. This is within the 30 minute requirement of face to
face contact with a G2
Evidence Gathered:
SOE CAD x 2
PALS report
Call recording
DM assessment on FRV attendance
Conclusion:
This report is subsequent to PALS investigation that was not resolved. Comparison between this
report and the original enquiry substantiates the findings of the PALS investigation.
The call was correctly handled, and 25 attempts were made by the Dispatcher to ensure an
ambulance was sent to this patient. The reason for the delay in attendance was as per stated in the
PALS report: higher priority calls; the Meal Break policy and a crew shortage.
The Clinical Skill Level of the crew that attended was Patient Transport Level. They attend with an
Ambulance, Stretcher, Oxygen and Basic Life Support training. This level of skill had been authorised
following a Medical Assessment by an EMAS Clinician which confirmed that the patient’s condition
was not life threatening.
The main reason for the difference in timings between the call on the 11th and 19th is that the patient
called 999 directly. This resulted in the call being treated as an emergency rather than an upgrade of
a transport request from 111.
There were priority ambulances available for the call on the 11th, but due to timing of the call numerous
vehicles were within their Meal Break Window. Due to this, they can only be assigned to life
threatening calls. This detail had been assessed by 111 and an EMAS Clinician as not life
threatening, therefore the Dispatchers were correct in not assigning them to this call.
Recommendations:
1. Dispatch officer to be commended for the continued attempts to locate a DCA to transport the
Patient.
Action: Message CEO for mention of DO in Bulletin
For:
Evidence: Copy of E-mail/letter
Deadline: 20/7/13
2. Establish more robust protocol for keeping patients informed of delays, especially in cases of
111 calls where they have not spoken directly to by someone from EMAS.
Action: Review setting up an automatic message in the Incoming Messaging Queue (IMQ) for
the EOC to welfare check patient.
For:
Evidence: Copy of report
Deadline: 11/9/2013
Learning point:
Failure to communicate with Patients increases their dissatisfaction with EMAS. Ensuring patient is
updated and informed re delays could potentially reduce complaints by a measurable level
Date feedback given to complainant: 11/07/2013
FC/031/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: email
Their reference: 118240
Logged by:
Incident Location:
Brief details of the Pt involved in an RTC. Pt claims that amb crew didn't assess her neck or
complaint: back for injuries even though she was complaining of pain there.
Type of Complaint: Pt. Assessment/Diagnosis (Quality of Care, Clinical Issue)
Division/Area: # A&E Lincolnshire. (A/E)
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Minor
Why was the patient not assessed for neck and back injuries?
With hospital 24/6/13
Expectations of Complainant: Explanation/apology
Date OSM/PTL/Manager informed: N/A
Staff involved informed: N/A information available on PRF.
Immediate actions taken: PRF and call audit requested
FC/031/13
Chronology of Events: taken from the Computer aided Dispatch (CAD) sequence of events (SOE)
for call reference 5570623 on 25 May 2013.
New call received at 23:03 hrs following a road traffic collision (RTC) between two vehicles. Resource
6345 double crewed ambulance allocated at 23:03 hrs. Resource 6722 double crewed ambulance
allocated at 23:04 hrs. Resource 6345 arrived on scene at 23:15 hrs, and the Fire Service was
requested to attend at 23:20 hrs as there was fluid leaking into the road. Resource 6722 arrived on
scene at 23:22 hrs, and it transported a patient to hospital. Resource 6345 called clear from the scene
at 23:53 hrs after treating the other patient on scene.
Evidence Gathered:
CAD report
Call audit notification
Patient report form (PRF)
Handling of the emergency call: the call was correctly assessed as requiring an ambulance
response within 30 minutes, with two resources dispatched to a two car collision. The two resources
arrived on scene 12 and 19 minutes after receipt of the emergency call.
Care and treatment of the patient: The crew who attended the patient who is the subject of the
complaint recorded on the PRF that on arrival she was sat in the driver’s seat. The patient moved
herself out of the car, and she advised that she was not injured and she did not wish to travel to
hospital. The patient had no pain and a pain score of 0/10 was recorded on the PRF on two separate
occasions. The crew also recorded that the patient had no back or neck pain on examination and she
was walking around unaided at the scene. A full set of observations was recorded including airway,
breathing and circulation assessment, oxygen saturation, pulse, blood pressure, respiratory rate and
Glasgow Coma Scale (GSC) reading. The PRF also states again that the patient refused travel to the
hospital and she signed the PRF to confirm this decision. The crew safety netted the patient by
advising her to visit her GP or the accident and emergency department if she felt any adverse effects
following the collision.
Conclusion
The patient was examined at the scene and was not showing any injuries. She did not wish to travel to
hospital and she signed the PRF to confirm this decision. The patient was given safety netting advice
which she subsequently followed the next day.
Recommendations:
No recommendations to be made on this occasion.
FC/032/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 10 February 2013
Patient Name:
Deceased? No
How Received: Email
Their reference:
Logged by:
Incident Location:
Brief details of the Did an A&E ambulance crew incorrectly sanction a Fire-fighter to drive
complaint: one of our ambulances?
Type of Complaint: Inappropriate Actions (Other)
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Establish if a Fire Fighter was given permission by EMAS crew to move ambulance
at the scene of an incident on 10 February 2013.
25 June 2013
Expectations of Complainant: Establish above
Date OSM/PTL/Manager informed: 25 June
Staff involved informed: 25 June 2013
FC/032/13
The IO contacted both members of staff by email, both responded, --- recalling that he was asked by a
member of the Fire Service if they could move the ambulance as it was causing a ‘slight’ instruction.
--- agreed.
The IO contacted the complainant on 27 June 2013 and informed him of the above. The complainant
apologised stating that he had settled the matter yesterday and thanked EMAS for all their assistance.
He also stated that he did not require any further correspondence and could he ask that the Formal
Complaint be closed. The IO stated that he would arrange for the matter to be closed.
Date report sent to Investigation Manager for approval: 27 June 2013
Date feedback given to complainant: 27 June 2013
Response letter sent: Not required
FC/033/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Their reference:
Logged by:
Incident Location:
Delayed response to patient with violent nosebleeds.
complaint: (HAPPENED THE SAME DAY AS THE ICT FAILURE)
Deceased? No
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
2214 – Control Room Sheets Unavailable to see staffing
Why was my Mum not treated as an Emergency?
Why do we have to be questioned every time 999 is called?
Why was the response not met in 8 minutes as per your government guidelines?
Letter sent - no phone contact made
FC/033/13
Chronology of Events: Taken from calls 5617091 and 5617102 received in to the Emergency
Operations Centre (EOC) on 12th June 2013 and the Electronic Patient Report Form (ePRF) details.
Date and Time
20:24
20:37
20:43
20:55
20:55
21:39
21:46
22:11
22:27
22:51
Events
On the date of this incident, the CAD system used to log all calls was not working. All
calls were being logged on paper to be entered retrospectively.
First call 5617091 received into the Emergency Operations Centre (EOC), Nosebleed.
Call coded correctly by Call Handler as 21B02 Green 2 (G2) 30 minute response
given. taped PDIs given – Help has been arranged
Second call 5617102 received into the EOC, Patient now bleeding from eyes. Call
coded incorrectly by Call Handler as 21A02 Green 3 (G3) 20 minute call back from the
Clinical Assessment Team (CAT). Should have been 21B01 Green 4 (G4) 1 hour call
back. –Call Handler states help has been arranged and gives bleeding PDIs.
Call Handler rings back to say Clinician would call them to gather further information
and provide more instructions.
Clinician speaks with caller. Establishes nosebleed since 1930hrs non-stop with
bleeding now from left eye and clots. Third nosebleed in 9 days. Patient is taking
Aspirin. Has Past Medical History of Triple Heart Bypass.
Upgraded to Green 1 (G1) 20 minute response by CAT after assessment.
2214 Double Crewed Ambulance (DCA) assigned to attend and mobile towards
incident.
2214 DCA arrives on scene with Patient.
2214 DCA leaves scene towards Hospital.
2214 DCA arrives at Hospital.
2214 DCA calls clear from this detail.
Evidence Gathered:
•
•
•
•
•
Sequence Of Events (SOE) from call 5617091 and 5617102.
Scanned copies of Resource Logs from Derby North Desk and Duty Manager.
Copy of Electronic Patient Report Form (ePRF).
Call audits for calls 5617091 and 5617102.
Voice recordings of calls 5617091 and 5617102 inbound and Clinical Assessment Call.
At approximately 09:45hrs on 12th June, the Emergency Operations Centre (EOC) was subject to an
IT major incident system failure. This meant that all calls received after this time on this day were
recorded on paper and entered retrospectively. All calls processed at this time would have been done
so using the Advanced Medical Priority Dispatch System (AMPDS) card sets. This is a manual
system.
Call number 5617091 was received into the EOC at 20:24hrs. The call was processed manually
through AMPDS and a Green 2 (G2) 30 minute Ambulance response was achieved. The Call Handler
gave instructions on how to help stop the flow of blood then played the Taped Post-Dispatch
Instructions (PDIs).
The second call was received into the EOC at 20:37hrs and processed through the AMPDS system by
the Call Handler. This was coded incorrectly gaining a Green 3 (G3) 20 minute call back response and
should have become a Green 4 (G4) 1 hour call back response. Due to this being the second call, it
did not have an impact on the delay for the first call. The Dispatcher will run on the first call, if further
calls are higher priority, the first call will be upgraded.
On the second call, the caller was under the impression that an Ambulance was already on route to
the property. The caller thought they had spoken to the Doctor and it’s the Doctor who arranged the
Ambulance. The second call was placed as the Patient now had blood coming from the corner of her
eyes.
Bleeding instructions were provided to the caller who stated these directions were already being
carried out. The other PDIs were then read over the phone.
At 20:43 the Call Handler made an outbound call to the address as the second call was coded G3, the
Clinical Assessment Team (CAT) script should have been delivered.
The Clinician telephoned the address at 20:50 and ran through an assessment to establish further
information about the Patient. On receipt of this information, the Clinician upgraded the call to Green 1
(G1) a 20 minute face to face response.
An Ambulance was allocated to the detail at 21:39hrs and arrived on scene with the Patient at
21:46hrs. 1hr 22minutes from the time of the first call.
Paper occurrence logs from the Duty Manager show at 21:01hrs there were 6 x G2 calls and 1 x G1
call being held in the North Derby area.
Conclusion:
The first call was received into the Emergency Operations Centre (EOC) at 20:24hrs and processed
through the Advanced Medical Priority Dispatch System (AMPDS); gaining a Green2 (G2) 30 minute
response. When calls are received into the EOC, they are coded using a nationally defined set of
priorities based upon the information given over the telephone. The calls are assessed and prioritised
in order of clinical need.
questions are answered, AMPDS gives the most appropriate response at that time. At this time there
was a high demand for Ambulances within that area. There were 6 incidents waiting to be allocated to
in this area at the time of the call.
At the time of the calls being received into the EOC, we were experiencing a high demand of calls for
the area and there were no crews available to respond to this call. All crews were assigned, backing
up solo responders on jobs or being diverted to higher priority emergencies.
A welfare call was carried out to the patient by the Clinical Assessment Team (CAT) due to the
delayed response. The call was then upgraded to a Green 1 (G1) 20 minute face to face response. As
there were still no crews available, it took a further 51 minutes for the crew to arrive with the patient.
In order to establish the condition of each Patient when a 999 call is placed, the caller is asked a
series of questions. These questions are designed to give the most appropriate Ambulance response
based upon the Patient’s presenting condition.
As a Patient’s condition may have changed from when the initial call is placed, it is pertinent to
process the caller through the questions and see this. A change in the patient’s condition could alter
the level of response that is given.
An 8 minute response is given to those calls which are classed as immediate life threatening
emergencies such as Cardiac Arrests and Heart Attacks. As the patient was processed through
AMPDS and considered to be in a more stable condition, a G2 response of 30 minutes was given.
Recommendations:
Action: To ensure feedback given to EMD regarding incorrect coding of second call.
For: Training Team
Deadline: Completed 02/07/13
Date Received:
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident:
Patient Name:
How Received:
Logged by:
Incident Location:
19 June 2013
14 June 2013
Deceased? No
Telephone
Their reference:
Enquirer called 999 as she was suffering severe abdo pain.
An FRV paramedic arrived who was very cocky from the outset.
He asked what meds she was on and she gave him her chart and
explained that she kept then upstairs and in a handbag.
She then thought he asked when her birthday was and she replied
'January'. He called her a liar as he had actually asked when she had last
called for an ambulance.
He initially stated that he would transport her in his car to Chesterfield
hospital and offered her Entonox but then stated that she would not be
able to take it on route. She was in too much pain and needed some relief
so explained that she couldn't travel in his car. He then offered morphine
but then withdrew the offer. He then stated that he would wiat with her
until an ambulance arrived but this may be up to 2 hours. He stated that
Brief details of the he could be trating rally ill people i this time and she said'don't put that on
me'.
complaint:
The ambulance arrived not long after and she then observed the FRV
para ging through her kitchen cupboard and taking out some out of date
meds (gabapentine) and taking them with him. She believes that this is
stealing.
On the way to hospital she was chatting to the trsnporting crew and they
discussed the ambulance programme on TV and ketamine was
mentioned.
On arrival at hospital the doctor stated that she has asked on crew to give
her ketamine and that another paramedic had advised that she had drugs
all over the house.
She is very unhappy anput the action of the FRV paramedic and wants to
see
him
disciplined.
She
is
taking
legal
advice.
CAD ref: 5614474
Type of Complaint:
Attitude (Attitude)
Division/Area:
# A&E Nottinghamshire (A/E)
10 July 2013
(15 working days)
Date for Investigation conclusion:
17
July
2013
(20 working days)
FC/034/13
Staff involved
& Station:
Initial grading
& Rationale:
What is the procedure for transporting a patient in an Fast Response Car (RRV)?
What pain relief can be given if patient is transported in RRV?
Scope
of What time scale was appropriate for the Paramedic to request the transporting
Investigation
Ambulance?
(must include all
complainant
concerns) :
Why did the Paramedic ask about existing medications?
What did the Paramedic do with the patient’s own medication removed from the
house?
Letter – no reply phone call
Member of staff is disciplined
10/7/2013
FC/034/13
Date and Time
14/7/2013 14:18
14:20
14:25
14:33
15:09
15:11
At scene
16:57
Events
Neighbour calls 999 as patient (Pt) has abdominal pain and vomiting
Call coded as G1 call requiring 20 min Face to Face response
Ambulance car (FRV) 2738 assigned to call
RRV arrives on scene – within the Guideline 20 mins response
Paramedic advises control Pt “wants morphine but this is against protocol as she has
had too much morphine”. Paramedic then requests Amber backup – this is request for
the next available ambulance to attend as a blue light emergency and can only be
diverted to a R1 call.
9413 conveying ambulance was assigned and arrived scene at 15:23, crew took pt to
Chesterfield Royal Hospital arriving at 16:06
PRF from crew notes paramedic gave entonox and IV cyclizine given. ‘…morphine
withheld due to amount of medication found in the house and that the HPC is
inconsitant. Pt has taken own meds to minimal effect…’
‘… pt has … handbag full of medications, in kitchen patient also had a large quantity of
POM’s. All taken to hospital with pt…’
Crew informed control they were making a safeguarding referrals
Evidence Gathered:
SOE CAD
Investigators Log Book
PRF
Email from
Patients transported by Solo Responder SOP
Duty of Care policy
Clinical Bulletin Priority Patient conveyance
At 14:18 a neighbour of the patient calls 999 from the address. The call is taken through the
Accredited Medical Priority Dispatch System (AMPDS) and coded for a G1, 20 minutes response call.
A Fast Response Vehicle (FRV) attends at 14:33, within the 20 minute guideline and assesses the
patient.
During the questions into the patient’s previous medical history (PMH) there is a communication
between the paramedic and patient. Paramedic notes that ‘…morphine was withheld due to amount
of medications found in the house and that the HPC (History of Previous Complaint) was
inconsistent….. Patient has taken own meds to minimal effect’
Initially, the paramedic’s observations supported taking the patient to hospital in the FRV. As the
Paramedic spoke with the patient, he was unable to ascertain how much morphine the patient had
taken prior to his arrival. Due to this the Paramedic had to revaluate how to get the patient to hospital.
An EMAS Consultant Paramedic outlines ‘One of the side effects of morphine is respiratory
depression and in cases of over administration respiratory arrest…’ and that it is ‘…unsafe to transport
on their own in a car due to the inability to verify what amount of morphine the patient had taken prior
to their attendance…’
The ‘Patients Transported by Solo Responders’ Standard Operating Procedure (SOP) states ‘…In any
case where there is doubt over the suitability of the patient for transport in a solo response vehicle the
clinician on scene has absolute say over whether or not transport can occur’.
The Paramedic then requested Amber Backup from a Double Crewed ambulance – this means the
next available ambulance would be assigned on blue lights. This vehicle would only divert to a life
threatening call coded R1. The Paramedic then remained with the patient and administered entonox
and IV cyclizine until a transporting resource arrived 14 minutes later. The patient was handed over to
hospital staff, as were the patient’s medications from the house.
Conclusion:
The procedure for transporting a patient in a Fast Response Car (FRV) states that the Paramedic has
the ultimate decision regards to whether the car is suitable for that patient. If the Paramedic has any
concerns about the patient’s conditions another form of transport needs to be arranged.
In this case where that Paramedic could not ascertain the amount of Morphine a patient has taken the
advice is not to convey in a car. This is due to the possible side effects which include respiratory
depression and in cases of over administration respiratory arrest. It would therefore be considered
unsafe to transport on their own in a car due to the inability to verify what amount of morphine the
patient had taken prior to their attendance.
The Paramedic requested for the next available ambulance to attend as a blue light emergency which
can only be diverted to a R1 call (an immediately life threatening call). The ambulance arrived on
scene with the Paramedic within 13 minutes of this request and he remained with the patient until that
time.
The reason why it is important for the Paramedic to ask about existing medication to understand what
effects that the medications taken can have on the patient’s condition as stated in paragraph 2 of the
conclusion.
The paramedic felt that the information given by the patient was inconsistent. Due to this he did not
feel it was safe to administer more morphine. This concern was noted at the time to the Control Room
and noted in the Patient Report Form.
All medications were handed over to the hospital staff and this was noted in record of the call on the
Patient Report Form
The Paramedic complied with the Standard Operating Procedures laid out regards to the transport of
patients in Fast Response Vehicles.
Recommendations:
No recommendations.
Summary Incident (SI) Description and Consequences Report
SI Unique Reference: 2013-20999
SI Criteria:
Incident Date:
Care Management Concern
06 March 2013
Source: PALS/FC035
Reported as Patient Safety Incident: Y
Harm Rate:
Level 5 – Patient Deceased
Initial Call Coding: Red 2
Area/Divisional:
Derbyshire
Base:
Patient Outcome:
Patient dies two days after incident in Hospital of Small Bowel Ischemia
Report Submission Date: 20 September 2013
Extension: none
Concise Introduction to the Incident
An Ambulance was called for a patient suffering from pain in his arms and right sided chest pain.
Concerns have been raised regarding assessment on scene and non-conveyance of the Patient.
The Patient died two day later in Hospital of Small Bowel Ischemia.
Terms of Reference (TOR)
Why was the automatic back up to a Double Technician Crew attending a Chest Pain Call, not provided?
Why was the patient not conveyed?
What is the rationale for the patient to contact the GP, rather than be conveyed?
What appropriate safety netting put in place?
Why did the crew not ask for Paramedic assistance to clinically review the ECG?
Why did the crew not speak directly to a Clinician?
TOR agreed by:
LQM Division
Date: Email 26/07/13
List Immediate Actions
Crew Stood Down: No
1.
The crew have engaged with the SI process and a Record of Interview was carried out by Clinical Team
2.
Mentor (CTM) on 07 August 2013.
Further training has been provided around the process of referral to GP and non-conveyance of Patients
to both crew members on 13 August 2013.
Staff Education and Support
Technician 1 ()
Technician 2 ()
Dispatch Officer 1 ()
Dispatch Officer 2 ()
EE Date: 28 May 2012.
EE date: 30 May 2012 .
EE date: 17 July 2012.
EE date: 04 September 2012.
IPR Date:26 February 2013.
IPR date:26 February 2013.
PDR date: 13 August 2013.
PDR date: 26 June 2013.
Road staff have been supported by the Clinical Team Mentor (CTM) throughout the investigation. The crew have
continued with their duties having taken the opportunity with the CTM to run through the correct processes. --has had further assistance from the CTM in relation to external issues to EMAS and, both have been given the
details for self-referral if required.
Dispatch staff were supported by the Duty Manager within the Emergency Operation Centre (EOC) and are
aware of the self-referral process.
Healthcare Decisions Panel (HDP) referral: No – Technician crew/Dispatch staff
Being Open
A call was made and email correspondence requested on 04 July 2013 in relation to the Formal Complaint. The
complainant was informed that an internal investigation is being conducted. Further communication has taken
place via email on 19 July with an update given and conclusion of investigation timescales. Upon conclusion, a
written response to the complainant will be provided explaining the full outcome and learning.
Timeline of Events
Date and Time
06 March 2013
Event
Incident Number 5376779
07:18hrs
07:19hrs
07:19hrs
07:20hrs
07:20hrs
07:28hrs
07:30hrs
07:40hrs
08:10hrs
08:11hrs
08.37hrs
Call received into Emergency operations Centre (EOC).
Double Crewed Ambulance (DCA) 2417 assigned to attend.
Call Taker establishes patient has Pain in Arms, Right Sided Chest Pain.
Coded correctly by Call taker as 10D03 Red2 (R2) 8 minute response.
DCA 2417 on route to incident.
DCA 2417 arrives on scene with patient. Delay caused due to no standby near location.
First set of observations taken from Patient. Pain score of patient recorded as 01/10.
Second set of observations taken. No Past Medical History Recorded.
Crew call clear from this detail.
Note entered from Dispatcher saying Patient had been referred to Immediate Care.
Crew return to base
Crew reserved for next call
14 June 2013
18 July 2013
Email received from complainant and logged as FC.
Case escalated from FC to SI.
Analysis of Findings
Following a call audit, this call was correctly coded as 10D03 Red 2 (R2). The target response time for the R2 is
8 minutes face to face ambulance response. A Double Crewed Ambulance (DCA) was reserved and allocated
at 07:19hrs. The DCA was a double Technician crew. The DCA arrived on scene outside of the 8 minute target
by 1 minute due to the distance from the patient when allocated. The crew were with the patient at 07:28hrs.
Two sets of observations were taken by the Technician crew over a period of 10 minutes with the patient. After
these were completed, the crew discussed with the Patient that it would be beneficial to seek advice from his
General Practitioner (GP) later that morning. The ePRF states the patient’s partner would ring for an emergency
GP appointment at 08:00hrs.
At 08:11hrs the call was closed and records indicate the crew had called clear from this detail and were returned
to base. A call can only be closed once all resources have cleared from dealing with it.
A clinical review of the electronic Patient Report Form (ePRF) was carried out by the Divisional Clinical Team
Mentor prior to meeting with the crew. The analysis of the Electronic Patient Report Form (ePRF) shows;
The patient had a long history of abdominal pain/problems but had not seen GP for 10 months. There is no
diagnosis recorded and nothing had been entered into the Past Medical History (PMH). The patient (according to
the ePRF) was not cold, grey or clammy whilst the crew were on scene.
In observations the patient was slightly tachycardic (fast heart rate) and lower than expected SPo2 (Oxygen
levels) although the physical examination would suggest the patient was well perfused (good colour). All other
observations were within normal limits for this patient with the noted on-going medical symptoms. Even though
the Patient had a long history of abdominal pain, the only new symptom was pleuritic chest pain on coughing.
As per EMAS guidelines a Technician crew should not leave a patient at home without speaking to a Clinician;
whether that is a nurse from the Trust Clinical Assessment Team or Out Of Hours or General Practitioner (GP).
The crew did not clear from the scene until 08:10hrs which is after the time the partner indicated they would call
to speak to the GP. It is reasonable to expect that the crew could also have spoken to the GP directly.
The crew have documented that there is no abdominal rigidity. The comments state there is an increase in pain
on coughing. Abdominal rigidity in a patient could suggest there is a mass or bleeding present. If rigid, the crew
would consider there to be something wrong with the Patient. The ePRF does not state if there is any tenderness
or not.
Crews are taught to conduct their own assessment and not necessarily act on what the chief complaint is
reported on the Computer Aided Dispatch (CAD) system. This takes in to consideration that the information
provided by the non-caller is not always accurate and once a clinician carries out initial observations the
complaint may be different.
Following the record of verbal interview, it was established that the Dispatcher on this date was following her
normal processes for sending a crew to the job and would normally dispatch the nearest resource. Trust Protocol
indicates a call to chest pain requires an automatic back up and must include the attendance of a Paramedic.
When sending the crew, the Dispatcher made an assumption that a Paramedic was on board and did not check
or clarify this assumption. The Dispatcher further understood that if required once at scene, a Technician crew
would inform Dispatch desk that a Paramedic is required, and be dispatched. On this occasion the crew did not
request Paramedic back up.
Information supplied by the Location Quality Manager states all crews are rostered to be Paramedic crews
(except dedicated Urgent crews). Leave and sickness means this does not always occur as the relief pool is
predominantly Emergency Care Assistants (ECA) so, if a Paramedic is off and they have a Technician crew
mate; they may be crewed up with an ECA. The assumption of the Dispatcher is therefore incorrect.
Technician 2 (T2) having been shown the ePRF was unable to remember the incident. From the writing style
(wording and terminology on the electronic document) she indicated this was not her own; after a conversation
with Technician 1 (T1), it was established that she was also unable to recall the incident but accepted she
completed the ePRF.
T1 stated that from looking at the observations and the ePRF the outcome for the Patient from their treatment
was correct. There were no concerns in the Patient’s observations, he was not in any pain and any intermittent
pain had been on-going for the last 10 months for which he had not sought help from a GP. The crew did not
establish the reason the patient felt the need to call for 999 assistance and whether there had been a change in
their chronic condition.
T1 knew that when a Patient was being left at home, a referral to another Healthcare professional should be
made. She was not aware it was the responsibility of the crew to make this referral to the Patient’s GP, an Out of
Hours GP or the Clinical Advice Team (CAT) desk within Control.
Conclusion
The call made to the Emergency Operations Centre (EOC) was coded correctly. The call was not responded to
within the target time of 8 minutes due to the distance needed to be travelled by the crew. The crew arrived on
scene within 09 minutes.
There were no clinical indicators observed or recorded that would suggest the patient was acutely unwell.
It was incorrectly expected by the Dispatcher that should a Paramedic be required the DCA Technician crew
would have asked for one via the Control Room. Protocol is that for chest pain calls, an automatic back up
should take place to ensure a Paramedic response. The Dispatcher made incorrect assumptions about the crew
skill mix and did not follow procedure to allocate a backup resource.
From the information provided by the Patient to the crew, the patient is recorded as having abdominal pain and
not Chest Pain as first reported to the Emergency Operations Centre.
A Technician crew are trained to observe the basics with regards to ECGs and given working time with other
Clinicians, enables them to increase their skill level and understanding through on the job training. The
Technician crew in attendance felt they were able to analyse the heart trace (ECG) and rule out anything
relevant to cardiac problems. The crew did not contact a senior clinician whilst on scene with the Patient to
confirm or discuss their understanding of the ECG output.
From the information gained by the crew on scene, it was appropriate to refer the patient to the GP however, the
crew should have made an effort to contact a clinician; either the Trust Clinical Assessment Team (CAT) nurse
triage desk, the out of hours GP or the patient’s own GP for a clinical handover. Given the timing of the incident it
was not appropriate to have left the patient’s partner to make this contact and the clinician should have spoken
directly to another clinician. The crew did not ring the GP, Out of Hours GP or Clinical Assessment Team within
Control and they were unaware of the full correct process to follow.
The assessments made indicated to the crew that the Patient required further assessment; they did not consider
this assessment needed to be through the hospital care pathway.
Root Cause
The crew did not establish what had changed in the patient’s chronic condition and why they had sought
emergency assistance.
Contributing Factors
•
•
•
•
•
•
•
•
•
The Patient’s presenting condition was not of cardiac origin.
The crew did not understand the referral process.
The Technician downgraded the call from chest to abdominal pain so no Paramedic was required.
The age of the condition being 10 months.
Pain presented was only upon coughing.
No clinical indicators presented to show acutely unwell. The Patient presented with normal observations
for him.
The full referral process for safety netting was not fully understood by the crew.
The time of day as the Doctor surgery would have been closed.
Dispatchers although aware of the back-up procedure to chest pain calls, from experience expected
Technician crews to make them aware if a Paramedic was required.
Organisation and Divisional Recommendations
Recommendation
Crews are reminded
of the process for
safety netting
Dispatchers to be
reminded of the
process for backing
up crews if required
Action
Communication sent
to all crews regarding
appropriate
safety
netting if a Patient is
left at home - to go to
all
non-registered
Clinicians.
Memo to be sent to
all Dispatchers to
read and sign. It is
not down to the crew
to
ask
for
the
Paramedic of the
deployment
SOP
states one should be
sent.
Dispatchers
should not assume a
crew
has
a
Paramedic on board.
Lead
Due Date
Evidence
01 November
2014
Copy of email to follow
01 November
2014
Copy of email to follow
Crew to have up to
date IPR
IPR to be completed
20 February
2014
Crew to retrain on
correct
referral
process
Retraining required
13
2013
August
Copy
email
of
IPR/Completion
Completed - Copy of email
Organisational Lessons Learned
Staff are making assumptions about procedure without gaining assurance and clarity of the process.
Evidence Gathered
Call Audit
PRF
ROVI
Clinical Review of PRF
Statements from crew and Dispatch
Sequence of events from call
Copy of Deployment of Planned resources SOP
Process of Investigation
The Investigation will establish the facts of this incident; identify any service or care delivery problems and root causes if
applicable and any associated contributory factors. It will identify any learning points to help prevent this type of concern
arising again in the future and improve service delivery.
The investigation has been approached in a fair, open and transparent manner without prejudice to any individuals
concerned and has sought to establish the facts surrounding the incident, the decisions made during the incident and to be
objective throughout. The results published will ensure both positive and negative findings will be shared, along with any
lessons identified.
The investigation methodology was to first establish the facts into the incident and draw up a chronological sequence of
events of the Trusts involvement starting from receipt of the first emergency call on behalf of the patient to the point at which
the patient arrives at hospital. The methodology for gathering data will be specific to each investigation.
The Root Cause Analysis (RCA) panel should comprise of the Investigation Officer (IO) as facilitator, the Divisional Deputy
Director and or any other delegated managers and specialists; on occasion it may be appropriate to include staff involved
with the incident. The panel is convened to identify the root cause(s) and associated contributory factors of the incident. The
RCA members must agree on the recommendations arising from this investigation to prevent and/or minimise recurrence and
associated action plan to ensure that the recommendations are implemented and embedded into practice.
FC/036/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Delayed response to pt who had an accident on his scooter. When the
amb did arrive, the crew didn't seem to be in command of the situation
complaint:
and got lost on route to A&E.
Division/Area: A&E Cont. Derbyshire (A/E Control)
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation •
(must include all •
Why was there a delay in the Ambulance Service responding?
Why did the crew not know where the local Hospital was located?
complainant
concerns) :
Letter sent 09/07/13
FC/036/13
Chronology of Events: Taken from calls 5611304, 5611261, 5611361, 5611372 received in to the
Emergency Operations Centre (EOC) on 12th June 2013 and the Patient Report Form (PRF) details.
Date and Time
17:24
17:24
Unknown time
17:25
Unknown time
17:30
17:55
17:59
18:40
19:00
19:42
Events
On the date of this incident, the CAD system used to log all calls was not working.
All calls were being logged on paper to be entered retrospectively.
First call received 5611261, knocked off motorbike.
This was coded as 29B04 Green1 (G1) response.
Second call received 5611304, RTC Motorcyclist v Van.
Second call duplicated up to first and closed correctly by the Dispatcher.
Third call received 5611361, RTC Van v Motorcycle.
Third call duplicated up to first and closed correctly by the Dispatcher.
Detail assigned to 3110 Double Crewed Ambulance (DCA).
DCA mobile from Derby City after completing late break.
Fourth call received from Police to state they were on scene and asking for estimated
time of arrival of crew.
3110 DCA arrives at scene of incident.
3110 DCA leaves scene of incident with patient heading towards Hospital.
Evidence Gathered:
•
•
•
•
•
•
•
Sequence of Events (SOE) for Emergency Calls 5611261, 5611304 and 5611361
Call audits for the calls received into the Emergency Operations Centre.
Delivery Manager (PDM) log for 12th June 2013.
Email with breakdown of calls in area from ---.
RAC route maps with times to travel.
Record of conversation from crew
At approximately 09:45hrs on 12th June, the Emergency Operations Centre (EOC) was subject to an
IT system failure. This meant that all calls received after this time on this day were recorded on paper
and entered retrospectively. All calls processed at this time would have been done so using the
Advanced Medical Priority Dispatch System (AMPDS) card sets. This is a manual system.
The first call recorded into the EOC was at 17:24hrs. After being processed correctly by the Call
Handler, the call was coded 29B04 Green1(G1) a 20 minute response.
At the same time a further call 5611304 was being received into the EOC. This was processed
incorrectly and coded as 29B01 Green2 (G2), a 30 minute response. The correct coding should be
29D02I G2, the same response time. This call was linked to the first call and closed.
A third call was received at 17:25hrs. This was coded correctly as 29B04 G1 and linked to the first call.
There is no indication from the retrospective details entered, that the original call was upgraded to G1.
There were 2 other incidents being processed for the ------------------ area during the time this incident
took place. Both were coded as G2 requiring the same response time.
At 17:30hrs, 3110 a Double Crewed Ambulance (DCA) was assigned to attend this incident and
travelled from Derby City Centre. A distance of approximately 19 miles and estimated time to travel of
29 minutes.
A call was received from the Police who were on scene at 17:55hrs. They asked for the estimated time
of arrival and were given any information that was available.
The DCA arrived on scene with the Patient at 17:59hrs.
After completing assessments, the Patient was conveyed to Hospital. They left the scene of the
incident at 18:40hrs arriving at the Hospital, for 19:00hrs.
The Emergency Care Assistant (ECA) driving to the Hospital was on her first day at work and had
never been to that Hospital so did not know directions. She states she got lost a few times when in the
town of the Hospital and asked for directions from the rear of the Ambulance. She does not know if
these came from the Patient or Paramedic. At the time of this incident, the Mobile Data Terminal
(MDT) was not in use due to the computerised systems within Control being offline.
Conclusion:
The first call was received into the Emergency Operations Centre (EOC) at 17:24hrs and processed
through the Advanced Medical Priority Dispatch System (AMPDS); gaining a Green2(G2) 30 minute
response. When calls are received into the EOC, they are coded using a nationally defined set of
priorities based upon the information given over the telephone. The calls are assessed and prioritised
in order of clinical need.
questions are answered, AMPDS gives the most appropriate response at that time. At this time there
was a high demand for Ambulances within that area. There were 3 incidents for Swadlincote requiring
the same timed response.
An Ambulance was assigned to the detail 6 minutes after the initial call. This was the nearest available
crew who were travelling from 19 miles away. The resource was with the patient 35 minutes after the
first call using the closest available resource. 5 minutes outside of target time.
At the time of this incident, the Mobile Data Terminal (MDT) was not in use due to the computerised
systems within Control being offline.
The Emergency Care Assistant (ECA) driving to the Hospital was on her first day at work and had
never been to that Hospital so did not know directions. She states she got lost a few times when in the
town of the Hospital and asked for directions from the rear of the Ambulance. She does not know if
these came from the Patient or Paramedic.
It is confirmed that should the Satellite Navigation system have been in use on that day, the crew
would need to know how to manually input into it and would require the post code of their destination.
Recommendations:
1. Action: Investigation Officer to brief ---- about incident and discuss possibilities of including
Satellite Navigation training to Driver Training School
For:
Deadline: 14/08/13
2. Action: LQM to consider viability of the local induction including ensuring local points of interest
are communicated to new staff.
For: LQM Division
Evidence: Copy of the report and evidence of rationale to alter local induction or not
Deadline: 14/08/13
Date report sent to Investigation Manager for approval: 18.07.2013
Date feedback given to complainant: 18.07.2013
FC/037/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
--- year old boy was involved in an RTC. When the amb crew arrived on
Brief details of the scene, the child's Father had taken him to another Grandparent's house,
complaint: then returned to the scene. Why didn't amb crew treat the boy or track
him down for treatment?
Type of Complaint: Pt. Management/Treatment (Quality of Care, Clinical Issue)
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of 1. Why was -------- not conveyed to hospital?
Investigation 2. What are the age guidelines regards to transporting young children to hospital?
(must include all
complainant
concerns) :
3. Were the crew aware of -------- being involved in the accident?
4. What is the standard actions Crews take if there is a possible patient at a different location?
Email sent as per request within PALS papers
Expectations of Complainant: Explanation of events
Date OSM/PTL/Manager informed: 04/072013
Staff involved informed: N/A
FC/037/13
Date and Time
25/5/2013 18:36
25/5/2013 18:37
25/5/2013 18:39
25/5/2013 18:40
25/5/2013 18:53
25/5/2013 18:58
25/5/2013 19:13
25/5/2013 19:45
25/5/2013
25/5/2013
Events
999 call made – CAD 5570059 – Road traffic collision between van and motorcycle
Call coded 29D02L G2 call requiring a 30 min Face to Face response
Ambulance car (RRV) 6430 assigned and arrived scene 18:52 within the 30 min
response Guideline
Police notified of RTC – Log 657
Double crewed ambulance (DCA) AMV04 assigned to call on blue lights
6430 requested Air Ambulance attendance
Lincolnshire Police Helicopter activated as no available Air Ambulances to assist
Lincolnshire Police Helicopter transports pillion passenger (P1) to Hull Royal A&E;
6915 transports rider (P2) to Scunthorpe Hospital
As crews about to leave scene are informed that a child had been in the vehicle and
father had removed him to another location before the crews arrived.
Police attend the address where the child is. There were no visible injuries and ----------------- agrees that child is fine. Police confirm if officers had any concerns they would
have called for an ambulance but this was not required. Confirmed that ---------------was happy for -------- to remain with her.
Evidence Gathered:
CAD SOE
PRF x 2 on injured pts treated
Email from ----------------------------- re Parent Parental Resposibility
PALS proforma
On the 25/5/2013 a van collided with a motorcycle. The two persons on the motorcycle sustained
serious injuries and a 999 call was made to East Midlands Ambulance Service (EMAS) at 18:36.
Prior to the attendance of the emergency services the van driver decided to leave the scene. He
travelled to an address in the area taking his --- year old son to family members. He then returned to
the scene. The child had been in the van when the collision took place.
Attending the Road Traffic Collision (RTC) were a Fast Response Car (FRV), two Double Crewed
Ambulances (DCA) and the Police Helicopter (OSC99). The most seriously injured patient was
transported to Hull Royal by OSC99. One of the ambulances then transported the rider to Scunthorpe
General.
As crew members were leaving the scene they were made aware by the van driver that he had
removed his son from the accident. The driver made no indication to the crews that the child needed
any treatment.
Police have on record that they attended the address where the child was removed to and state he
had no visible injuries. They spoke to the child’s Grandmother who was looking after the child and she
had no concerns either. Police confirm that had they had concerns they would have called an
ambulance to the child but did not feel this was necessary.
Location Quality Manager (LQM) was asked about the age where patient should be transported
‘…Under 2’s should be either transported to A & E or if appropriate referred to another clinician i.e.
ECP or GP ...’ The child in this incident was 3 years so was outside of this guideline even if he had
been on scene.
Additionally LQM states ‘The crews will only deal with casualties at a scene. They cannot be made
responsible for other participants removing a patient from scene before being assessed. If the patient
is removed by another participant i.e. in this case a parent they should be held responsible.’
Conclusion:
This child was removed by his father who has full parental responsibility for the care of his son. This
legal responsibility lies with the father not with the crews to obtain treatment. If he felt it was safe to
remove his son from the scene he has the right to do so.
It is not the responsibility of crews to locate this child and the father made no indication to the crews
that the child was injured. This has been confirmed with police who attended the address where the
child was. They saw no obvious injuries and they did not feel an ambulance was required to which the
Grandmother present agreed.
Guidelines for transportation of any child under the age of 2 are in place. The child in this case was
over the guideline age and so there is no requirement for the crew to transport if the child had he been
at the scene.
The crews acted correctly in this detail by concentrating on the seriously injured patients present. The
responsibility for the care of the child removed was that of the father alone.
Recommendations:
No recommendations
Approved 19 07 13
FC/038/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: Email
Their reference:
Logged by:
Incident Location:
Pt in pain and leg swollen. Rang 999 several times. Waited over 2 hours
for ambulance. Had a blood clot in leg. Also unhappy with amb crew
complaint:
making him walk down the stairs, and “showing no compassion”.
(15 working days)
25
July
2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Why was there a delay in responding?
Why was ------------- asked to walk down the stairs?
Why was the call not prioritised?
Message left 28/06/13 – Spoken with on 01/07/13
Above scope to be answered, wants to know why was not a
Expectations of Complainant: priority.
FC/038/13
Chronology of Events: Taken from calls 5346131, 5346145, 5346157, 5346201, 5346205 received
in to the Emergency Operations Centre (EOC) on 21 February 2013 and the Patient Report Form
(PRF) details.
Date and
Time
Unknown
18:44
18:53
18:57
18:59
19:08
19:18
19:20
19:22
19:23
19:31
19:32
19:50
20:06
20:13
20:37
20:52
st
Events – 21 February 2013
Previous Medical History (PMH) – Patient undergoing investigations for heart condition.
First call received 5346131, patient had pain in leg – call was passed to Clinical Assessment
(CAT) team. This was coded as 26O01 which is Green4 (G4). CAT due to call back within
one hour.
Second call received 5346145, Patient having abdominal pain, lying on the floor with cramps
in stomach – confirmed CAT will call back. This was coded as 01A01 G4.
The dispatcher shuts down call two 5346145 as a duplicate of original detail 5346131.
Third call received 5346157, patient had pain in legs, was sweating, has a history of heart
problems – the patient was not alert so coded 26D01 Green2 (G2).
The Dispatcher shuts down call three 5346157 as a duplicate of original detail 5346131 and
recodes original to G2.
Fourth call received 5346201, patient now vomiting and in pain. Caller was told there was no
ambulance available at present and given worsening advice. This was coded as 26A11 G4.
Fifth call received 5346205, patient has a serious heart condition, in severe pain in leg, not
alert. Call was passed to CAT who confirmed an ambulance will come once available. This
was coded as 26D01 G2.
The Dispatcher shuts down call four 5346201 as a duplicate of original detail 5346131.
The Dispatcher shuts down call five 5346205 as a duplicate of original detail 5346131.
RES allocate opened.
Detail assigned to 3526 Double Crewed Ambulance (DCA)
3526 DCA stood down – required for a priority backup.
3218 DCA allocated after multiple Res/allocate attempts.
3218 DCA arrived on scene.
Left scene.
Arrived Hospital.
Evidence Gathered:
•
•
•
•
•
Sequence of Events (SOE) for Emergency Calls 5346131, 5346145, 5346157, 5346201, 5346205.
st
Delivery Manager (PDM) Log for 21 February 2013.
Voice recordings of calls received into the EOC.
Review of ePRF from Locality Quality Manager (LQM)
The first call was received in to the Emergency Operations Centre (EOC) at 18:44hrs. After being
processed by a Call Handler through the Advanced Medical Priority Dispatch System (AMPDS), the
call was coded Green4 (G4). The patient was told to wait for a call back from a Clinician which could
take anything up to one hour.
questions are answered, AMPDS gives the most appropriate response at that time.
A second call was received at 18:53hours stating the patient had abdominal pains. This call was
processed through AMPDS and received the same response of G4. The caller was reminded to leave
the line free and allow for a clinician to call back.
At 18:59hrs, a third call was received. The patient was now sweaty and not alert. This was processed
through AMPDS and gained a coding of Green2 (G2) which is a 30 minute response.
The dispatcher recoded the original job to a G2 at 19:08hrs, nine minutes after the third call was
received.
A fourth call was received and processed at 19:18hrs achieving the coding of G4. At this point the
caller was told there was currently no ambulance available and as soon as one becomes free, it will be
sent.
The fifth call was received at 19:20hrs and processed to receive a coding of G2. This call was made
by the neighbour who was with the patient. As the patient was not alert, the call handler stayed on the
line and then passed the call to a clinician who took some further details. The clinician spoke with the
patient directly and assessed their condition. The patient was told that an ambulance had been
arranged and would be with them as soon as possible.
At 19:31hrs the Dispatcher accessed the resource allocation (res/all) function. This shows all available
resources available in that area at that time. One minute later at 19:32hrs, a double crewed
ambulance (DCA) was allocated to the job.
Whilst on route to this detail, a higher priority call was received into the EOC. The DCA travelling was
diverted and no longer able to attend from 19:50hrs.
The res/all function was accessed again four times in an attempt to assign another DCA. On the fifth
attempt at 20:06hrs, another DCA was allocated. This crew arrived on scene with the patient at
20:13hrs, 1hr and 14 minutes after the call was escalated to a G2.
Comments from LQM
A full examination had been carried out on the patient taking into consideration not only the patients
Chief Complaint but also a more holistic approach.
The Patient Report Form (PRF) is extremely comprehensive and all the assessment fields are
completed even the fields that would not routinely be assessed for a patient presenting with leg pain.
The patient is observed as being in considerable pain with a score of 10/10 but has not required any
analgesia (pain relief). There are three full sets of observations recorded and they are all in within
normal limits with the exception of the first heart rate recorded which was slightly tachycardic (fast) at
106 (normal range 60-100). The two subsequent heart rates are back within the normal range. A 12
lead ECG was recorded and showed no acute changes.
From the assessment the crew have documented that they have assessed all the systems and from
these assessments the findings of note are related to the affected limb i.e. the left leg
They found the following
•
•
•
•
Diminished circulation to the entire left leg.
Left leg feels cool to touch – more so than the right leg
Capillary refill on left foot 5 seconds
Unable to palpate a pedal pulse on left foot.
These findings are extremely important and could be classed as a ‘Red flags’ for an ischaemic limb.
An ischaemic limb occurs when there is a sudden lack of blood flow to a limb. With proper surgical
care, acute limb ischemia is a highly treatable condition.
With a clot in the lower limbs there is a risk of part or all of the clot dislodging and moving to the lungs
potentially causing a pulmonary embolism (PE) – to minimise this risk it would have been advisable to
reduce the movement in the limb and therefore it may have been advisable not to ask the patient to
walk.
Conclusion:
There was a delay in responding to the G2 upgraded call due all other resources being fully committed in
The crew completed a clinical assessment of the patient and his condition. ‘Red flags’ or identifying symptoms
were present. It would have been more appropriate for the crew to provide physical assistance in the form of a
carry chair to mobilise the patient.
The call was prioritised as appropriate. When calls are received into the EOC, they are coded using a nationally
defined set of priorities based upon the information given over the telephone. The calls are assessed and
prioritised in order of clinical need. At the time we received the patient’s calls into the EOC, the information given
did not require an Ambulance response and instead, was triaged as requiring a specialist clinician to call back
and gather more detailed information in person.
The first call 5346131 was upgraded as to requiring an Ambulance (G2) after the third call was received and
triaged through CAD at 18:59hrs.
Due to higher priority calls such as Red2 (8 Minute response) calls waiting to be assigned and ‘Hot Backup’
(back-up on lights and sirens) requests, there was a delay in sending a DCA to the patient.
The Dispatcher allocated a DCA at 19:32hrs which was diverted to a higher priority call for ‘Hot Backup’. Another
DCA did not become available to respond until 20:06hrs when it was allocated to this detail and attended as
required.
Recommendations:
Action: Crew to attend Kingsway education centre for a patient assessment update
For:
Deadline: 09/08/2013
Action: Complete an academic 1000 word reflective piece on ischaemic limbs, their
assessment and management (within 2 months of attending Kingsway)
For:
Deadline: 2 months after assessment update
Date report sent to Investigation Manager for approval: 15.07.13 same day sign off
FC/039/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? Yes
Their reference:
Logged by:
Incident Location:
Pt was yellow, confused & disorientated, & had swollen abdomen.
Brief details of the Paramedic said it was a urine infection & a doctor was needed to
complaint: prescribe antibiotics. Pt admitted to hospital next day and a month later
died of liver disease.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of Why was ------------- not conveyed to hospital on the 13/02/13?
Investigation Do Doctors/General Practitioners normally act upon a diagnosis of a Paramedic?
(must include all
complainant
concerns) :
Do Paramedics normally diagnose?
Email on 02/07/13. Updated on 11/07/13.
Expectations of Complainant: For EMAS only queries to be answered by us.
FC/039/13
Chronology of Events: Taken from call 5325837 received in to the Emergency Operations Centre
(EOC) on 13 February 2013 and the PRF details.
Date and Time
15:10
15:11
15:14
15:18
15:26
15:53
16:23
16:36
Unknown time
th
14 February 2013
Events
New call 5325837 received into Emergency Control Centre. Passed verbally by 111
with a DX011 RED2 8 minute response code requested.
Resource availability (Res/All) list entered. Resource 2433 Rapid Response Vehicle
(RRV) consisting of a Paramedic and Observer allocated and dispatched to attend.
Clinical Assessment Team access call and downgrade to Green1 (G1). No delay
caused.
2433 RRV Arrives at scene of incident.
Paramedic checks observations/vital signs of patient.
2433 RRV Arranging for Doctor to attend as impression of Urinary Tract Infection
given.
Paramedic completes second set of observations/vital signs of patient.
Paramedic calls clear from this detail.
A Doctor arrives and administers antibiotics then leaves – patient still at home.
General Practitioner from B Medical Practice arranged for patient to be taken to
Hospital 1 based on Paramedic diagnosis.
th
20 February 2013
Patient taken to Hospital 2 ward after being found confused and on the floor at
previous location.
th
28 February 2013
Patient discharged from Hospital 2 ward to home.
rd
3 March 2013
Spouse unable to rouse patient, dialled 111, taken to Hospital 2.
th
5 March 2013
Patient dies in ITU of Hepatic Encephalopathy, Liver Disease and Tricuspid
Regurgitation.
Evidence Gathered:
•
•
•
•
•
Sequence of Events (SOE) for Emergency Call 5325837
Electronic Patient Report Form (ePRF) in relation to call 5325837
Review of ePRF from Locality Quality Manager (LQM)
Health and Care Professions Council Standards of Proficiency for Paramedics.
Copy of email correspondence.
A call was received into the Emergency Operations Centre (EOC) at 15:10hrs from the 111 triage
service. This had already been processed by them on their own system and a disposition of an 8
minute Ambulance response was given to the Call Handler at EOC.
At 15:11hrs the Dispatcher accessed the resource allocation (res/all) function. This shows all available
resources available in that area at that time. The Dispatcher then allocated a Rapid Response Vehicle
(RRV) to the job. This RRV was logged onto the resource stack as a single Paramedic. No mention
was made of a second crew member or Observer.
A Nurse from the Clinical Assessment Team (CAT) called back the patient at 15:14hrs and made an
assessment on the patient’s condition, taking further details into consideration. The grading of the call
was then changed to Green1 (G1), this did not affect the response time to the patient.
The RRV arrived on scene with the patient at 15:18hrs.
After making observations (recorded on the ePRF) and making a referral for a Doctor to attend, the
RRV called clear from this detail at 16:36hrs.
Comments from Locality Quality Manager (LQM)
The ePRF is generally well completed. There could have been further information around the
assessment undertaken and the history gathered in the comments section as the RRV was on scene
for one hour 18 minutes.
The Symptoms section has not been completed, resulting in limited information gained from the
patient regarding their current state of health. A small amount of history and clinical findings are
documented within the comments section. This could have been expanded upon. The patient’s past
medical history is documented although the patient’s medications are not.
A Primary Survey was completed to check if the patient was alert, responded to voice, responded to
pain or, whether they were unresponsive. This is documented as alert with confusion. A FAS test was
also completed with a negative outcome. This test is used to check for the symptoms of a Stroke.
The patient’s breathing is documented as normal for the patient. Skin temperature, colour, moisture,
turgor (the time it takes the skin to recoil if pinched) are documented as normal and the capillary refill
(time it takes for colour to return to skin if pressed) is within 2 seconds. The patient’s mental status is
documented as confused.
Two sets of observations have been documented during 57 minutes. An irregular heart rate is noted
which relates to the Atrial Fibrillation shown in the past medical history.
The heart rate, respiratory rate (breathing rate), blood pressure, Oxygen Levels (SPO2), Blood Sugar
levels (BM) and pain scores are documented. With the exception of the BM and temperature these are
all within the normal range for this patient.
The BM is high compared to normal standards at 15.7 with no documented past medical history for
diabetes. The temperature is slightly low at 36.0 C and the Glasgow Coma Scale (GCS) is reduced as
14 out of 15 due to the observed confusion. The GCS is a neurological scale which aims to give a
reliable, objective way of recording the conscious state of a person, for initial as well as continuing
assessment. A patient is assessed against the criteria of the scale, and the resulting points give a
patient score between 3 (indicating deep unconsciousness) and 15 (indicating fully alert and
responsive).
A 12 lead ECG has been performed which showed Atrial Fibrillation which is also documented within
the past medical history. This would indicate that it is not an acute change.
All systems have been examined as normal with the Genital Urinary/Gastro Intestinal system being
examined to include the presence of bowel sounds and the exclusion of rebound tenderness and
guarding (pain in the abdomen area when tensing). There is no mention that the patient was
jaundiced (yellow).
The Clinician has made a clinical impression of a Urinary Tract Infection (UTI) and has safety netted
by referring the patient to a General Practitioner (GP) within primary care. An Advice Leaflet was left
by the Clinician.
There is nothing on the PRF that indicates that the patient required immediate hospital treatment and
a GP appointment was arranged for within 4 hours.
Overall the patient was appropriately assessed and the conclusion reached was reasonable. The
decision to refer to the GP was also appropriate.
The Health and Care Professions Council Standards of Proficiency for Paramedics states under
section 2a2 for skills required for the application of practice; “Registrant Paramedics must be able to
conduct a thorough and detailed physical examination of the patient using observations, palpation,
auscultation and other assessment skills to inform clinical reasoning and to guide
the formulation of a diagnosis across all age ranges, including calling for specialist help where
available”.
Conclusion:
The second ‘Paramedic’ attending was an Observer in the vehicle and not qualified to assist when at
scene.
The Paramedic carried out a thorough assessment of the patient ensuring the Past Medical History
(PMH) was taken into consideration. Checks were done to ensure any PMH was within the normal
level for the patient.
From the assessment made, the impression of a Urinary Tract Infection was given by the Paramedic.
Appropriate safety netting was put in place with the Paramedic contacting an OOH GP to attend to the
patient and the appropriate advice leaflet was left for the patient on their condition and what to do
should they deteriorate.
It was acceptable from the observations taken and assessment made, for the patient to be left at
home in order for a GP to attend later on. There was no requirement for an immediate transfer to
hospital to take place.
The Health and Care Professions Council Standards of Proficiency for Paramedics states under
section 2a2 for skills required for the application of practice; “Registrant Paramedics must be able to
conduct a thorough and detailed physical examination of the patient using observations, palpation,
auscultation and other assessment skills to inform clinical reasoning and to guide
the formulation of a diagnosis across all age ranges, including calling for specialist help where
available”. Paramedics do formulate a diagnosis based on the assessment which has been made by
them.
The patient would have been re-assessed by the GP from the Out of Hours (OOH) service and they
would not have relied on the Clinician’s assessment. The patient would have also been reassessed
during any subsequent visits.
Recommendations:
6. Paramedic involved to be reminded of the importance of an accurate ePRF to include details of
any assessment taking place.
Action: Identify what support or training is required to ensure PRFs are accurate and concise
ensuring best practice for the patient assessment. Further training to be given if required.
For:
Deadline: 13/8/2013
7. Crews to ensure logging details if observers on vehicles in excess to crews.
Action: Ensure appropriate communications to all Crews via message and/or Clinical Bulletin.
For:
8. Dispatch Officers to ensure logging details if observers on vehicles in excess to crew.
Action: Ensure appropriate communications to all Dispatchers via message/email/verbal.
For:
SI Criteria:
Incident Date:
Source: Formal Complaint
Care Management
16/9/2010
Reported as Mother Safety Incident: Y
Initial Call Coding: 24D03 Cat B
Harm Rate:
Area/Divisional:
5
Held for Data Protection Act Reasons
Base:
Submission Date:
Outcome:
Child Deceased/Mother no harm
base of crew
04/07/13
A Paramedic and Technician crew were allocated to attend a call for a mother in active labour with her second
child. The crew arrived and following initial observations established the head had part delivered. Difficulties
arose in the delivering the remainder of the baby.
A Midwife attended and following attempts to deliver the baby by repositioning were unsuccessful. The Midwife
initially noted no respiratory effort and/or heartbeat and CPR was instigated by the Crew. The baby was
delivered and taken via ambulance to ---------------------------------------. The baby was conveyed separately from
mother. Paediatrics team were on pre-alert for the arrival as the crew notified them the baby was in cardiac
arrest and under active CPR. The Baby died 38 hours after birth.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Were the crew alerted en route, that birth was imminent?
Did the Paramedic follow appropriate procedures for this maternity call?
Why were the second crew requested?
What information did the crew gain from mother and family?
Did the crew provide to the family with information to advise them what was happening?
Who contacted the community midwife and when?
Was contact made with the local obstetric unit?
Establish whether contact was maintained?
Did the crew make a visual inspection of the mother and the presenting baby?
Was there confirmation that the baby was ‘breathing’ on the birth of the head?
Were the actions of the crew in line with JRCALC i.e. McRoberts and Supra pubic pressure initiated by the
crew?
12. What steps were taken to complete effective neonatal resuscitation?
13. Establish the outcome of the Coroner’s Inquest
TOR agreed by:
Safeguarding Manager
Date: 5/7/13
Actions Taken
Crew Stood Down: No.
This incident took place in 2010. Initial investigations were carried out by the then Clinical Quality Manager
(CQM) and the local Divisional Management Team. The crew remained on duty, but were separated as crews on
the understanding that a higher level skill mix was required. It was not procedure at that time to stand down
crews. All interviews and statements were taken and provided to the Coroner at the time of the incident.
Due to the timescales of this incident and the family informing EMAS that the Coroner’s Office hearing was due
in August 2013; standing down the crew was not appropriate. The current SI procedure is to immediately stand
down staff involved in a Serious Incident (SI) to provide support, guidance and assurance to all interested
parties. Stand down time will be considered on an individual and incident basis and the outcome of the initial
investigation.
Union/Staff Side Representation has been provided continuously since this incident. Due to management
changes within Division, several managers have been involved in the support of the staff up to and through the
Coroner’s hearing.
The crew were invited to take part in the SI meeting to discuss the report, the incident and agreeing the root
cause and contributing factors. They all confirmed that involvement with the process has enables some closure
for them after three years.
Involvement and Support of Staff
•
•
•
•
Paramedic, EE date: 14/7/2012; IPR date: 9/8/2012
Technician, EE date: 25/5/2012; IPR date: 27/10/2012
ECA, EE date: 17/5/2012; no IPR date is recorded.
EE date: 7/7/2010 (no longer member of EMAS)
Staff have continued to be supported by current LQM in preparation for the Coroner’s Inquest. This support was
in place previous to the registration of the SI.
Being Open:
This incident was submitted as a Formal Complaint (FC) in 2013. A Being Open letter has
been sent to inform her that the SI investigation is taking place. P1 and Trade Union Representative met mother
and grandmother at the Coroner’s inquest and mother thanked P1 for attending to the birth. Following conclusion
of the investigation, the investigation officer and LQM will offer to meet the family to discuss the report findings.
Timeline of Events
Date and Time
15/09/2010
16/09/2010
Event
The Hospital advised the mother her baby was large and should birth commence come
straight to hospital.
05:30
Labour commenced, the mother asked a relative (grandmother) be informed.
There was a delay in the grandmother travelling due to child care arrangements.
07.23
07.24
A 999 call received to a 21 year old in Labour
A Paramedic/Technician crew assigned to the call
Call was coded 24D03, which at the time was a Category B response requiring a 19
minute on scene response
Crew arrive on scene
Paramedic (P1) administered gas and air on arrival following initial assessments
P1 requests Midwife attend scene via Trust Control
Control Room notes; “Hospital Bed Bureau informed and contacting Out Of Hours (CTC
OOH) Midwife”
Emergency Care Assistant (ECA) Double Ambulance Crew (DCA) were sent assist the
crew as mother delivering at home
ECA crew arrive on scene
Community Midwife receives call to attend mother in labour
07.39
07.40
07.44
07.49
07:51
07:53
08:05
08:07
08:08
08:10
08:14
08:15
08:25
08:35
08:36
08:48
08:56
08:58
09:00
09:08
09:14
09:23
09:54
09:55
10:28
Control try to obtain ETA for Midwife
CAD note states: “Baby’s head delivers – body not out”
Midwife arrives on scene
CAD note “The baby is born – cardiac pulmonary resuscitation starts”
EMD notes in CAD that there is no answer from the desk
Midwife notes that mother having further abdominal tightening.
P1 continues care of baby whilst Midwife assisted mother.
Midwife and P1 agree baby should be transferred to hospital.
First crew left scene with the baby.
Hospital pre-alerted, mum travels with second crew
Both crews are advised to go to Maternity
After sustained CPR, P1 stated in the statement an “irregular heart rhythm developed into
a palpable rhythm in the baby’s neck.”
Update from crew transporting baby in CAD notes: “now has an output, but still not
breathing”
Second ambulance leaves scene with mother and midwife on board
First crew with the baby arrive at the hospital
CAD notes states “OSM contacted to arrange Crew welfare”
First crew completed hand over to hospital
Second crew arrive at hospital with mother
Midwife hands over mother to delivery suite
Both crews clear hospital
Call Handling: At 07:23 a 999 call was received for a --------------- female in labour. The Advance Medical
Priority Dispatch System (AMPDS) Audit Team have confirmed that the code assigned was correct; 24D03 was
a Category B 19 minute response.
Dispatch Handling: A Dispatcher assigned the most appropriate crew to the call. The crew were on scene at
07:39 within the 19 minute response target.
Patient care: On 4 September 2010 at 05:15 the mother initially felt she was having Braxton Hicks Contractions
but soon realised she was going into labour. At 06:37 she rang the hospital who advised her to go straight in as
the contractions were 3-5 minutes apart. At 07:23, 2 hours and 8 minutes after labour started, mother and
partner called 999.
Upon allocation of call coding AMPDS automatically generated a message advising the crew they were
attending an imminent delivery (5 months/20 weeks). The crew were sent a message by the EMD informing
them the mother wanted to push. The Sequence of Events (SOE), a digital record of all actions relating to this
call, shows that these messages were received by the mobile data terminal in the ambulance, whilst en route to
the call.
Upon arrival the Paramedic (P1) states that the mother had been having contractions for a while. P1
administered entonox (gas and air pain relief) to the mother after assessment, and the maternity pack was
opened as the birth was confirmed as imminent. P1 then ascertained that the mother wanted to push, that this
was her second delivery and that there were no previous complications during the pregnancy.
At 07:44, P1’s statement indicated he contacted the Control Room and requested the attendance of a Midwife.
P1 additionally stated he requested a Midwife and backup crew at the same time. This is correct as per
Paramedic Training Guidelines at the time. CAD notes show the Hospital Bed Bureau was informed at 07:49 and
they would inform the Out of Hours Midwives. The Midwife indicates receiving the call at 08.05 from the Bed
Bureau.
When asked by P1 whether her waters had broken the mother indicated she did not know. The Technician (T1)
then confirmed that the mother still had the urge to push. P1 advised the mother to pant the head out. As per
JRCALC maternity guidelines, P1 would not initially perform a visual check to see how labour was progressing.
The patient’s mother coached her through the breathing. At this point, her waters broke and were reported by P1
to have “expelled with great force, unlike I have ever seen before”.
At 07:53 an Emergency Care Assistant (ECA) DCA arrives on scene. In his statement P1 noted that the delivery
was not progressing as quickly as he would consider normal. As per his Paramedic training, P1 tried to
reposition the mother to enhance delivery of the baby. P1 and T1 discussed possible shoulder dystocia
(unusually difficult childbirth) and as mother appeared exhausted they assisted her into the McRoberts position
The Royal College of Obstetricians and Gynaecologists describe shoulder dystocia as when the baby’s head has
been born, but one/or both of the shoulders is stuck behind the mother’s pelvic bone. This condition prevents the
baby from breathing as the chest remains compressed in the mother’s pelvis, and potentially squashes the
umbilical cord. This is classed as an obstetric emergency.
The McRoberts position allows the baby the maximum room inside the birth canal. It
involves the mother lying on her back with her legs pushed towards the abdomen
(stomach). T1 was on the left leg pushing, P1 was on the right leg pushing.
Grandmother was behind the mother.
P1 stated that this allowed the slow delivery of part of the head only. After further
contractions P1 and T1 suggested the mother move on to an all fours position so
the gravity could assist in the delivery.
P1 noted in his statement that “whilst getting into this position (the mother)
proceeded to stand up for approximately one or two minutes before getting in to
position on all fours.” This position allowed the rest of the head to come out, but baby still did not deliver. P1
notes that he then observed blood tinged meconium draining from the baby’s nose and mouth. Meconium is the
early faeces passed by the baby whilst still in the womb and can be an indication that the baby is in distress
whilst inside the mother. At this point due to exhaustion, the mother began to struggle to hold herself in the
position on all fours. At this time, the Midwife has not arrived on scene.
At 08:05 the Community Midwife states she was contacted and informed that the mother was in labour with
contractions 1 in every 2 minutes. The Midwife arrived at scene at 08:10 and in her statement indicates “the
baby’s head had been out for 6 minutes and the (crews) had tried several different positions to deliver the baby
with no success.”
The Midwife stated that she prepared for an emergency delivery that would require the baby being resuscitated
on delivery. At this point the mother was in a kneeling position on the floor, with her chest and head on the floor
whilst breathing Entonox. The Midwife’s statement notes she could see that the baby’s head appeared
completely out at the entrance to the vagina, but that no part of the neck was visible. The head was described as
cream and pale in colour; no cord was visible.
P1 stated to the Midwife they were in need of specialist help and needed assistance. The crew believe the
Midwife then took charge of the delivery. The Midwife asked mother to push and quickly ascertained that no
progress was being made. The Midwife placed the mother back in the McRoberts position on the floor and again
encourage mother to push. The Midwife requested that the Entonox be removed so mother could concentrate on
pushing. The Midwife encouraged mother to “hold onto her legs (behind the knees) and pull back a little further
to help increase the pelvic outlet (space), in order facilitate the baby’s birth.”
Delivery progress was made and the neck began to emerge. The Midwife then felt gently around the baby’s
neck, and brought the cord over the baby’s neck. The Midwife noted that the shoulders had not rotated and were
in the transverse position (lying across the pelvis instead of leading down the birth canal). The mother continued
to push and, with minimal help, the shoulder semi-rotated as the baby was expelled. P1 noted that the Midwife
manipulated the baby “using and invasive technique, beyond the scope of Paramedic practice.” P1 states this
was successful after several attempts at twisting and pulling. P1 then noted that baby’s head was purple.
The baby was born at approximately 08:14 and placed between mum’s legs. The Midwife reported the baby was
feeling limp and heavy, without muscle tone. Baby is not known to have made attempts to breathe. The Midwife
passed the baby to P1 who commenced inflation breaths using an Ambu bag and Mask (medical devices to
assist with the ventilation of the baby). Five rescue breaths were initially attempted but were not successful due
to excess secretion.
P1 remembers he was unable to hear a heartbeat. The Midwife placed a stethoscope over the right side of
baby’s chest, and is reported to indicate hearing a faint 120 beats per minute. Whilst the baby was being
ventilated the Midwife could hear fluid secretions right and left side lung area. This indicated that the baby had
inhaled fluids into her lungs. P1 placed the baby in a neutral position where the airway was not compromised.
P1 noticed that there was excessive sputum (mucus) in the baby’s mouth that needed suctioning. On suggestion
of the Midwife the baby was intubated with an endotracheal tube (ET); size 2.5mm which is the smallest the crew
carry. This tube is designed to keep the airway open. P1 listened to the baby’s lungs and abdomen. P1 verified
that the tube was secure and appropriately placed. P1 noted that “there was bubbling, which sounded like the
baby was congested with fluid.” P1 requested Midwife verify tube placement, which she did. Throughout cardiac
massage was continued by one of the other crew members.
The Midwife examined mother and found her to be in a stable condition with minimal blood loss. Midwife then
checked mother’s notes to check blood group (rhesus positive) and gave her an injection of 1ml syntometrin.
This is a synthetic hormone designed to cause the womb to contract to help deliver the placenta.
At 08:25 the Midwife noted that the mother was having further abdominal tightening. The Midwife checked that
P1 would continue care of baby whilst the Midwife assisted to the mother.
At approximately 08:32 P1 calls over the Midwife and states that the baby was still unable to initiate breathing
and baby’s eyes remained closed. P1 believed he was acting under the direction of the Midwife at this point. P1
was unable to see the baby’s chest rise. P1 recalls mucous secretions from the ET tube. The chest
compressions and ventilations continued. P1 states the Midwife asked him to address the congestion, and he
performed a suction technique on the tube. After further ventilations P1 noticed fluid came up through the nose
of the baby which again required suctioning. P1 noted no spontaneous breathing and no heart rate at this point;
Cardio Pulmonary Resuscitation (CPR) continued.
At 08:35 the Midwife and P1 agree baby should be transferred to hospital. Midwife advised convey directly to the
Neonatal Intensive Care Unit (NICU) as the receiving hospital. The Midwife advised the Crew that the
ambulance would need to be warm for the baby and that the baby should be covered in as many towels as
possible whilst resuscitation continued on way to hospital. P1 recalls he apologised for separating baby from
mother before leaving scene. The baby was conveyed to NICU in the first ambulance with both the Paramedic
and Technician attending whilst a crew member from the second ambulance drove.
After discussion with the Midwife, it was decided the Midwife should travel with mother to minimise potential of
post-partum haemorrhage (post-delivery bleeding). The Midwife wrote in mother’s notes that baby’s Apgar was 1
at 1 minute; 3 at 5 minutes and 3 at 10 minutes. The Apgar score is a score of between 1 and 10 given to
indicate the health of a new born baby. A score of 7-9 is considered as a baby born in good health. Any score
lower than 7 will indicate a baby that needs medical attention.
En route to the hospital, on blue lights, P1 decided that the ET tube had possibly become displaced. This tube
was removed, additional suctioning was performed, and an oropharyngeal airway (a tube to maintain an open
airway) was inserted and CPR continued. A further attempt was made to intubate the baby, which was
unsuccessful due to excessive secretions (fluids). The baby was placed on an electrocardiogram (ECG) to
monitor its heart rate. P1 “identified the rhythm as ventricular stand still – there was no ventricular contraction
and therefore no blood being pumped around the baby’s body, which implies cardiac arrest, insufficient to
sustain life.”
Throughout the conveyance, the Control Room maintain contact with the NICU and advise the crews that
paediatrics will be waiting at the unit for the baby. Maternity ward is noted as being made aware the baby is in
cardiac arrest and being worked on.
At 08:54 the Control Room contacts the original general hospital that was expecting the mother, and informs
them that mother and baby are both going to the NICU direct. At 09:00 the second ambulance left scene with the
mother and midwife. NICU were given mother’s details.
After sustained CPR, P1 noted an irregular heart rhythm developed into a palpable pulse (one that can be
physically felt) in the baby’s neck. The baby’s heart beat was recorded at 133 beats per minute, with oxygen
saturations (levels) of 96% and the colour of baby now pink. Rescue breathing (ventilation) was continued until
the baby was handed over to Maternity staff at 09:08.
Arrangements were made for the Operational Service Manager (OSM) to welfare check all crew members
involved. The OSM discussed restocking ambulances and resourcing with the crew but do not recall being
offered stand down time and recall feeling unsupported post incident.
The Coroner’s Report: The Inquest was held on the 10 July 2013 and established the cause of death as
Hypoxic Ischaemic Encephalopathy. This is a lack of blood and oxygen to organs causing swelling to organs.
The Coroner identified that shoulder dystocia was a known hazard and that Paramedic Training Guidelines are
to put the mother into different positions to aid natural birth; which the crew correctly did.
Evidence given by an expert in Paramedic Training stated that current training prohibited the Paramedic from
providing traction to the baby’s head, or providing any internal or external manipulation of the baby whilst in the
mother’s vagina.
A Consultant in Obstetrics and Foetal Maternal Medicine evidenced that the baby was large, and that the birth
had been hindered by soft tissue dystocia rather than shoulder dystocia. Soft tissue dystocia relates to possible
pelvic masses or general malformations within the mother’s pelvis causing an obstruction.
Coroner’s recommendations were that consideration should be given to amend the National Paramedic Training
Manuals and Guidelines to assist a birth by providing gentle traction of the baby’s head and/or gentle internal
manipulation of the baby whilst in the mother’s vagina.
Conclusion
The crew were made aware by the call coding sent to the vehicle display, that they were attending an imminent
birth. Messages were also sent and received that the mother felt the need to push.
The Paramedic did follow appropriate procedures for this call. The crew attended the scene with appropriate
maternity pack and quickly confirmed the labour was imminent. As per Paramedic training a requested was
made to control to send a second crew and that a Midwife was needed. A second crew was called in the event
there was a need to convey the mother if further complications were encountered such as post-partum
haemorrhage. As per the Divisional guidelines the Control Room contacted the Bed Bureau to ensure Midwife
attendance
Limited information was gained from the mother and family upon arrival; the maternity notes were available but
due to the time critical nature of the incident, the crew’s priority was to attend to the mother and baby. They were
not able to read the notes.
The crew kept the family informed of their actions in respect of calling a Midwife to assist and concentrated on
the continued clinical care of the mother and delivering baby; such as moving in to alternative birthing positions.
The crew believe clinical lead was taken over upon arrival of the Midwife (a specialist clinician) and all
communication from that point with the mother was via the Midwife.
As per JRCALC guidance the crew did not make a visual inspection of the mother; but continued to discuss her
progress and care needed to establish the delivery.
The crew correctly applied JRCAL guidelines for altering the mother’s position to assist with the birth. There was
no indication that supra pubic pressure was initiated or appropriate at this time due to the concerns the crew
already had about dystocia and further complicating the birth.
There was no confirmation during their time on scene that the baby was breathing either on delivery or after.
This is supported by continuous CPR and ventilation was being carried out up to the point of hand over to the
Maternity staff at Neonatal Intensive Care Unit (NICU).
The Control Room made contact with the Bed Bureau, who then made contact with the Community Midwife.
Timings reported during the Coroner’s hearing indicate the call was not made to the Midwife until 16 minutes
after the call was made by the Control Room. This information was not discussed in detail at the hearing.
Radio communication between the crew and Control was maintained throughout. The Midwife initially made
contact with the Neonatal Intensive Care Unit (NICU). Once travelling the crew kept NICU informed of progress
and baby’s condition. Contact was maintained with the Bed Bureau, and then with the Neo-Natal Intensive Care
Department (NICU) throughout the call by Control.
Coroner’s Inquest has established the cause of death as Hypoxic Ischaemic Encephalopathy. This is a lack of
blood and oxygen to organs causing swelling to organs. Evidence given by an expert in Paramedic training
stated that current training prohibited the paramedic from providing traction to the baby’s head, or providing any
internal or external manipulation of the baby whilst in the mother’s vagina. A recommendation to amend
National Paramedic training so that it includes gentle traction has been made by the Coroner. The report
established that the Paramedic did act within the scope of his training during this delivery and acted
appropriately. The family thanked the Paramedic at the end of the hearing.
Root Cause
The presentation condition of mother with a complicated imminent child birth was outside the skill set of the
ambulance service’s standard operational crews.
•
•
•
•
•
•
•
•
•
•
Advice given on the previous day by Hospital Midwifery Team was not followed. The patient remained at
home awaiting family support and did not call for an ambulance until delivery was imminent.
On call for 999 for imminent birth Midwives are not requested immediately by EOC
The Bed Bureau took 16 minutes to contact the Midwife
Paramedic was not informed there would be a delay in the Midwife arriving on scene
The decision to convey the mother was delayed due to waiting for the Midwife to attend
The Midwife arrived on scene 21 minutes after the request was made by the crew
The baby’s crown had delivered at the point the midwife arrived
The Crew believed the Midwife was taking clinical/specialist lead on scene. The Professional
Communication between Health Care Practitioners (HCP) was vague and Clinical Lead was not established
but implied
Trust P1 was not aware of Midwife skills
This was a unique, time critical situation, the P1 was not able to read the patient notes whilst on scene
Recommendations
Action
Lead
Due
Evidence
There is a need for
crews to have direct
access to specialist
services such as
midwifery services
in this instance
Orginsational review
of Midwifery
Specialist/Leads.
For discussion at
DLRG and
progression to
SLRG.
Medical Director
supported by
Community
Paramedic
20/12/13
DLRG minutes and
copy of any review
with actions agreed.
Explore direct
communications
‘red phones’ with
the midwifery team,
with the ability to
pre-alert and
provide an advice
line.
LQM and CP to
meet with the local
Midwifery Leads.
LQM and CP
20/12/13
Minutes from
meeting and any
actions to be taken
to the DLRG or
appropriate
organisational
meetings
Establish what the
Trust’s legal
perspective of the
Coroner’s outcome
and the referral to
JRCALC for
amendment to
Paramedic training.
LQM to contact
Solicitor to check on
progress and to be
fed back to the
Medical Director
LQM
31/10/13
Letter of response
from solicitor
Clarification to
managers on
supporting staff
when attending
traumatic incidents.
Raise in SLT to
ensure Frontline
escalation.
Consultant
Paramedic to place
on agenda
Consultant
Paramedic
20/10/13
Minutes of meeting
There is a need to ensure for staff welfare is managed consistently and with clarity.
This is a very rare set of circumstances that has pulled together a wide range of clinical skills. Paramedics were
placed in a difficult position and operating at the limit of their training. Communication can be less effective
between Health Care Professional (HCP) in challenging situations.
Manager training for incident debrief and support needs to be considered the appropriate and referral to timely
counselling services. The organisation as a whole needs to view the mechanism by which staff are treated
following attendance at a traumatic incident and that the psychological impact this can have on individuals may
be different.
Evidence Gathered
Letter of Complaint
Time Line FC/040/13
SOE CAD
FC Proforma
Email ref Terms of Reference (TOR)
Email response --- ref TOR
Email confirmation --- ref Coroners Inquest
Investigation Log Book
Introduction letter to mother
Bailer Revised witness statement
Midwife Statement
Mother Statement
------ Report
P1 statement Statement
Coroner’s Report
Dr Report
PRF 3080346
--- Statement
Case Progress Sheet
Birth imminent delivery guideline
--- – Training Record
--- – Technical Training Log
--- – Summons from Coroners
--- – Paramedic Certificate
--- – Ambulance Service Para Training
--- – Ambulance Service Para Training Certificate
--- – Summons letter re
SI Reference No:
Date of
Submission
Date of Review
Status of SI
Report
Feedback Points
SI 2013-19619
30/9/13
2/10/13
Open
•
Establish if this SI related to Rule 43
Coroner has requested that JRCALC review the Paramedic Training regards to
maternity deliveries on a national level. There is no specific requirement on a Trust
level.
•
EMAS need to provide assurance that midwife specialist lead reviewed this SI
report.
Report was submitted to Midwife lead, who advised on full report and on
interpreting the statement from the attending midwife ref birthing positions.
•
EMAS also need to review specialist midwifery within the organisation.
Medical Director
Resubmission
Date
•
It would be useful to see the formal complaint received for this SI
•
In the Contributing factors – re: communication with mother we felt this was not
relevant to the incident
17/10/13
The investigation has been approached in a fair, open and transparent manner without prejudice to any individuals
concerned and has sought to establish the facts surrounding the incident, the decisions made during the incident and to be
objective throughout. The results published will ensure both positive and negative findings will be shared, along with any
lessons identified.
The investigation methodology was to first establish the facts into the incident and draw up a chronological sequence of
events of the Trusts involvement starting from receipt of the first emergency call on behalf of the mother to the point at which
the mother arrives at hospital. The methodology for gathering data will be specific to each investigation.
Director and or any other delegated managers and specialists; on occasion it may be appropriate to include staff involved
with the incident. The panel is convened to identify the root cause(s) and associated contributory factors of the incident. The
RCA members must agree on the recommendations arising from this investigation to prevent and/or minimise recurrence and
FC/041/13
Date Received: 02 July 2013
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: email
Their reference:
Logged by:
Incident Location:
--- year old child injured on school football field. LIVES responder &
AMVALE attended. The Amvale crew seemed to be lacking skill in the
complaint:
use of collar, spinal board & scoop stretcher.
Division/Area: Other
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
AMVALE
Why did the crew not seem competent once on scene?
Why did the crew not know how to use the equipment/find this difficult?
Email sent 10/07 16:04
FC/041/13
(EOC) on 2 May 2013.
Date and Time
12:36
12:36
12:37
12:39
12:44
12:50
12:53
13:24
13:25
13:44
14:39
Events
Cal 5515822 received into the Emergency Operations Centre (EOC) for male
complaining of neck and back pain after a fall. Coded correctly 17B01G Green2 (G2)
by call handler.
AMVALE crew AMV05 assigned to attend detail by Dispatcher.
AMV05 on route to detail.
LIVES Responder allocated by Dispatcher to attend incident.
LIVES Responder arrives on scene.
Update from LIVES Responder. Patient has tingling in hand and arms. Currently
immobilising.
AMV05 Arrive on scene.
Concern raised from LIVES Responder over care given to Patient from AMV05.
Pre-alert given to Hospital for AMV05. Estimated time to Hospital 20 minutes. Leave
scene.
AMV05 arrive at Hospital.
AMV05 clear from Hospital.
Evidence Gathered:
•
•
•
Sequence of Events (SOE) for Emergency Calls 5515822.
Email correspondence from AMVALE Investigations Officer.
Voice recording of call received into the EOC.
A call was received into the Emergency Operations Centre (EOC) at 12:36hrs. After being correctly
processed through the Advanced Medical Priority Dispatch system (AMPDS) it was coded Green2
(G2). A 30 minute response time.
Whilst the call was being processed at 12:36, the Dispatcher accessed the Resource Allocation
(Res/All) option and assigned the job to AMV05. AMV05 is an AMVALE crew which is a company
external to East Midlands Ambulance Service (EMAS). EMAS use external companies to assist with
the amount of calls received each day. The crews on these vehicles range in qualifications however,
the Dispatchers are aware of who is work to ensure the most appropriate response is sent.
At 12:39hrs, the Community First Responder Dispatcher allocated the job to the LIVES responder to
attend. LIVES responders are volunteers trained to give medical aid to the appropriate level they have
skills for.
The LIVES Responder arrived on scene at 12:44hrs and assessed the patient. By 12:50hrs he had
immobilised the patient and awaited the crews’ attendance. He contacted the EOC to update them on
the Patient’s condition.
By 12:53hrs the AMVALE crew were on scene and received a handover from the Responder. The
Responder has then raised concerns over the care given by AMVALE as it seems clinically they were
unaware of how to use the equipment.
At 13:25hrs, the AMVALE crew have the patient in the Ambulance ready to transport to Hospital. The
Hospital are pre-alerted to the patients condition.
From AMVALE Investigations Officer (IO);
The IO for AMVALE has explained to the LIVES Responder that the Emergency Care Assistant who
was part of the crew on this particular occasion has been interviewed. He has also tried several times
to speak to the nurse who works as a Technician for AMVALE but without success. As a result the
AMVALE IO emailed the nurse and asked specific questions based upon the concerns raised by the
LIVES Responder. The response from the nurse created more questions than answers. The AMVALE
IO has then emailed the Nurse three times since then insisting that he responds to emails. To date he
has failed to contact the AMVALE IO either by telephone or email. It is the intention of the AMVALE IO
to raise this at the next Clinical Governance meeting and ask that the Nurse is referred to the Nursing
and Midwifery Council for breaching his code of conduct.
In response to the concerns:
The nurse claims that he did not have a child or paediatric cervical collar on the vehicle and tried to fit a ‘small’
adult collar.
o The vehicle inventory clearly lists adjustable cervical collars as standard on all vehicles. The IO
asked the question why, if as stated, there was no child collar, that this was not picked up during
the vehicle daily inspection? There are stocks in the station store so there is no excuse why this
piece of equipment should have been missing.
o The nurse refers to the operation of the orthopaedic scoop stretcher as being ‘tough’. The ECA
stated that he didn’t think there was a particular issue with its operation. However, the Nurse
does have a disability where the ligaments in his fingers have become fibrous which may have
caused the LIVES Responder to assume that he had difficulty in operating the release catches.
The LIVES Responder questions the clinical abilities of the crew.
o
o
The Nurse is a registered General Nurse and is a specialist Critical Care Nurse and has
undertaken role specific training in a variety of advanced clinical procedures. He has also
undertaken role specific training as a technician for work on a front line Ambulance whilst
employed by AMVALE
The ECA has undertaken the AMVALE ECA Course which is based upon the Btec Emergency
Care Assistant course with additional modules that include ‘Assisting the Paramedic to include;
assisting with cannulation and Intravenous (IV) Fluid administration, drug therapy; assisting with
intubation; immobilisation and Support; use of the KED, Scoop and Long Board including
extrication, preparation of drugs and IV fluid.
The AMVALE crew fully immobilised the child onto the spinal board for the inbound journey into Lincoln County
Hospital and pre-alerted due to possible delayed hand over times.
Conclusion:
The crew from AMVALE attending the incident were fully qualified and competently trained to deal
with this. By not checking the vehicle thoroughly at the start of their shift, they neglected to have the
correct equipment on board to deal with a younger patient.
Both the Emergency Care Assistant and Nurse are trained and competent in the use of the scoop and
long board. The Nurse has a condition where the ligaments in his fingers have become fibrous. This
may make him appear to have difficulty operating the equipment however, this is not the case.
By pre-alerting the receiving Hospital, the crew were ensuring the patient received the most
appropriate care in a timely manner.
Recommendations:
Action: Communications for AMVALE crews to ensure vehicles are checked and the time for this not used as tick
box exercise.
For: AMVALE
Action: To share report with Amvale to support Clinical Governance Meeting with regards to the NMC
referral
For: AMVALE
FC/042/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 08 April 2013
Patient Name:
Deceased? Yes
Their reference:
Logged by:
Incident Location:
Brief details of the Patient had difficulty breathing. Amb crew did not take her to hospital. Pt
complaint: died the next day.
Division/Area: # A&E Lincolnshire (A/E)
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Were the patient and family fully advised of the patient condition?
Were they able to make an informed decision as to whether the patient should stay
at home?
Scope of Did the crew consider taking the patient in their ambulance, rather than using the
Investigation Bariatric Ambulance only? If not, why not?
(must include all
What is the maximum weight of the equipment in a standard ambulance?
complainant
concerns) : Was the patient adequately safety netted to stay at home?
Was the patient’s condition fully assessed and supported by both sets of
observations?
Telephone call and letter sent
Expectations of Complainant: Some understanding of what happened
Fc/042/13
Date and Time
8/4/2013
22:24
22:26
22:42
23:03 - PRF
Events
999 call received to a female reported as ‘Can’t breathe’.
This resulted in an automatic R1 coding under the Accredited Priority Medical
Dispatch System – this is the highest priority available and requires an 8
minute response.
Attending crew was stood down from a R2 Chest Pain call once coding was
confirmed with a 16 min ETA. Since call received, and crew arrived on scene
there were 6 checks of the Resource Allocation (Res/Alloc) button – this
shows all the available resources in the area available to be assigned to the
call.
Crew arrived on scene 16 minutes after call received – this was outside the 8
minute required response.
BMP 136
RR – 21 BPM
BP 140/102
SPO2 -97%
BM 21
Temp 37.1c
Pain – 0
GCS 15
Care plan – patient wishes to get meds in the morning for possible chest
infection
Impression Chest Infection/Pneumonia
(only one set of observations taken)
00:02
Crew cleared scene: ‘…treated on scene – refused to travel – may ring back
later - ?bariatric vehicle if does need to travel – approx. 26 stone..’
09/04/2013
12:44
12:45
999 call received to the address – CAD 5537236 – ‘collapsed –finding it hard
to breathe’
Dispatcher notes Out of Performance Report: Crew on Mablethorpe base
have 2 mins left of undis(turbed) meal break.’
Call coded as Cardiac Arrest of Female aged --- year old. Community First
Responder (CFR) assigned to the detail and Res allocate checked 5 times
between the Dispatch Officers and the CFR dispatcher.
Call Taker (EMD) notes patient ‘…weighs ----------- – caller struggling to move
pt…’ Two crews assigned to the detail – as per policy requiring at least 3
EMAS staff to attend all cardiac arrest call.
Crew arrived on scene – 1 minute outside of 8 minute response. This crew is
the nearest and most appropriate resource throughout the allocation process.
CFR arrives on scene to assist crew on scene
Second EMAS crew arrives to assist as per EMAS policy.
Police informed that patient Deceased
12:47
12:48
12:54
12:59
13:16
13:29
Evidence Gathered:
Letter of complaint
PRF Call 1
PRF Call 2
Call 1 SOE
Call 2 SOE
Call 1 WAV file
Interview Request Form P1
Out of Performance Reason Email
Radio Transmission request
Performance data
ROVI P1
Statement P1
Record of phone call – T1
DM notification of interview request
Email assessment of P1 statement
ECS live memo – patients left at home.
IF file copy of equipment maximum weights
Record of conversation with Mr G
At 22:24, on 8 April 2013, a 999 call was received for a --- year old female who had breathing
problems. This was coded as an R1, the highest priority response within the Accredited Priority
Medical Dispatch System. This requires an ambulance to attend within 8 minutes as is deemed
immediately life-threatening. The nearest vehicle, en route to a lower priority call, was diverted and
was on scene by 22:42. This was outside the 8 minute response requirement, but the location was
confirmed by Control Delivery Manager as only obtainable if attending from --------------------.
Whilst at scene T1 took observations, whilst P1 completed an Electronic Patient Report Form (ePRF).
P1 identified patient was having a panic attack and a chest infection. This was due to diminished
sounds on the right side. Only one set of observations were recorded and notes on patient care were
very limited.
P1 was interviewed, in presence of Team Leader (TL) and a statement was obtained. P1 admitted the
ePRF poorly constructed and was lacking in information regards this patient. P1 recalled the call in
detail, from memory, and recalls doing additional observations on the patient. When asked why the
Observations were not noted down, he could only say he may have over-written the original set. P1 is
aware of the fact that patients require two sets of observations, and that if it is not in the ePRF it must
be assumed they were not done.
An examination of the ePRF showed that the buttons ‘Edit’, ’Delete’, and ‘Save’ are beside each other.
TL confirmed that it was possible for observations to be overwritten if P1 pressed a button other than
‘Save’. An enquiry with Clinical Trainer, MB, confirms that there is no data footprint that can be used
to ascertain if other observations were over-written this way.
P1 confirms that his training on the ePRF system was when the system was introduced. This was in
2010, and that he had not used it till the local hospital went live with the system in 2012. He states he
had no interim training, and that he had still used paper PRFs for patients that were left at home. TL
asked P1 had not complied with the ECS memo regards to patients left at home. P1 stated he had not
been aware of this.
A clinical review of the ePRF, and statement, raised numerous concerns regards to the quality of the
report. This failing means that P1 had insufficient information to substantiate his actions on scene.
Locality Quality Manager (LQM), ---, reviewed the statement and states that had P1 ‘...placed more
safety netting in the comments box, and two sets of obs(ervations)..’ all issues would have been
resolved immediately.
When asked if he would have done anything differently regards this patient, he stated that he took all
the action he could to convince the patient to travel, but that he had to abide by her decision to stay at
home. T1 made enquiries with the Control Room regards to the Bariatric Ambulance attending, and
was given a 1 and half hour for arrival. When P1 spoke to the patient she did not want to travel in this
ambulance again, and agreed to see her GP in the morning. Husband agreed to arrange this.
Following this incident, husband was told the B.M. reading of 21. The husband felt was quite normal
for his wife. Both crew state they had no indication that the patient may have had a PE. That there
was no chest pain on inhalation, that the breathing was eased with Salbutamol, and repositioning. The
husband has confirmed this as correct.
The husband’s main concern was why the crew were only considering the Bariatric Ambulance. P1
stated that this was the only appropriate method of transport so the patient could be on a stretcher.
Husband wanted to know if she could have sat up in the chair, that is on the Ambulance, for the
journey. The Paramedic stated this was not possible as they would not have been able to monitor, or
treat her safely had she deteriorated on route. The husband had confirmed on the second call that
patient weight approximately --------. No TL attendance was requested to assess the patient as she
would not consider being transported. According to the Information File (IF) the maximum weight limit
on a Falcon stretcher is 28st, and the Ferno MK1 carry chair is 18st. The crew acted correctly by
wanting to transport on the correct equipment only.
On speaking with the patient’s husband, 26/7/13, he confirmed that his wife had capacity, and that a
B.M. of 21 was not unusual for her so not a concern in their eyes. Patient’s husband wanted to know
why the Crew had not told her she was going to hospital and not given her a choice. It was explained
that, as she had capacity, it is a legal requirement that the crew honour her wishes. That they
remained on scene 1 hour 20 minutes, and tried to convince her to travel. When the patient still
refused to travel that they both agreed to see the GP in the morning instead. The husband confirmed
that this had been agreed.
Conclusion:
Was the patient and family fully advised of the patient condition?
The ePRF information is extremely limited and does not evidence the information given to the family.
Both crew states they spoke with the patient, and her husband, about the patient’s condition, that they
had no concern of a Pulmonary Emboli (PE). P1 recalls telling the patient how high her blood sugar
level was, but did not tell the husband. He has, subsequently, been told the BM level of 21. Husband
did not feel this was unusual for his wife.
Were they able to make an informed decision as to whether the patient should stay at home?
The crew did not doubt that the patient had full capacity, and that she made an informed decision to
stay at home. The lack of details in the ePRF means there is no details supporting this other than her
signature.
Did the crew consider taking the patient in their ambulance, rather than using the Bariatric Ambulance
only? If not, why not?
The Paramedic stated that had they not used a stretcher, they would not have been able to monitor, or
treat her safely had she deteriorated on route. The husband had confirmed on the second call that
patient weighed, approximately, --- stone. No Team Leader attendance was requested to assess the
patient as she would not consider being transported.
What is the maximum weight of the equipment in a standard ambulance?
According to the Information File (IF) the maximum weight limit on a Falcon stretcher is 28st, and the
Ferno MK1 carry chair - 18st. The crew acted correctly by wanting to transport on the correct
equipment only as exact weight could not be confirmed.
Was the patient adequately safety netted to stay at home?
Yes. When the patient still refused to travel that she agreed to see the GP in the morning instead.
The husband confirmed that this had been agreed. The patient signed the ePRF confirming this
action also.
Was the patient’s condition fully assessed and supported by both sets of observations?
Statement from P1 outlines the patient was fully assessed, but this is not supported by the ePRF.
This form was below the standard required of Crew attending patients. It had only one set of
observations and contains limited information regards to actions on the scene. Clinical assessment of
ePRF, and the statement, raises no concerns regards to treatment of the patient on scene. The
Paramedic has been referred to additional training to ensure better quality Patient Report Forms in the
future.
Recommendations:
1. P1 to attend first available date for training on completing ePRF’s
Action: LQM
Evidence: Copy of certificate of attendance
Deadline: 21/8/2013
2. ePRF Audits to be monitored for 3 month period to ensure of a sufficient standard is
maintained
Action: TL
Evidence: Report of satisfactory completion
3. P1 to seek guidance from TL, and Peers, regards ePRF issues he has with using the system.
Action: P1
Evidence: Co-sign the TL report of satisfactory completion.
Learning Outcome: Staff members may need additional support with changes in Information
Technology. It is not sufficient to give Initial Training and expect all staff to take the lead in the
development of their skills. Some staff will shy away from its use. More robust monitoring must be
performed to ensure this support is in place, and people not using the systems must be identified and
given additional training to increase their confidence at the earliest point possible.
FC/043/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the Complaint regarding paramedics not taking child with abdo pain to
complaint: hospital. 2 days later his appendix ruptured.
Division/Area: # A&E Northamptonshire. (A/E)
(15 working days)
(20 working days)
Staff involved Technician - No longer employed by the EMAS.
& Station: Paramedic
Training Dates – Paramedic
EE: 23/5/2012
CRT: 29/5/2012
ETLS: 28/5/2012
Resus Update: 13/7/2012
IPR: 5/5/2012 & 28/6/2013
Initial grading
& Rationale:
Moderate
The investigation covered the period between receipt of the emergency call and the
point at which the crew booked clear from the scene, and it addressed the following
concerns raised by the complainant:
Scope of
Investigation
Please explain why paramedics failed to suspect appendicitis as a differential
(must include
diagnosis?
all
complainant
Please explain why paramedics did not transport my son to hospital on the day of
concerns) :
their attendance?
18/07/2013
Expectations of Complainant: Explanation and apology
Date LQM/Manager informed: Friday 5th July 2013 at 12:44hrs
Investigation launched 6/7/13
Immediate actions taken: Copy of PRF requested & obtained 7/7/13 & 8/7/13
Statements requested 8/7/13
FC/043/13
Chronology of Events: Taken from the Computer Aided Dispatch (CAD) sequence of events (SOE)
for call reference 4447574 on 29 February 2012.
New call received at 10:42 hrs on 29 February 2012 on behalf of a 12 year old male with pain in the
legs and abdomen. The patient was also vomiting. The call was coded as 26C02, sick person,
abnormal breathing, and allocated a response within 30 minutes. Resource 0614, double crewed
ambulance, was allocated at 10:44 and this arrived on scene within one minute. The patient was
examined and a medical history obtained. The crew called clear at 11:16 hrs having treated the patient
on scene.
Evidence Gathered:
CAD report
Statement of attending paramedic.
Handling of emergency call: the call was correctly coded as a Green 2 30 minute response, and the
ambulance arrived at the scene within two minutes.
Care and treatment of the patient: The patient was complaining of being generally unwell for the
past 2 days with a recent episode of vomiting and mild abdominal pain.
In a statement received from the attending Paramedic he states that ‘on arrival at 10:44, we
commenced history taking and examination of the patient. The history established that there was no
past medical history of note, he was not on any current medications and there were no reported
allergies’.
Please explain why Paramedics failed to suspect appendicitis as a differential diagnosis?
In a statement from the attending Paramedic its states that ‘whilst examining the patient it was found
that his abdomen was slightly tender on palpation. With a history of abdominal pain and vomiting; I
considered appendicitis as a differential diagnosis. The patient was assessed for rebound tenderness,
Psoas sign (assessment used to gauge abdominal pain) and any referred pain, of which they were all
negative. The observations recorded were within normal range for a patient of his age; capillary refill
time was good at < 2 seconds, oxygen saturations on air were 98%, the pulse was 106; the mild
tachycardia was accredited to our presence and the patient feeling generally unwell with mild pain and
temperature was 37.1 C.
The patient was taking oral fluids and managing the pain with paracetamol. At the time of examination
there was no indication that the patient was experiencing acute appendicitis. A collective decision
involving the family was made not to transport the patient to hospital and remain in the care of the
family’.
Please explain why Paramedics did not transport my son to hospital on the day of their attendance?
The Paramedic states that advice given to the parent of the patient was to visit the family GP if they
felt it was necessary or to call 999 if they were concerned at any time. The patient report form was
filled in and these points explained to the parent before they signed to confirm they understood what to
do if concerned. The Paramedic also highlighted the self-care advice on the rear of the form that he
left with the family, emphasising the signs to be aware of. The crew booked clear from scene at 11:16.
The PRF disclaimer signed by -------------------------------- on the 29/02/12 stating that - ‘I hereby
understand and accept all responsibility for my refusal of transport to hospital and agree with the
alternate arrangements above’ – which clearly states ‘advice given to parents to see GP if necessary
or call back’. This indicated appropriate safety netting undertaken by crew.
No ‘call back’ details found for this address on CAD within the two days following initial attendance
and the child’s admission to hospital.
No other clinical concerns/incidents raised since incident on Feb 2012 for the attending Paramedic –
decision not to remove the Paramedic from patient facing duties due to time elapsed and no further
incidents to indicate significant care management and/or performance concerns.
Conclusion:
Documentary evidence on the PRF suggests that the crew did consider differential diagnosis of
appendicitis/peritonitis given the documented findings of: negative psoas, negative referred pain and
no rebound tenderness: signs commonly associated with peritonism and/or appendicitis.
At the time of examination there was no indication that the patient was experiencing acute
appendicitis. A collective decision involving the family was made not to transport the patient to hospital
and remain in the care of the family. Appropriate safety netting was delivered by the crew prior to
booking clear from the scene.
A letter of explanation will be sent to the complainant.
Potential Learning Outcomes:
Only one set of baseline observations recorded, and PRF not fully completed.
PRF details basic palpation of abdomen, but no further examination is stated (inspection, palpation,
percussion, auscultation).
No pain score documented on PRF
Patient was pale, tachycardic (106 / 116) and temp 37.1 having taken paracetamol – which could be
considered potential ‘red flags’.
Crew could have considered arranging GP appointment prior to leaving scene and not reliant upon
mother making contact with GP, as a safety netting measure.
Recommendations:
The observations made by the Locality Quality Manager in respect of potential learning outcomes will
be fed back to the attending Paramedic.
Action: File noted discussion between the attending Paramedic and his line manager to discuss the
observations and learning outcomes.
For: Locality Quality Manager.
Deadline: 18 August 2013.
Evidence: Documentary evidence of file noted discussion.
FC/044/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 21 June 2013/ 14 August 2012.
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the Patient’s daughter believes that the attitude & arrogance of paramedic
complaint: compromised her father’s treatment.
Type of Complaint: Attitude (Attitude)
Division/Area: # A&E Nottinghamshire (A/E)
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Minor
Did the previous incident with -------------- compromise the treatment given to the patient on
21 June?
Was the treatment given on 14 August 2012 appropriate?
Contact attempted 16/7, 18/7. Message not left as the IO is
unsure if the number is ---------------. 24/7 spoke to ---------------------. Number given for ------------ but this is not
recognised. Verified the number with ------------- but it is still
not recognised. Contact made with --------------- 26/7.
Immediate actions taken: PRF’s requested.
FC/044/13
Chronology of Events: taken from the Computer Aided Dispatch (CAD) sequence of events (SOE)
for call reference 5632676 on 21 June 2013 and call reference 4860404 on 14 August 2012.
14 August 2012: new call received at 01:19 hrs on behalf of a --- year old female who has difficulty in
breathing. The call is assessed as requiring an emergency eight minute response, and at 01:20 hrs a
DCA is allocated to the incident. The prioritisation for the response is amended to 20 minutes at 01:24
hrs. At 01:27 hrs a CAD message is entered which reads: “Spoken to the caller states patient may
have whooping cough and is having a breathing problem at present. Heard talking in the background.
Crew to attend”. The resource arrived on scene at 01:28 hrs. After treating the patient on scene the
crew call clear at 01:56 hrs.
21 June 2013: new call received at 20:38 hrs on behalf of a male who is unable to pass water. The
call is assessed as requiring an ambulance response within 30 minutes. A message on CAD reads: “-- year old male onset of abdominal pain and inability to pass urine, severe pain, on antibiotics for uti
from gp but now unable to cope with pain, pain relief advice given. Green 2 response arranged”. A
double crewed ambulance (DCA) is allocated at 20:50 hrs, arriving on scene at 20:59 hrs. The crew
leave the scene with the patient at 21:13 hrs and arrive at hospital at 21:28 hrs. The patient is handed
over to hospital staff at 21:38 hrs.
Evidence Gathered:
CAD reports
Patient Report Forms (PRF).
Statement from complainant.
Statements from crew members.
Handling of emergency calls: Both incidents were allocated a 30 minute response, and crews
arrived with the patient within this timescale on both occasions.
Analysis of information collected in respect of the incident in August 2012: the attending crew
have advised that on arrival they were taken through to the patient who reported that she was having
trouble breathing. The patient also advised that she thought she may have whooping cough.
A full set of observations were taken including chest sounds which all appeared normal. The crew
advised that they offered to transport the patient to hospital but she declined.
As a precautionary measure it was suggested that the patient should see her GP as he was already
aware of her presenting condition. The crew formed the impression that the patient was not completely
happy with the outcome although she had declined transportation to hospital. A PRF for this incident
could not be found in EMAS records, and the crew could not recall whether the form completed was
electronic or paper based. The complainant cannot recall signing a PRF on this occasion but she
could not state for certain whether one was issued to her or not given the lapse in time since the
incident.
The complainant advised that she formed the impression from the outset that the attending Technician
thought she was uptight and her problem was more psychological than physical. She advised that she
was subsequently admitted to hospital with a diagnosis of whooping cough.
Analysis of information collected in respect of the incident in June 2013: The complainant
advised that on arrival the attending Technician was dismissive towards her, and she advised him that
she had had an issue with him on their previous meeting in 2012.
The ambulance crew took her father onto the ambulance at her request and a set of observations was
carried out prior to the ambulance leaving for the hospital. The Technician declined to take the
complainant to hospital with her father, and her mother travelled instead in the ambulance.
The complainant advised that en route to the hospital the Technician had passed comment about the
complainant’s attitude. On arrival at the hospital the Technician took a nurse to one side to discuss the
situation, and as a result of this her father was discharged with a suspected UTI after little
examination. It was only after the complainant intervened that her father was re-examined and
retention was identified.
The crew members advised that shortly after their arrival the complainant had advised that she had
had a previous issue with the Technician following the crew’s attendance to her in 2012. The crew
wanted to take a set of observations in the house but the complainant insisted that her father be taken
directly to the ambulance and they complied with this.
On board the vehicle a full set of observations and medical history was taken and it was established
that the patient had been diagnosed with a urinary tract infection and been prescribed medication for
this. The Technician confirmed that he did refuse to allow the complainant to travel with her father as
her attitude was unhelpful to the situation.
The Paramedic observed that en route to the hospital the interaction between the Technician and the
patient and his wife was light hearted. Pain relief was offered to the patient but this was declined.
On arrival at the hospital the patient was taken into Accident and Emergency and transferred to a
hospital trolley. After a short time he was taken through into a cubicle. The Technician approached a
nurse in the cubicle and took her to one side to give a handover. The Technician confirmed that this
was a normal handover of presenting condition and medical history. He did advise that he thought the
complainant was unhappy with the crew following an earlier incident, but this had not in any way
compromised the treatment and care given to the patient.
Conclusion:
In respect of the incident in 2012, the crew have acknowledged that the patient did not appear
completely happy with the outcome of their attendance to the patient, although she did decline
transportation to the hospital. The investigation officer has been unable to trace a PRF relating to this
incident in EMAS records.
In respect of the 2013 incident, it was acknowledged that the complainant was unhappy with the crew
following their earlier interaction and she believed that this affected the care and treatment given to
her father. The Technician confirmed that he did comment on the demeanour of the complainant to the
patient and his wife and to the nurse on handover, but his did not in any way compromise the care and
treatment the patient received.
Recommendations:
As the PRF could not be found and the crew are certain one was completed the TL should meet with
the staff to ensure they are filing PRFs correctly and where ePRF is available that training is up to
standard.
Action: TL to speak with staff to establish their understanding of the PRF filing process
For: CTM
Deadline: 30 September 2013
Outcome: to ensure that staff are filing correctly and that if any areas of the process are not robust, the
CTM can action.
The Crew members state they were aware that the patient was unhappy about the decisions made on
scene, despite agreeing not to be conveyed.
Action: Reflective discussion with the crew on how to use CRT to resolve matters on scene
For: CTM
Outcome: to ensure patient experience is to a high standard and that staff are able to implement their
CRT effectively.
Date report sent to Investigation Manager for approval: 15/08/2013 approved
Date feedback given to complainant: Verbal feedback given
FC/045/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the Attitude and inappropriate comments of female member of ambulance
complaint: crew.
(15 working days)
(20 working days)
Date to post response letter: 02 August 2013
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Establish did the paramedic use inappropriate and unprofessional behaviour
towards patient, family and staff? If so, what action is to be taken regards to this
behaviour?
Contact made with complainant: Email to CPN sent
Expectations of Complainant: Informed of action to be taken re Paramedic
FC/045/13
Date and Time
17/5/2013 13:33
13:36
13:35
1/7/2013
Events
999 call received CAD 5551030 to the address for a --- year old female who
had tried to hang herself.
Patient was reported not to be alert; had MS and a history of self-harm.
Crew assigned and call coded G2 response – face to face contact within 30
minutes. Crew arrived at 13:40 (within the target timescale and transported
the patient to hospital.
Letter received from CPN at hospital stating the Paramedic (P1) had stated to
Worker at Care Home “people like ------------ should be put in a wicker basket
(cheapest coffin), dumped in the ground and forgotten about”). P1 is also
stated to have made negative comments to the patient’s sister.
Then comments from P1 reported to have been made to nursing staff:
“(Patient)… is schizophrenic and should be locked up and the keys thrown
away and she should stop wasting government money’. P1 was additionally
reported to have spoken, audibly in the public foyer of the hospital in a ‘vocal
and unprofessional manner’.
Evidence Gathered:
SOE CAD
Record phone call
PRF 5551030
Record phone call
AT 13:33 --- year old patient was found by care home staff having tried to hang herself with an
exercise band. Patient was reported to have a history of Multiple Sclerosis (MS) and self-harm. The
call received a G2, within 30 minutes ambulance required, coding and an ambulance was immediately
dispatched.
Crew arrived on scene, within 5 minutes, and were shown through to patient. Staff members, --- and -- were with the patient. They escorted patient to the ambulance with the crew but, as patient had not
requested an escort, it was decided that --- would follow in her own car. No staff were in the
ambulance during transport. --- stayed at the home with the other patients. Whilst --- was in the car
park Paramedic (P1) returned from the ambulance to inform her that the patient had tried to grab
some scissors. On arrival at hospital --- joined the patient and crew.
Both --- and --- have been spoken to. Neither have any concern about P1’s behaviour. They feel that
P1 acted appropriately at all times whilst they were present. --- mentioned that P1 had tried to stress
to the patient what would have happened if she had succeeded, that patient would now be dead. --felt that P1 had been firm to the patient but that in the circumstances the patient needed to be handled
with a firm voice. --- felt that P1 was empathetic and very understanding of the family’s situation.
Conclusion:
Both witnesses, provided by the CPN, have been spoken to. Neither have any concerns with the
Paramedics behaviour, and both spoke highly of the Paramedics approach to the patient.
Recommendations:
None
FC/046/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
How Received: Email
Their reference:
Logged by:
Incident Location:
Brief details of the Pt in labour. Unhappy with how the ambulance crew dealt with the pt.
complaint: Baby was delivered, but died next day.
Division/Area: Protected under Data Protection Act
(15 working days)
Date for Investigation conclusion: 01 August 2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
What time did the ambulance arrive?
Scope of Who assessed the Situation?
Investigation What was the outcome of the assessment?
(must include all
complainant
concerns) :
Was Samantha placed on any monitoring device?
Was Samantha told at any point that the baby was in distress?
What time did the arrive at the hospital?
Email staff – 22/7/13
Expectations of Complainant: Full response
FC/046/13
Date and Time
18/5/13 18:10
18:10
Approx 18:14
19:06
19:12
Events
999 call received from Maternity at Hospital – CAD 5553826. Stated patient was in
labour and midwife was on phone assisting with the delivery. Contractions were
approximately 3 mins apart and patient was full term. Attempts were being made for a
Community Midwife to attend but they were currently on another call.
The Crew arrived with the patient at 18:18. The call was coded as a G2 response and
the crew arrived within 8 minutes of the call connecting. A G2 requires that an
ambulance be on scene within 30 minutes, the crew were within the G2 on scene
attendance
Crew state that two midwives arrived on scene a couple of minutes after them, the
midwives then took over the care of the patient and baby. Midwives requested patient
was not moved as they did not want to deliver in ambulance.
PRF states that patient overdue by 5 days, and returned from Maternity twice that day.
Patient not crowning and dilated at 9 cm. Crew members waited in another room as
both midwives were on scene attending the patient.
Crew left scene with patient on instructions of midwife when the baby went into
distress.
Arrived at Maternity with the patient
Evidence Gathered:
Complaint
PRF
CAD SOE
Crew Email response
At 1810 on the 18 May 2013 the Maternity Department requested a 999 call to the address. The crew
arrived within 8 minutes. The Paramedic (P1) completed an assessment of the patient on arrival
‘…(t)he patient wasn’t crowning, and contractions were difficult to time as patient was verbalising her
discomfort continually.’ The Maternity Unit were still on the phone advising family at this time. The
patient was offered entonox whilst crew obtained an update from the maternity department.
P1 attempted to obtain a blood pressure reading but was ‘…unable to record a blood pressure due to
(patient’s) constant movement of her arms.’ Two midwives arrived on scene within a couple of
minutes of the crew. The Midwives took over care of the patient, took her blood pressure and
completed several auscultations of fetal heart.
As Midwives were managing the care of the patient both EMAS staff waited in another room.
Midwives had not wanted to transport patient initially as they did not want the patient to deliver in the
Ambulance. The crew do not know when patient was told that the baby was in distress as they were
not in the room. At 19:06 the crew left scene with the patient and midwife and arrived at the Maternity
Department at 19:12. The Midwife took clinical lead throughout.
Conclusion:
The Ambulance arrived on scene at 18:18, 8 minutes after the 999 call was received. During the call a
Midwife from the Maternity department remained on the line with the family members.
An initial assessment was completed by the Paramedic (P1) and, on visual inspection the vertex of the
baby was not visible. The patient was in discomfort and constantly moving her arms so the Paramedic
was not able to obtain a Blood Pressure measurement. Two midwives arrived on scene, within
minutes of the crew, therefore the midwives took primacy in the care of the woman and her family.
When Midwives took over care of the patient they were able to obtain her blood pressure and
completed several auscultations of the fetal heart. Ambulance personnel do not possess equipment to
monitor the well being of the baby therefore all information regarding fetal wellbeing would have been
assessed by the attending midwives.
The crew do not know what the patient was told by the midwives as they were not in the room. The
midwives took clinical lead once they arrived at the address. EMAS staff interaction with the patient
was minimal.
The crew left with the patient and midwife at 19:06 on the Midwives instruction. They arrived at the
Maternity Department at 19:12. The crew left the hospital at 19:27 as the Midwife had taken over care
of the patient on arrival at scene.
Recommendations:
No Recommendations identified
FC/047/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the Pt with back pain. Unhappy with FRV attitude, lack of examination,
complaint: diagnosis, and referral to GP.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
1. Was the first attending paramedic’s examination complete and correct?
2. Was it appropriate for you to be referred to the GP? If not, should you have
been transported to hospital on that first call?
3. What action did the ECP (second vehicle) take when on scene?
4. Was an urgent transport within 4 hours the correct transport timescale for
your condition?
Intro letter
Expectations of Complainant: Explanation
Fc/047/13
Date and Time
3/5/13 07:28
07:51
13:48
14:35
15:16
15:23
16:24
19:35
19:50
19:54
21:12
21:17
21:39
Events
111 send through call on the Automatic system: 5517583 requesting a G2, emergency
transport request within 30 minutes. Patient in agony; cannot get out of chair; lower
back shoulder, legs and left side of face. Numbness in cheeks.
Single crewed Ambulance assigned to the call, driven by P1. Arrived on scene at
08:13 hours – outside of the G2 response time. P1 left scene at 09:20 – detail closed
as Treated on scene, and referred to GP for additional medication
Call received to a major RTC on A46, approximately 20 miles for patients address.
Detail requires 6 EMAS vehicles to attend, with last vehicle clearing scene at 16:42.
One EMAS vehicle receives damage and is taken off line.
999 call to address for back problems – CAD 5518408 . This was taken through the
AMPDS system and coded G4 – to send to EMAS Clinician for triage.
999 call to address for male with back problems – CAD 5518497 . Patient requesting
ETA on TAS call. This Coded G3 which is a Triage call back.
TAS spoke to the patient call and created CAD 5518547. Back pain since 20:00, ongoing problem for 16 months. Got worse last week, then again last night. Alert.
Lower back pain just above his bottom. Pain level 10. Taken morphine, tramadol and
amitriptyline. Pain too bad to get up. No temp. Legs weakened but no loss of
sensation. Patient said weakness was due to pain causing legs to give way. No time
scale given for ambulance due to large number of calls. TAS upgraded call to G2
response.
ECP was assigned to CAD 5518547 at arrived scene at 16:35. Patient told ECP on
arrival that he did not need a paramedic, and that an ambulance was supposed to be
on the way. ECP radioed the Control Room and explained that patient required
Ambulance transport and that he was an inappropriate response. Dispatcher then
created another CAD 5518675 as a within 4 hour collection. Request was made that
the patient be welfare checked if not collected by 18:45 and a warning alert to the
Dispatcher was placed on the detail. ECP remained on scene for 9 minutes, no PRF
completed, ECP states no examination of patient completed, no supporting
documentation.
Welfare check request not completed at 18:45; Dispatcher now checks Resource
Allocation (Res/Alloc) and crew assigned to attend the patient – no blue lights.
999 call to male with back pain – CAD 5519065. Coded G4 and advised ambulance
will be with them as soon as possible. Urgent was not out of time so not upgraded by
dispatcher – check urgent policy at time.
Performance Delivery Manager’s Log Reports: CAT Team welfare checking holding
calls
Crew arrive on scene and transport the patient to the hospital. Urgent collection was
total of 4 hours and 37 minutes.
Performance Delivery Manager’s Log Reports: R1 triage suspended to assist with
Triage backlog.
Performance Delivery Manager’s Log reports:
26 uncovered 999 calls holding; 11 G3/4 Calls awaiting triage and 7 out of time urgents
across EMAS. Capacity Plan (CP3) implemented
Evidence Gathered:
SOE CAD Call 1
SOE CAD Call 2
SOE CAD Call 3
SOE CAD Call 4
SOE CAD Call 5
SOE CAD Call 6
Letter Complaint
EMAS Daily Performance Review
Call 1 WAV file
Call 2 WAV file
Call 3 WAV file
PRF Call 1
Performance Delivery Managers Resource Log
Lincs Resource Log
PRF Call 3
Email LQM re 2nd RRV attendance
LQM response to 2nd RRV attendance
EMAS Clinical Record Keeping Policy
Performance Review
East Midlands Ambulance Service (EMAS) was under performing on all categories of calls. There was an
increase in calls of 9.76% on previous week across the board. Response times to Red calls, requiring 8 minute
response was 72.9% (below 75% required); G1 performance was 80.58% (should be 95%); and G2 performance
was 82.04% (should be 85%).
Capacity Plan (CP) 3 implemented at 21:39: 26 uncovered 999 calls holding; 11 G3/4 Calls awaiting triage and 7
out of time urgent calls across EMAS.
Serious RTC in Lincolnshire Division, 20 miles for patients address, requiring 6 resources at attend. Last unit
clearing at 17:00, Delivery manager noted this as effecting response to other details.
At 08:20 on Friday, 3 May 2013, Paramedic (P1) attended patient for on-going back pain problem.
Patient spoke with P1 and with own GP. A care plan was established for the GP to call back later to
monitor patient’s pain level. Patient signed to say that this was acceptable.
At 14:35, first 999 call was received for the patient. This was taken through the Accredited Medical
Priority Dispatch System (AMPDS) and coded as suitable for further triage by an EMAS Clinician
(CAT) within the hour. Clinician spoke with patient, within 50 minutes of this call, and assessed his
condition. CAT upgraded call to a G2 call, ambulance required within 30 minutes.
Due to a serious Road Traffic Collision in the area, an Ambulance was not available to attend within
this timescale. The Dispatcher assigned an Emergency Care Practitioner (ECP) to this call. On arrival
ECP states he was informed by the patient an ambulance was organised already. ECP remained on
scene for 9 minutes and there is no record that the patient was examined.
ECP cleared scene and an ambulance was requested for within 4 hours, and that patient be welfare
checked if not collected within 2 hours. Records have been searched and there is no trace of a PRF
for the ECP visit. As there is no PRF there is no evidence to show if this was an appropriate response
to the patient. Section 3.2 of the Clinical Records Keeping Policy states that PRF is to be completed
‘…by all personnel for each patient attended…’ and a ‘…form should be generated whenever a vehicle
arrives on scene at an incident.’
At 21:12, ambulance arrives on scene to collect patient on the urgent booking. This is 37 minutes
outside of the 4 hour timescale requested by the ECP. No welfare check was instigated at the 2 hour
mark. A note was made in the Performance Delivery Managers resource log that CAT were
completing welfare checks, but this patient was not noted as checked, nor was the computer log
opened in this timescale. Capacity Management Plan (CP) 3 was instigated at 21:39 as demand on
EMAS services outstripped the services available resources.
Conclusion:
Care plan instigated by Paramedic (P1) was done in conjunction with discussions with patient’s GP,
and with agreement of the patient himself. GP spoke with patient and Paramedic. This was an
acceptable course of action as condition was indicated to have been on-going for 18 months. GP
agreed to monitor patient’s pain levels.
The ECP, attending later that day remained on scene for only 9 minutes. ECP confirms no treatment
or observations completed. No PRF on file recorded. These failures breach the Clinical Records
Keeping Policy.
There is no evidence to support the booking of a 4 hour urgent for this patient. No observations were
done, no PRF completed, due to this a 4 hour booking cannot be supported.
Delay in attending patient with in the 4 hour urgent was due to high level of calls being received
outstripping EMAS’ resources available to respond. Twenty five minutes after crew arrived with patient
Capacity Management Plan 3 was instigated.
Recommendations:
ECP to be file noted for breach of Clinical Records Keeping Policy.
Action:
Evidence: Copy of File Note
Deadline: 31/7/2013
Date report sent to Investigation Manager for approval: 23/07/2013 approved 24/07/2013
FC/048/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 11 July 2013
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Incorrect diagnosis by 999 call taker and delayed response.
complaint:
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Paramedic
moderate
Why did the call handler diagnose incorrectly?
Why was a Paramedic not sent straight away?
What was the reason for the delayed response in treatment?
19/07/13 11:25hrs
As above
FC/048/13
Operations Centre (EOC) on 11 July 2013 and the Patient Report Form (PRF) details.
Date and Time
16:38
16:43
16:51
17:00
17:02
17:05
17:22
17:59
Events
Call 5680462 received into the Emergency Operations Centre (EOC) Correctly coded
as 06C01A Green 3(G3) 20 minute Clinical Assessment Team (CAT) call back. Caller
was not the Patient.
CAT called back patient and spoke with her gaining further information. Patient
Husband attending shortly, advised to make own way to Casualty/Walk in Centre.
Call 5680462 correctly closed by Dispatcher as no resource required.
Second call 5680512 received into the EOC. Correctly coded as 06D01 Red 2 (R2) 8
minute response. Caller was not with the Patient.
Rapid Response Vehicle (RRV) 4730 correctly allocated by Dispatcher and en route to
attend detail.
RRV arrives on scene of incident.
RRV confirms no crew required and is dealing with incident.
RRV calls clear from detail and Dispatcher correctly closes job.
Evidence Gathered:
• Sequence of Events (SOE) for Emergency Calls 5680462 and 5680512.
• Voice recordings of calls received into the EOC.
• Call audit reviews for 5680462 and 5680512.
• Correspondence for Making own way to Hospital from Clinical Assessment Team Manager.
The first call was received into the Emergency Operations Centre (EOC) at 16:38hrs. The call was
made to the EOC by someone who was with the Patient; and processed through the Advanced
Medical Priority Dispatch System (AMPDS). The response gained from this process was a Green 3
(G3) 20 minute call back from a Clinician on the Clinical Assessment Team. The caller was not told
that a Nurse would be sent.
At 16:43hrs, a Paramedic working in Control as part of the CAT rang back. The phone was answered
by someone other than the patient. As the Patient was able to talk they were put on the phone. The
Patient told the Paramedic of her presenting condition and symptoms that she had. The Patient was
able to talk in full sentences and answered the questions posed to her such as; does it hurt more in
your chest when breathing in or all the time?
Information was provided to the Paramedic that the Patient had previously had an Asthma Attack and
she normally manages them, this did not feel the same. No mention was made with regards to an
onset of paralysis.
The Patient advised the Paramedic that her Husband was on the way. The Clinician stated that as she
was talking in full sentences, it would be better for her Husband to take her to Casualty or the nearest
Walk in Centre to get checked out. The Patient had said yes to the instruction of the Paramedic.
A second call was received into the EOC at 17:00hrs. The call was made by someone with the Patient
and again processed through AMPDS in order to give the most appropriate response. From the
information given on the second call, the response was given a correct code of Red 2 (R2) 8 minutes.
The Dispatcher accessed the Resource Allocation(Res/All) function and dispatched an Ambulance
Car at 17:02hrs which arrived with the Patient by 17:05hrs. The Paramedic assessed the Patient and
treated at scene with no requirement for a Double Crewed Ambulance to attend. At 17:59 the
Paramedic called clear from this detail.
Conclusion:
Why did the call handler diagnose incorrectly?
When a call is received into the Emergency Operations Centre (EOC), it is triaged using information
gained from the caller following a set of pre-defined questions on the Advanced Medical Priority
Dispatch System (AMPDS). The Call Handler does not diagnose and allows the system to provide the
most appropriate response based upon the facts that are provided.
Why was a Paramedic not sent straight away?
From the information gained in the first call to the EOC alternative care pathways were identified and
in accordance with the process a Clinician was requested to call back and triage the Patient further;
ensuring the most appropriate response was given.
A Paramedic from the Clinical Assessment Team (CAT) called back and spoke to the Patient. The
Patient was able to speak in full sentences and provide the Paramedic with answers to the questions
that were being asked. From the assessment made, there was no immediate clinical need for an
Emergency response to be sent. No mention was made with regards to an onset of paralysis.
The Patient made the CAT Paramedic aware that her Husband was travelling to her. It was then
suggested by the CAT Paramedic that in order to be checked out appropriately she should make her
way with her Husband to the nearest Casualty or Walk In Centre. The Paramedic by this stage had
ruled out certain conditions in the questions that had been asked such as ‘does it hurt more when you
breathe in or all the time?’
Following a Clinical assessment, if the Clinician feels that the Patient is clinically stable then they can
advise the Patient to make their own way to Hospital.
What was the reason for the delayed response in treatment?
When the second call was received into the EOC at 17:00hrs, it was coded correctly by the call
handler with the new symptoms presented. An immediate response was dispatched. A Paramedic was
on scene within 5 minutes of the call being placed.
The Paramedic on scene was able to fully examine the Patient in person and rule out life threatening
conditions. The Patient was treated on scene.
Recommendations:
Good Practice: CAT advised Make own way (MOW). Paramedic called later. Patient treated on
scene. No Ambulance response was required.
Date report sent to Investigation Manager for approval: Approval 080813
FC/049/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? Yes
Their reference:
Logged by:
Incident Location:
Brief details of the 90 minute delayed response to elderly Warfarin pt on oxygen that had
complaint: fallen.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Why was there a delay in responding to the Patient?
Were there any personnel in the local Station who could have assisted?
16/07/13 1435hrs by telephone
As above
FC/049/13
Operations Centre (EOC) on 9 July 2013 and the PRF details.
Date and Time
14:42
14:44
15:19
15:43
15:53
15:54
15:54
15:56
16:05
16:05
16:06
16:09
16:56
17:20
18:04
Events
First call 5675640 received into the Emergency Operations Centre (EOC).
Patient fallen and trapped behind door.
Incorrectly coded by the Call Handler as 17A01G Green2 (G2) 30 minute response.
CFR Dispatcher accesses Resource Allocation (Res/All) to check if any suitable CFR
available.
nd
Second call 5675738 received into the EOC. 2 Call Fallen.
Coded correctly by the Call Handler as 17B01G G2.
Call passed to Clinical Assessment Team (CAT).
Upgraded by CAT to Green1 (G1) 20 minute response.
Trainee Dispatcher accesses Res/All function, no crews available.
Notes from CAT, Patient been on floor a long time, on O2(Oxygen) and has Warfarin
(blood thinner). Patient at high risk normally of Pressure Sores.
Notes from CAT, arm behind her. Toes and lips tinged blue, normal but slightly darker
at present.
Trainee Dispatcher accesses Res/All function to find crew.
Double Crewed Ambulance (DCA) 2214 allocated to attend incident.
DCA 2214 Mobile to incident.
DCA 2214 Arrives at scene.
DCA 2214 leaves scene towards Hospital.
DCA 2214 arrives at Hospital with Patient.
DCA 2214 come clear from incident.
Evidence Gathered:
•
•
•
•
•
•
Sequence of Events (SOE) for Emergency Calls 5675640 and 5675738
Resource Log for DM.
Performance Data for 9 July 2013.
Resource Log for Notts Dispatch Desk
Copies of emails from Dispatch Manager regarding Dispatch training.
On the day of this incident, the Dispatcher was training a member of staff on how to Dispatch. The
trainee was logged into CAD with the Dispatcher observing.
The first call was received into the Emergency Operations Centre (EOC) at 14:42hrs stating a patient
had fallen and was trapped behind a door. The call coding was incorrect but achieved the correct
response a Green2 (G2) 30 minute face to face contact.
At 14:44hrs a Community First Responder Dispatcher checked for any resources in the area via the
Resource Allocation (Res/All) function. There were no suitably trained responders who could attend.
By 15:19hrs, a second call was being received into the EOC. Information was entered as ‘2nd Call
Fallen’. This was coded correctly as G2 by the Call Handler.
Due to the time the Patient had been waiting, a member of the Clinical Assessment Team (CAT) made
contact with the caller and carried out a clinical assessment. The call was then upgraded to Green1
(G1) 20 minute response.
The Trainee Dispatcher accesses the job fully for the first time at 15:54hrs. The Res/All function is
accessed with no vehicles being available.
Notes are made by the CAT Nurse as to the Patient’s condition. The Patient had been on the floor a
long time and was now on Oxygen (O2). The patient also takes Warfarin (a blood thinner). The Patient
was deemed to be of high risk especially of developing pressure sores. Also noted was the colour of
the Patient with darker than normal blue tinges to her lips and toes.
Again at 16:05hrs, the Trainee Dispatcher accesses the Res/All function and assigns a Double
Crewed Ambulance 2214 to the detail.
The crew arrive at the scene of the incident by 16:09hrs and have the patient to the Hospital by
17:20hrs.
On the day of this incident, East Midlands Ambulance Service had vehicle losses in the
Nottinghamshire area of 10%. Of the 89 vehicles due to be responding, 9 were off the road.
Only 75.40% of G2 calls received into East Midlands Ambulance Service on the 9 July were
responded to within the 30 minute timescale. East Midlands Ambulance Service aim to respond to G2
calls at a rate of 85%.
EMAS deploys its available resource to stand by points, vehicles are not always located at station
when waiting to attend calls.
Conclusion:
The call was correctly handled by the Call Taker and attempts were made by both the Dispatcher and
Community First Responder Dispatcher to ensure a response was sent to this Patient.
At the time of the calls being received into the Emergency Operations Centre, all of the resources
within the call area were attending to Emergencies, responding to Emergencies or; within their
allocated Meal Break Window and unable to be allocated; there were no crews available to attend.
Selecting Resource Allocation more regularly, although should have been done, did not have a
detrimental effect on this job as there were no resources available.
On the day this incident occurred, there were 9 vehicles off the road in the Nottinghamshire Division,
10% of the overall resources normally available for the area.
Due to the delays, a call was made from the Clinical Assessment Team (CAT) to the property. The
Clinician was able to assess the Patient further. From the information provided, the call was then
upgraded to a higher priority Green1 (G1) 20 minute face to face response. After the upgrade, the
crew arrived on scene at 16:09hrs, 16 minutes later. 1hr 27 minutes after the original call was
received.
Ambulance Stations do not always have crews or vehicles within them able to respond to incidents
directly from the Station. East Midlands Ambulance Service do have standby points. If a crew is free
and available to respond to jobs; they will be dispatched to a standby point and not their starting
Station.
If there had been a free vehicle at the local Station which had the capabilities to respond, this would
have been sent to the incident.
Recommendations:
9. Action: Dispatchers to check Resource Allocation more frequently to ensure a response is sent
if available.
For:
Deadline: 28/08/13
10. Action: Operations Staff to ensure they are using their Conflict Resolution training to try and
resolve issues on the road rather than not deal with problem and escalate immediately to
PALS
For:
Deadline: 31/08/13
Date report sent to Investigation Manager for approval: Approved 18 08 13
Date Received:
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident:
Patient Name:
How Received:
Logged by:
Incident Location:
FC/050/13
Brief details
complaint:
of
the
16 July 2013
02 March 2013
Deceased? No
Telephone
Their reference:
Patient is ‘hazy’ about the events.
Therefore was he suitable to be left at home without being taken to
hospital or someone visiting within the next few hours?
Use of Refusal to Travel (Quality of Care, Clinical Issue)
# A&E Derbyshire (A/E)
Type of Complaint:
Division/Area:
08 August 2013
13 August 2013
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope
of
Investigation
(must include all
complainant
concerns) :
Why was the patient left at home despite refusing to travel?
Due to age and condition, should he have been made to go to Hospital?
Why did the crew not do anything other than lift onto the bed?
19/07/13 – 10:40hrs
FC/050/13
Chronology of Events: Taken from calls 5368552 received in to the Emergency Operations Centre
(EOC) on 02 March 2013 and the Patient Report Form (PRF) details.
Time
21:38
21:39
21:39
21:39
21:39
21:42
21:44
21:50
22:01
22:19
22:31
22:46
23:24
23:24
Events
Call 5368552 received into the Emergency Operations Centre (EOC)
Problem given as ‘Male on floor – tried to ring son in Ripley’.
Dispatcher accesses Resource Allocation (Res/All) screen.
Rapid Response Vehicle (RRV) 2734 allocated correctly by Dispatcher.
Call coded correctly as 17D03 Red2 (R2) by Call Handler.
Call handler attempts to call patient at home address, no answer.
RRV 2734 arrives on scene.
Police contacted via Dispatch for access to property as door locked.
RRV 2734 makes contact with patient and requests for crew to attend.
Double Crewed Ambulance (DCA) 8711 allocated correctly by Dispatcher to attend as
back up.
DCA 8711 arrives on scene with patient.
DCA 8711 calls clear from detail.
Update from RRV 2734 on scene noted by Dispatcher ‘Patient not injured refused to
travel. Details passed to GP. Patient wanted to go to bed’.
RRV 2734 clear from detail and job closed correctly by Dispatcher.
Evidence Gathered:
•
•
•
•
•
•
Sequence of Events (SOE) for Emergency Call 5368552.
Electronic Patient Report Form (ePRF).
Voice recording of call 5368552.
Call audit for call.
ePRF review from PALS complaint.
Review of ePRF from LQM.
A call was received into the Emergency Operations Centre at 21:38hrs from the Patient’s son. He was
not with the Patient and only able to supply limited information.
At 21:39hrs a Dispatcher had accessed the Resource Allocation (Res/All) function and a Rapid
Response Vehicle (RRV) was assigned to attend. The Call Handler correctly processed the call
through the Advanced Medical Priority Dispatch System (AMPDS) with the limited information given
and a coding of 17D03 Red2(R2) 8 minute response was correctly given. The response time was 6
minutes, within the target 8 minute response time.
Once on scene at 21:44hrs the RRV requested the assistance of the Police at 21:50hrs as they were
unable to gain access to the property. Access was gained at 22:01hrs. The RRV asked for a crew to
attend before he had assessed the Patient fully. The Double Crewed Ambulance (DCA) arrived on
scene at 22:31hrs.
The Patient was put into bed after all observations are completed. The Patient was uninjured and
refused to travel to Hospital informing the staff he wanted to go to bed. The RRV arranged for details
of the contact to be passed to the Patient’s General Practitioner (GP). After assisting, the DCA called
clear at 22:46hrs and the RRV at 23:24hrs. The patient was made aware to call 999 again should he
not be able to help himself.
Analysis of PRF by LQM
The PRF is generally well completed and I would make the following comments;
1. Although consent is not documented specifically it would be assumed given the answers from the patient
and also there are no issues with observations taken.
2. Only 1 set of observations were taken whilst the Clinician was on scene
3. Advice given to the patient is documented.
Regarding the need for a Safeguarding referral there is nothing on the form to indicate that a referral
would be required. The patient was appropriately safety netted and referred onto his GP and a copy of
the PRF was sent to the GP
Conclusion:
Why was the patient left at home despite refusing to travel? Due to age and condition, should
have been made to go to Hospital?
After all observations are taken the crew make an assessment whether a Patient has Mental
Capacity, and that the Patient can make their own choice whether or not to travel to Hospital. The
crew are not able to force a Patient to go to Hospital in this circumstance regardless to the age of the
Patient.
Why did the crew not do anything other than lift onto the bed?
The crew did do more than lift the patient on to the bed. The RRV arrived on scene after gaining
access via the Police. Once with the patient the clinician made an assessment and noted clinical
observations. The Patient was advised due to poor mobility that they should go to Hospital to be
checked however, refused to travel. The Patient was uninjured and following appropriate safety netting
being put in place, i.e. the crew passing the details of this contact onto the GP; they called clear from
the scene.
Recommendations:
The quality of PRF completion is not to standard and as per training guidance and staff should
be aware and reminded of the legal requirements of this documentation to be completed
correctly and in full.
1. Action: Where practicable, more than one set of Observations should be carried out as is good
practice.
For:
Deadline: 02/09/13
05/08/13 approved 18.08.13
FC/051/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Logged by:
Incident Location:
Alleged inappropriate comments from ambulance crew
complaint:
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading PALS case escalated to FC due to complexity of case and severity of accusations.
& Rationale:
Scope of
Investigation Why did the crew not convey the patient?
Why was the E-PRF not completed adequately?
(must include all
complainant
Why did the crew not make a Safeguarding referral?
concerns) :
Prior to escalation to an FC by PALS Co-ordinator and also
during interview with the Division TL
Incident to be investigated fully
14th June 2013 (when case first logged as PALS)
14th June 2013 (when case first logged as PALS)
None
FC/051/13
Date and Time
10 June 2013
approx 8pm
14 June 2013
20 June 2013
1 July 2013
18 July 2013
30 July 2013
1 August 2013
7 August 2013
19 August 2013
Events
DCA 6723 dispatched to G1 in Vale Road, Spilsby to a call for --- year old female
?miscarriage in a public place
On arrival the crew found the patient on the grass, other young people were present as
was a police officer. The patient was said to be under the influence of drink, combative
and difficult, resisting assessment and observation. The crew managed to get the
patient on the ambulance but she became abusive. The police officer had left the
scene and was asked to re-attend. The patient agreed to travel to hospital with the
police officer in the police car. PRF completion was poor and no safeguarding referral
was made.
Call to PALS by school nurse registering this case. School nurse had seen the patient
and her friend (who had made the 999 call) on 12 June. The girls had alleged poor
attitude/conduct against the DCA crew.
School nurse interviewed at ------------ station by TL
Crew interviewed at ------------ station by TL
Case escalated from PALS to FC
Patient Safety and Experience Manager (PSEM) call to police officer on-scene
Crew interviewed for the second time by TL
PSEM attempted to contact school nurse to feedback re investigation – on holiday; left
message to call back or PSEM will try to call again in one week.
PSEM attempted to contact school nurse to feedback re investigation – on holiday; left
message to call back or PSEM will try to call again in one week.
Evidence Gathered:
E-PRF
Two statements from each crew member (taken 1 July and 1 August)
Statements from school nurse (complainant)
Report from Divisional IO
E-PRF completion was extremely poor. It included no observations, assessment or rationale for
decisions taken.
Decision to allow patient to be conveyed to hospital by the police officer was not documented.
Lack of Safeguarding referral was unacceptable.
Conclusion:
Although it is acknowledged that this patient was challenging for the crew, there appears to have been
a lack of care and compassion exhibited as evidenced through the extremely poor E-PRF. Even
taking into account the fact that the patient was combative and would not allow observations to be
taken, nothing was recorded on the E-PRF indicating this or the subsequent decision making process
and rationale. The decision to allow the patient to be conveyed to hospital by the police officer onscene is also not documented or rationalised. The crew also had a professional responsibility to make
a safeguarding referral for this patient and failed to do so.
Recommendations:
Action
Both crew members will have
PRF audits for 6 months
Both crew members will have the
specialist safeguarding audit
carried out by the Safeguarding
Team
Both crew should receive
additional education re
safeguarding and PRF
completion and their
responsibilities/accountability in
these areas.
Following the additional
education both should produce a
reflective practice piece detailing
acknowledged errors in this case
and how they aim to improve
their future practice
PALS will monitor future attitude
concerns for these staff
members’ involvement
Lead
TL East Division
Timeframe
Complete by 28 Feb 2014
Adult Safeguarding Lead
Complete by end of Q2
TL East Division
Complete by 31 Oct 2013
PALS and Service Improvement
Co-ordinator
Report to PSEM at end of Q3,
Q4, Q1 and Q2
Date feedback given to complainant: 19/09/13 – due to complainant
being on holiday for two weeks
prior to this date so being
unavailable.
Response letter sent: N/A
No
FC/052/13
Date Received:
19 July 2013
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident:
26 June 2013
Patient Name:
Deceased? No
How Received:
Telephone
Logged by:
Incident Location:
Delayed response to pt in labour with 6th baby. Previous PALS/0248/13
complaint:
Type of Complaint:
Delayed Response (Timeliness, Activation/Response)
Division/Area:
A&E Cont. Derbyshire (A/E Control)
14 August 2013
(15 working days)
16 August 2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope
of
Investigation
(must include all
complainant
concerns) :
N/A EOC delay
Minor
Why was no ambulance sent to female in labour?
24 July 2013
Explanation and apology
N/A
N/a
Call audits requested.
FC/052/13
for call ref numbers 5644484 and 5644522 on 26 June 2013.
The first emergency call was received at 22:40 hrs on behalf of a --- year old female in labour. The
lady was full term, expecting her sixth child, and there were no known complications. The call was
coded as a Green 2 30 minute response, and the caller was advised help was being arranged.
A second emergency call was received at 23:00 hrs with the caller enquiring how long it would be
before the ambulance arrived. The call taker advised that an ambulance had not yet been allocated,
and the caller advised he would take his wife to hospital himself.
Evidence Gathered:
Call audits
CAD reports
Performance data
Handling of emergency calls: the first emergency call was correctly coded as a Green 2 30 minute
response. The call taker attempted to establish the length of time between contractions, but the patient
only had one contraction during the call. The audit of the call confirmed that the call taker should have
stayed on the line with the caller while help was being arranged.
When the second call was received this was also coded as a Green 2 30 minute response, and the
caller advised he would take the patient to hospital when it was established that we had been unable
to dispatch a resource so far.
Response to emergency calls: there had been no double crewed ambulances available to dispatch
to the patient since receipt of the first emergency call. When the call taker advised that a resource had
not yet been allocated on the second call the caller advised he would take his wife to hospital himself.
Available resources: although the performance logs detail some issues with Airwave at the time of
this incident, affecting communications with crews on the road, there were no demand issues
identified. The CAD reports show that 14 double crewed ambulances were operating on the day of the
incident in the area and none of these had been available in the time period between receipt of the
first emergency call and the time at which the caller advised he would take the patient himself.
Conclusion:
There had been no double crewed ambulances available to dispatch to the patient in the time between
receipt of the first emergency call and at the point at which the caller advised he would take his wife to
hospital himself.
Feedback has been given to the call taker in respect of staying on the line with the caller while help
was being arranged in respect of the first emergency call received. It has been confirmed however that
the call was correctly coded.
Recommendations:
There are no recommendations to make on this occasion.
13 August 2013
FC/053/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Paramedic is alleged to have provided poor service & quality of care;
used inappropriate handling methods and demonstrated little dignity or
complaint:
care towards this patient.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Why was -------------- subject to ridicule by the Paramedic?
Why did the Paramedic provide own symptoms to same problem rather than treat Patient sciatica?
What was the reasoning behind taking a bumpy route to the Ambulance on the chair?
Why not taken on a stretcher?
What did the Paramedic give --------------- to breathe in, Pain relief or O2? This was not
explained how to use it.
24/07/13 14:15hrs and email from 24/07/13 23:05hrs
Answers to above
FC/053/13
Operations Centre (EOC) on 28 June 2013 and the Patient Report Form (PRF) details.
Time
22:47
22:48
23:04
23:06
23:07
23:07
23:13
23:18
23:22
23:46
23:52
29 June 2013
00:13
00:13
Events
First call 5648963 received into the Emergency Operations Centre (EOC). Coded
correctly by Call Handler as 05A01 Green 4 (G4) 1 hour Clinical Assessment Team
(CAT) call back.
Dispatcher access Resource Allocation (Res/All) function, call coded as G4, no
resource sent.
Second call 5648999 received into the EOC. Coded incorrectly by Call Handler as
06D04 Green1 (G1). 20 minute face to face response.
Dispatcher accesses Res/All function and diverts 7120 Double Crewed Ambulance
(DCA) from Green2 (G2) to attend detail.
Dispatcher correctly closes call two 5648999 as a duplicate to call one 5648963.
Clinical Assessment Team (CAT) member looks at first job 5648963, unable to triage
as now G1.
DCA 7120 stood down from attending incident.
Dispatcher accesses Res/All function and allocates detail to DCA 6410.
DCA 6410 arrive on scene of incident.
DCA 6410 leaves scene of incident towards Hospital.
DCA 6410 arrives at Hospital with Patient.
DCA 6410 calls clear from this detail.
Dispatcher correctly closes this call.
Evidence Gathered:
•
•
•
•
•
Sequence of Events (SOE) for Emergency Calls 5648963 and 5648999.
Patient Report Form (PRF).
Voice recording of calls 5648963 and 5648999.
Call audits for calls.
Review of PRF from LQM.
The first call was received in to the Emergency Operations Centre (EOC) at 22:47hrs. After being
processed by a Call Handler through the Advanced Medical Priority Dispatch System (AMPDS), the
call was coded Green4 (G4). The patient was told to wait for a call back from a Clinician which could
take anything up to one hour.
A second call was received at 23:04hrs and processed to receive a coding of Green 1 (G1) a 20
minute response. Having been processed, the Call Handler should have coded this to receive a Red 2
(R2) 8 minute response.
At 23:06hrs the Dispatcher accesses the Resource Allocation (Res/All) function and diverts Double
Crewed Ambulance (DCA) 7120 to this incident.
By 23:13hrs DCA 7120 are stood down from this incident due to a nearer DCA becoming available.
DCA 6410 are assigned to attend this incident at 23:18hrs and arrive on scene with the Patient at
23:22hrs.
The Patient is conveyed to Hospital by the DCA and arrives there by 23:52hrs.
Once conveyed, the DCA calls clear from this incident at 00:13hrs.
The Paramedic having seen the PRF is unable to recollect the incident. He states as this would have
been a normal job; it’s not one that would stick out in his memory. The details he has recorded on the
PRF are clinical and do not demonstrate the non-clinical care that would have been given.
Information gained from the Paramedic shows he would have given symptoms to his own health
issues to try and help the Patient relax. He also states that ‘even if the patient has used entonox
previously, I always still explain what it is, how to use it, it’s effects and side effects. I also always
monitor how the patient is self-administering and the effects gained. This is a routine course of action
and is carried out automatically.’
The PRF was reviewed by the Locality Quality Manager (LQM) and shows the Paramedic has ruled
out conditions such as Neck of Femur (NOF) injury as there was no shortening or rotation of that area.
No information was recorded with regards to the Patient’s pain score although pain relief was
attempted and; there is little evidence other than Sciatica shown.
As the PRF is poorly written, there is no evidence showing all bases have been covered to rule out a
NOF injury
Having asked the LQM with regards to the use of stretchers and chairs, the LQM states a chair is
normally used within a Patient’s property. This is unless it is physically impossible or they crew are
unable to do so.
Conclusion:
The Paramedic who attended the scene is unable to remember the incident. He states with his
experiences he does not feel he would ridicule a Patient. The Paramedic did state to build rapport with
a Patient he sometimes has light hearted banter with them. The Paramedic apologises if this banter
was misconstrued in any way.
Being unable to remember this incident, the Paramedic is unsure as to why he would offer his own
symptoms other than, to set the mind at ease for the Patient and to reassure them of their condition.
The Paramedic states he would in normal circumstances take the smoothest and quickest route to the
Ambulance. He states sometimes hedges and plants get in the way meaning you have to touch on a
bumpy surface. He does not remember the incident so cannot state the route he took. The Paramedic
states he would not intentionally go via a bumpy route to cause further harm or pain to a Patient.
It’s not common practice to take a stretcher into a property. Crews normally use the carry chair unless
it’s physically impossible or they are unable to.
The Gas the Patient would have been given was Entonox which is an analgesic gas. This would have
been appropriate given just muscular, nerve back pain. It should always be explained how to use it
unless someone has taken it before and is familiar with its operation. The Paramedic states his normal
process is to explain the use of the equipment and its side effects if there are any. He cannot see any
reason why he would not have done this.
Recommendations:
Action: Paramedic to have a review of PRFs completed randomly for a period of three months
to ensure correct completion.
For:
Deadline: 01/12/13
Action: Team Leader to ensure appropriate conversation is held and recorded regarding
coding of calls with Emergency Medical Dispatcher.
For:
Deadline: 01/09/13
Date report sent to Investigation Manager for approval: Approved 22 08 13
FC/054/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 11 November 2012
Patient Name:
Deceased? Yes
How Received: Email
Logged by:
Incident Location:
Brief details of the Terminally ill pt died at home as expected. Care agency rang 999. Family
complaint: unhappy with EOC ringing the house & interfering.
(15 working days)
(20 working days)
Staff involved –EMD – EOC Lincs
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
The rationale of questioning the sister with regards to ---------- although questions not
relevant as was ‘gone’.
Why the operator needed to keep confirming the address of the incident and stated a
wrong postcode had been given.
Why was it noted that the initial call into EMAS was from a Nurse when this was not the
case?
Tried 29/07/13 12:00hrs Letter sent 30/07/13. Spoken with on
Contact made with complainant: 05/08/13.
As above
FC/054/13
Chronology of Events: Taken from call 5082963 received in to and called back from the Emergency
Operations Centre (EOC) on 11 November 2012 and the Patient Report Form (PRF) details.
Time
12:55
12:55
12:56
12:57
12:57
12:58
Events
Call received into the Emergency Operations Centre (EOC).
Call Handler searches address.
Address given by carers.
Carers mentioned this is in ------------------.
Dispatcher accesses Resource Allocation (Res/All) function, No resources available.
Call Handler manually inputs address and overrides system as not able to find.
Call Handler establishes problem as Cardiac Arrest, caller not with the Patient.
Is calling from the Care Agency. Carers en route back to Patient.
Res/All function accessed by Dispatcher.
Double Crewed Ambulance (DCA) 3320 diverted to this job.
Call Handler takes telephone number of someone with Patient and calls back.
Daughter states Dad died half an hour ago and hasn’t called Ambulance.
Has CA and terminally ill. States Nurse went out to see him and he has died.
Confirms does have a Do Not Resuscitate order in Nurse notes in the Dad’s Cottage.
Been on syringe driver, pale, no breathing.
Call Handler concentrates on the address and states wrong Postcode given
12:58
13:00
13:07
13:13
13:32
13:34
When the Daughter is told there is an Ambulance on the way she states there is a
Doctor en route. Call Handler again skips this information and goes back to the
address – No compassion.
Says Ambulance on way and they can he assist with anything further.
Call Handler speaks with Daughter on scene and codes call as 09E01 Red 1 (R1)
Cardiac Arrest. Call not complied as outbound call.
Another Call Handler makes changes to address.
Note made by Call Handler. ‘This call came from Nurse who had left the Patient about
30 mins previous just as he arrested then went to Surgery and made call. I called the
family back and the daughter refused to do CPR and said the patient was K1 but
wasn’t cold and stiff’.
Crew struggling to find the address. EOC ring West Midlands Ambulance to see if this
is their area.
West Midlands Ambulance searched on the original postcode, This is in their area.
West Midlands Ambulance confirm East Midlands Ambulance Service stand down, not
a workable arrest.
Evidence Gathered:
• Sequence of Events (SOE) for Emergency Call 5082963.
• Voice recording of call 5082963.
• Call audit for call.
• Information regarding Do not Resuscitate Orders
A 999 call reference 5082963 was received into the Emergency Operations Centre (EOC) at 12:55hrs.
This was from a Care Agency after the Carers had left the scene of the incident and driven to get a
signal to call the Agency.
The correct address for the property was given by the Care Agency. The Care Agency also mentioned
this would be in the Staffordshire area.
The Call Hander establishes at 12:57hrs this could be a Cardiac Arrest and gains information from the
person not with the Patient. The Call Handler does not process the call with the 3rd party through the
Advanced Medical Priority Dispatch System (AMPDS) as they should have.
At 12:58hrs, the Call Handler rings the patient’s daughter who is at the property. The Daughter does
not know why an Ambulance has been called. The Daughter states her father has Cancer and was
terminally ill. A Nurse did visit the property but left when he died. The Daughter was arranging for the
Doctor to attend and certify the death. When asked if there was a Care Plan for the Patient, the
Daughter confirmed to the Call Handler there was a Do Not Attempt Resuscitation (DNAR) in place
which was in the pack for the Carers.
The outbound call to the address cannot be audited formally through AMPDS due to this being an
outgoing call. It is correct that that Call Handler processed the rest of the call through AMPDS.
The Call Handler throughout the call re-clarifies the address. When checking the full address, the Call
Handler states they were previously given the incorrect postcode details by the Carer, this is not the
case. The correct full address was given by the Carer.
Whilst the Call Handler is talking, two other Lincolnshire EOC staff are seen to be attempting to locate
the address by accessing and searching the address within the call.
It is noted by the Call Handler that a Nurse had seen the Patient then left the scene and went back to
the Surgery to make the call to 999. This is not the case and not mentioned in the inbound or
outbound calls.
The Call Handler also notes that the Daughter who is on scene refuses to do Cardio Pulmonary
Resuscitation (CPR). This information is not offered to the Daughter. The Daughter keeps mentioning
that a DNAR is in place and her father had been dead for some time.
At 13:13hrs, the crew call through to Dispatch to confirm they are struggling to find the address.
Staffordshire Ambulance is contacted and they confirm the original postcode is in their area.
Staffordshire Ambulance sends a response and East Midlands Ambulance stand down theirs at
13:34hrs.
Prior to 2010 it was process for East Midlands Ambulance Service (EMAS) to store details of Do Not
Attempt Resuscitation (DNAR) orders on the CAD system. This would mean that should occasions
such as this occur there would be notes on the system to state the DNAR is in place and; only the
relevant resources would be sent.
After 2010, any new DNAR information was no longer stored in CAD and had to be located on arrival
by the attending crew.
Conclusion:
EMAS do not store DNAR information on system and have not done so since 2010.
When 999 calls are received into the Emergency Operations Centre (EOC) we have to act upon each
one as a new call as if it were an Emergency. The Carers who had driven away from scene made a
999 call and mentioned a person had died at the property. Due to this information, the Call Handler
correctly started to process the call on the ‘Cardiac Arrest’ card. The call should have been processed
in full with the Carer despite them not being with the Patient.
When an outbound call was made to the Patient’s Daughter, the Call Handler processed the rest of
the call through the Advanced Medical Priority Dispatch System (AMPDS). AMPDS is a set of
questions relating to a Chief Complaint used to rule out priority symptoms. Once questions are
answered, AMPDS gives the most appropriate response at that time. This process is in place to
ensure that if a Patient can be helped, the relevant information is given to do so.
Although the patient’s daughter confirmed the patient had died, the Call Handler was correct in
processing the call through AMPDS to establish this.
EMAS covers Nottingham, Derby, Leicester, Northamptonshire, Lincoln and Rutland. For these areas
our system has a mapping system which allows us to track jobs to addresses within these areas.
When a job is called through to EMAS that is not within our mapping system area, the Call Handler
manually inputs the address to allow the Dispatcher to start sending the nearest resource to the job. If
this is not near to EMAS boundaries, ie Scotland, the call is passed to the relevant Service.
The Call Handler asked the Patient’s Daughter to confirm the address to ensure we were travelling to
the correct location. This should have been re-confirmed at the start of the call or, once all other
information had been obtained from the caller regarding the Patient’s condition.
It is confirmed that the Call Handler incorrectly quoted a postcode which had been given. All of the
correct address details had already been passed.
Notes have been incorrectly made by the Call Handler to say a Nurse had made the call to 999. It is
clear in the voice recordings that the initial call was made from the Carer.
Confusion has occurred when the Call Handler spoke to the Daughter at the Patient’s address. The
Call Handler stated ‘so a Nurse has been and seen him and left half an hour ago’ and this was
confirmed by the Patient’s Daughter. Due to this conversation, incorrect notes have been inputted into
the system.
Recommendations:
1. Action: Call Handlers to be reminded of accurate record keeping/use of notes.
For:
Deadline: 23/09/13
2. Action: Call Handlers to be reminded to complete the call in full and not deviate.
For:
Deadline: 23/09/13
3. Action: Call Handler to be trained with regards to compassion and Customer Service.
For:
Deadline: 23/09/13
4. Action: To ensure Call Handlers and Dispatchers on both sites fully up to date with EMAS
boundaries and what to do if addresses are not on the EMAS system.
For:
Deadline: 23/09/13
5. Action: Calls to be reviewed at Customer Service Review Group
For:
Deadline: 23/09/13
6. Action: To clarify what response and coding should be given within EOC when a DNAR is in
place and; if the call is downgraded what should be said by the Call Handler
For:
Deadline: 23/09/13
FC/055/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the Delayed response to --- year old male who had been assaulted. Also
complaint: concerns about the information not given to the police.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
N/a EOC delay
Minor
Why was there a delay in responding to the patient?
Was all relevant information given to the Police regarding the incident?
29 July 2013
Date OSM/PTL/Manager informed: N/a
Immediate actions taken: PALS IO report obtained, audio files reviewed.
FC/055/13
Chronology of Events: Taken from the Computer Aided Dispatch (CAD) sequence of events
(SOE) for call references 5686395 and 5686450 on 13 July 2013.
At 22:33 hours a 999 call CAD 5686395 was received into the Emergency Operations Centre (EOC)
and coded 04D02A (assault) Green 2 (30 minute response)
The Emergency Medical Dispatcher (EMD) noted on the CAD ‘assaulted facial cuts, patient has cuts
to arms, face and back, clarifying what kind of weapon was used, glass bottle was used, patient may
have query broken jaw, patient was hit with a pole also across the back’
At 22:35 hours the dispatch officer noted on the CAD ‘K0 at this time’ (no crews)
At 22:36 hours it is noted on the CAD ‘Police informed log 576’
At 22:44 hours the EMD noted on the CAD ‘patient is about to pass out and is shivering, patient is
experiencing difficulty in breathing, patient is coughing up blood’
At 22:47 hours the call was passed to nurse triage
At 22:48 hours the CAT team upgraded the call to a Green 1 response
At 22:49 hours the CAT team noted on the CAD ‘patient is slipping into unconsciousness and is
breathing’
At 22:51 hours a DCA was mobile to the scene. ETA 46 minutes having come clear at Boston Pilgrim
hospital
At 22:53 hours the DCA was stood down and diverted to CAD 5686354 chest pains
At 22:54 hours a single crew was mobile to the scene. ETA 21 minutes having been stood down from
another call
At 22:54 hours a 2nd 999 call CAD 5686450 was received from the patients father and coded 04D02A
(assault) Green 2 (30 minute response)
The EMD noted on the CAD ‘badly beaten up’
The dispatch officer noted on the CAD ‘resource en route’
The EMD noted on the CAD ‘patient’s condition is worsening, looking at previous call, patient not alert,
police not on scene, patient was at a party in -----------, 10 lads attacked the patient, patient was
assaulted with a bat’
This call was correctly stopped as a duplicate of the first call
At 22:55 hours the CAT team upgraded the call to a Red 2 response and noted on the CAD ‘patient is
fitting and breathing is compromised’
At 22:59 hours it is noted on the CAD ‘Police requested update from crew, conveying to hospital or
not, they don’t have anyone to send at present’
At 23:01 hours a LIVES responder was mobile to the scene. (Fire responder)
At 23:02 hours the CAT team noted on the CAD ‘patient not fitting now but breathing remains a
problem, conscious at present’
At 23:05 hours an FRV was mobile to the scene. ETA 55 minutes
At 23:07 hours the CAT team noted on the CAD ‘choking at present and coughing up blood’
At 23:08 hours an EMD noted on the CAD ‘patient is in and out of consciousness now, caller is
patient’s dad, very anxious and frustrated, patient was hit over the head with a bat, vomiting now’
At 23:09 hours the CAT team noted on the CAD ‘patient has wounds with glass embedded in them’
At 23:10 hours a 2nd DCA was mobile to the scene. ETA 46 minutes having come clear at Boston
Pilgrim hospital
At 23:11 hours the FRV was stood down as the DCA was nearer vehicle
At 23:11 hours the single crew arrived on scene. Response time 38 minutes
At 23:14 hours the LIVES responder was stood down and it was noted on the CAD ‘Fire unable to
raise crew’
At 23:17 hours the single crew noted ‘please update police this is a serious assault’
At 23:25 hours it is noted on the CAD ‘police rang to advise that they are sending an officer to assist
as well and are wondering if the DCA can wait for the officer to arrive as otherwise if the patient is
being taken to ------------------ police would have to send an officer from another force to assist’
At 23:35 hours the DCA arrived on scene. Response time 1 hr. 2 minutes
At 23:53 hours the DCA left scene with the patient for -------------------------------At 00:07 hours the DCA arrived at the hospital
At 00:58 hours the DCA was clear at the hospital (51 minute turnaround)
Evidence Gathered:
CAD reports
Call audits
Audio files of emergency calls and calls from EMAS to the Police
Performance data from the Lincolnshire dispatch desk (LINCS) and Performance Delivery Manager
(PDM) logs.
Handling of emergency calls: the first emergency call was correctly coded as a Green 2 30 minute
response from the information given and the patient’s presenting condition. It was upgraded to a
Green 1 20 minute response by the triage nurse after additional review, and upgraded again to a red 2
eight minute response at 22:55 hrs. after the patient’s breathing became compromised and he started
fitting. At this point the nearest resource had already been allocated at 22:51 hrs. with an estimated
travel time of 46 minutes. This resource was stood down at 22:53 hrs. as a nearer resource was
identified 21 minutes from the scene, and this solo responder arrived at 23:11 hrs. A double crewed
ambulance was allocated as back up at 23:10 hrs. and this arrived at 23:35 hrs. This was a response
of 38 minutes for the solo responder with the back-up ambulance arriving 62 minutes after receipt of
the emergency call.
When the second call was received from the patient’s father, call reference 5686450, the nearest
resource had already been dispatched to the incident. This was stood down in favour of a nearer
resource as detailed above. There was a period between receipt of this second call and 23:09 hrs.
when the EOC were dealing with both calls simultaneously.
Referral to the Police: the Police were contacted at 22:36 hrs. to request their attendance at the
scene. However on review of the audio file for this call it was established that the Police were only
informed that the patient had suffered facial cuts, and this affected the priority the Police gave to this
incident. On review of the SOE the full information in respect of the patient’s injuries appears after the
note that the Police have been informed. When the double crewed ambulance left the scene with the
patient at 23:53 hrs. the Police had not been able to attend.
Issues affecting the response time: on the day of the incident the Lincolnshire division was operating
with a shortfall of 11 planned resources due to staff absences.
Entries from the (LINCS) log:
22:22 hrs. handover delays at Lincoln City hospital with crew at Accident and Emergency since 21:39
hrs.
22:23 hrs: Incidents outstanding 1 x Red 2, 1 x Green 1, 1 x Green 3 and 1 x Green 4.
22:31 hrs: we have two crews waiting at accident and emergency.
22:46 hrs: stacking 2 x Green 2 calls.
Entry from the PDM log:
14 July 00:52 hrs: holding 12 uncovered 999 calls in Lincolnshire.
Support from Neighbouring services: as the call was initially graded as a Green 2 call, under normal
protocols support would not have been requested from the neighbouring East of England service for
this type of call. When the call was upgraded to a Red 2 status we already had a resource travelling to
the scene.
Conclusion:
The delay in response was caused by high demand for emergency responses with all available
resources already fully committed elsewhere. This was exacerbated by a number of crew shortfalls in
the area on the day of the incident.
The call was appropriately upgraded to a Green 1 and then a Red 2 call, and a clinician stayed on the
line until a response arrived.
The Police response to the incident was not correctly prioritised because not all of the information
available about the assault and the patient’s presenting condition was passed to them by EMAS. The
full information appears on the CAD SOE after confirmation that the Police have been informed.
Recommendations:
Feedback will be given to members of staff in the EOC in respect of passing ALL relevant information
regarding an incident to an assisting emergency service.
Action: Bulletin issued to all members of staff in the EOC to reinforce the importance of relaying all
relevant information to other emergency services when requesting assistance at or attendance to
incidents.
For:
Evidence: Bulletin issued to all staff.
Action: Feedback to be given to EOC member of staff wenb to discuss the impact of not passing
across all relevant information.
For:
Evidence: Note of conversation with member of staff.
Action: A review of the process for requesting Police assistance and attendance should be
undertaken to ensure all relevant information is gathered and passed to enable the Police to correctly
prioritise their response.
For:
Evidence: Review of current process and amendment if necessary.
Date report sent to Investigation Manager for approval: 16 August 2013
FC/056/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the Delayed response to pt with Haematemesis & abdo pain. GP rang 999.
complaint: After 135 minutes they couldn't wait any longer and went by car.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Why does the service have no capacity for an Urgent Ambulance?
Why would it take 135 minutes for a 999 Ambulance?
Contact made with complainant: 01/08/13
Expectations of Complainant: As Above
FC/056/13
Operations Centre (EOC) on 16 July 2013.
Date and Time
13:29
13:30
13:30
13:30
13:31
13:34
13:52
13:58
14:11
14:13
14:14
14:15
14:16
14:17
14:26
14:29
14:48
14:51
14:52
14:52
15:01
15:03
15:12
Events
First call 5692677 received into the Emergency Operations Centre (EOC).
Call correctly processed through the Advanced Medical Priority Dispatch System
(AMPDS) and coded 21B01 Green 4 (G4) a 60 minute Clinical Assessment Team
(CAT) call back by the Call Handler
Call correctly upgraded by Call Handler to Green 2 (G2) 30 minute response due to
Health Care Professional (HCP) call.
Dispatcher accesses Resource Allocation (Res/All) function and incorrectly allocates
HCP to the job as Defib is shown as on site although not confirmed.
Dispatcher accesses Res/All function. No resources available.
Note made in PDM resource log of jobs awaiting resources in North Nottingham.
1xRed 2 (R2), 2 x G2 and 5 x Doctors Urgents.
Dispatcher accesses Res/All function. Double Crewed Ambulance (DCA) 3526
allocated to attend incident.
Second call 5692774 received into EOC. Incorrectly coded by Call Handler as 01A01
G4.
Dispatcher diverts DCA 3526 to higher priority Red 2(R2) Chest Pain call.
Dispatcher correctly closes second call 5692774 as a duplicate to 5692677.
Call Handler of second call noted Patient now experiencing heavy breathing due to
pain.
Clinician tried to call due to wait – in a queue. Not able to get through.
CAT called back, stated 47mins to travel to the site
Dispatcher accesses Res/All function. DCA 2113 allocated to attend incident. Showing
Estimated Time of Arrival of 48 minutes from a Lincoln Hospital.
Update from CAT that Ambulance not required. Doctor not happy regarding the wait.
Family to take Patient to A and E.
DCA 2113 stood down from detail.
Call closed correctly by Dispatcher.
Evidence Gathered:
•
•
•
•
•
•
Sequence of Events (SOE) for Emergency Calls 5692774 and 5692677.
Voice recordings of calls 5692774, 5692677 and outbound CAT call.
Call audit for calls.
Feedback to EMD of audited calls
Resource Log for Double Crew Ambulance 2113.
Resource Log fro PDM from 16 July 2013
The first call 5692677 made by the Doctor was received into the Emergency Operations Centre (EOC)
at 13:29hrs. The Doctor was with the Patient.
This call was processed through the Advanced Medical Priority Dispatch System (AMPDS) and gained
a Green 4 (G4) 1 hour Clinical Assessment Team (CAT) call back. As the call was from a Healthcare
Professional, this was upgraded to a Green 2 (G2) 30 minute face to face response.
questions are answered, AMPDS gives the most appropriate response at that time. These questions
are asked of the Public, Fire, Police and Doctors when making or passing a 999 call.
The CAD notes show there is a Defibrillator at the Surgery. The Call Handler did not ask if this was
there or whether anyone was on site trained to use the equipment. As the call is processed, the
Dispatcher incorrectly assigns the Call sign HCP to the job. This Call sign is used to show there is a
Healthcare Professional on site with a Defibrillator.
Between 13:31hrs and 14:13hrs, the Dispatcher accesses the Resource Allocation (Res/All) function
five times. This function allows the Dispatcher to see any available resources that are free to attend
the detail. On the fifth Res/All attempt, a Double Crewed Ambulance (DCA) 3526 was allocated the
job.
Notes are made in the Duty Managers Resource Log of the amounts of calls waiting to be assigned to.
At this time, there were three calls waiting in the North Nottingham area, one of which was a Red 2
(R2) 8 minute response.
At 14:14hrs a second call 5692774 was received into the EOC. This call was being made by someone
else at the Surgery who was not with the Patient. The Call Handler processed the call incorrectly
through AMPDS and gained the response G4. Once processed, the Dispatcher correctly closes the
second call as a duplicate to the first. The Call Handler on the second call incorrectly coded this call
meaning the call may have been upgraded to receive a higher priority response. Due to the questions
not being asked at the time, it is not possible to determine if this would be the case.
The DCA 3526 travelling to this detail is diverted to a higher priority R2 call at 14:15hrs.
Due to the length of time waiting, a Clinician from CAT tried to call back the Surgery at 14:26hrs. They
were unable to get through. The Dispatcher tries three further times at 14:29hrs, 14:48hrs and
14:51hrs to Res/All on this job. There were no vehicles available to attend.
Again the CAT Clinician makes a call to the surgery and manages to speak to someone at 14:52hrs.
At the same time, the Dispatcher accesses the Res/All function and allocated a DCA 2113 to this
detail. Travelling from distance with an Estimated time of Arrival (ETA) showing at 48 minutes.
After speaking with the Doctor who is with the Patient, he is not happy for the family to wait any longer
for an Ambulance and despite the Patient’s condition; the family will attempt to take the Patient to
Hospital themselves. The Dispatcher is made aware and the Ambulance is stood down at 15:03hrs.
The call is closed correctly at 15:12hrs by the Dispatcher.
Conclusion:
There was a delay in responding to the calls due to all other resources being fully committed in
Allocating the call sign HCP to a Green 2 call does not stop the clock in relation to response times.
The call sign HCP does not act as a conveying response so 30 minutes after the first call was
received, we would have needed a crew on scene in order to arrive within our intended time limits.
The calls were prioritised as appropriate. The calls were assessed and prioritised in order of clinical
need.
At the time we received the first two calls into the EOC, the information given did not meet the criteria
for an immediate 8 minute Ambulance response and instead, was allocated as a Green 2 (G2) 30
minute response.
Although the patient has been assessed by a Medical Professional; when taking a call on the 999 line,
we always re-assess the patient to ensure the most appropriate response is being given.
The Call Handler on the second call incorrectly coded this call meaning the call may have been
upgraded to receive a higher priority response. Due to the questions not being asked at the time, it is
not possible to determine if this would be the case.
Throughout the time we were in receipt of the calls, the Dispatcher tried to allocate a resource to
attend however, all resources were either attending to Emergencies or; being diverted to higher
priority ones. The Ambulance which was assigned at 14:52hrs was travelling from a distance and, was
the nearest available resource.
Recommendations:
1. Dispatchers to be reminded when to allocate HCP.
Action: Communicate to all Dispatch Staff that HCP should only be allocated once it’s
confirmed there is a Defibrillator on scene with a trained person to use it.
For: EOC ----------------- – As per FC/026/13
Deadline: 01/09/13 -Already completed
2. Call Handlers to be reminded to ask if there is a Defibrillator and trained staff when
appropriate.
Action: Communicate to all Call Handlers of the importance of asking the Defibrillator question.
For: – As per FC/026/13
Deadline: 16/09/13 -Already completed
3. Call Handler of second call to be given feedback and further training regarding the coding of
calls through the Advanced Medical Priority Dispatch System.
Action: Feedback and training to be provided.
For:
Deadline: 16/09/13 -Already completed by M Thiele on 08/08/13
4. Surgery staff to be invited to EOC to see how calls are prioritised and dispatched upon.
Action: Communication with Surgery to invite them to attend the EOC.
For:
Deadline: 16/09/13
FC/057/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: Email
Their reference:
Logged by:
Incident Location:
Brief details of the --- year old child with breathing difficulties was not pre-alerted to A&E.
complaint: Department unhappy with handover & treatment.
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Moderate 6 – Patient care issue which is unlikely to re-occur
Why was a Community First Responder not activated to this call?
Why was the hospital not pre-alerted?
Why was the patient taken to G hospital and not LC Hospital?
What were the Paramedic’s observations on the PRF?
Does clinical assessment of the observations support the Paramedic’s treatment
plan?
Did the paramedic notice tracheal tug or intercostal recession? If not, what training
are crews given to identify this?
Were O2 Sats taken? If so, what were they?
Why was patient not given nebuliser or O2 by paramedic?
Did the observations support patient being booked as a P1 transfer – time critical,
and immediately life-threatening condition?
Phone call 31/7/13
Expectations of Complainant: Explanation of paramedic actions
Date OSM/PTL/Manager informed: 12/8/13 ST
FC/057/13
Date and Time
4/7/13 22:45
22:46
22:47
22.49
23:17
5/7/13 00:58
01:15
Events
Automated 111 call received requesting R2 ambulance to child with shortness of
breath, tummy sucked in, palpitations. Patient reported to be fighting for breath –
seems confused. CAD 5663408
As this call was taken by 111 there is no call recording available and so will not be
subject to call audit by EMAS.
Community First Responder (CFR) desk notes that the detail is not suitable for a
responder. No Resource Allocation check is done by CFR
Dispatcher completes resource allocation check (Res/Alloc) – Single Emergency Care
Assistant (ECA) showing nearest with 26 minute ETA. Dispatcher notes in log that not
suitable resource to send to call
However, the Res/Alloc shows that a Level 4 (intermediate) responder is available 2.9
mins away with a 6 minute eta. This level CFR can attend all types of calls, whatever
the age of the patient other than Road Traffic Collisions. This responder should have
been allocated to this detail
Initial crew assigned but stood down when nearer crew became available. Crew
arrived on scene 23:06. This was an 18 minute attendance – outside of the 8 minute
response level required by a R2 call. On assignment crew ETA was shown to be 14
minutes from local A&E. Patient handover logged at 23:45
Out of performance officers log states: ‘No R2 assessments tonight’
Crew marked as left scene to hospital. Total on time on scene – 26 minutes. Arrived
AE 23:37. Handed over 23:45. Clear hospital: 23:49
PRF details:
Patient been unwell for past week, generally unwell, then started with cold like
symptoms in week and a non-productive cough.
Worsened today, not been his usual self today, clingy to mother and consolable by
mother.
Mother worried about patients breathing tonight and rang 111.
o/a patient alert, conscious, good colour, non-productive cough. UTR 02 levels due to
no pead sats probe. Mother states patiernt had intercostal resession throughout the
night.
Poor fluid intake and poor appetite. Water works normal. Mother given 5ml calpol at
2000hrs. Mother doesnt think patient had temperature, not been too hot to touch.
Transported to (G) A/E for further assessment. Had similiar problems with breathing
last year.
st
1 obs: Heart Rate 120; Resp rate 28; GCS 15
nd
2 obs: heart rate 124; Resp rate 28; GCS 15
999 call from AE requesting P1 transfer of same patient on CAD 5663615 requiring an
8 minute response. Crew arrived on scene at 01:01 – within the 8 minute response
required. Same crew used as brought in the patient originally.
nd
Crew left scene with child and family members, arrived 2 hospital at 01:51. Cleared
hospital 02:24.
PRF details:
Patient been unwell for past week, generally unwell with cold like symptoms and nonproductive cough.
Parents became worried last night about breathing, has intercostal recession.
Had poor fluid intake and poor appetite for 1 week.
Patient transported to Grantham A/E. Transported out to LCH by same crew.
Onroute patient had a further 2.5mg salbutamol to good effect. Patient put on sats
monitor as soon as got to LCH to check 02 levels, maintaining well at 95% on air.
Pulse of 137, resps up at 45-50 breaths per min. Patient settled well and asleep
onroute. No obvious signs of respiratory distress onroute, happy and playing in chair.
Grantham booked transfer to LCH A/E. Arrived at A/E, maintaininhg sats therefore
crew taken patient to ward as A/e spoken to ward and advised this.
Obs show no pyrexia; sweating; nausea; vomiting; rash or productive cough.
st
1 set obs: Heart Rate 140; Breaths per minute 50; GCS 15.
No abnormal breathing signs but respiratory rate fast.
2nd set: Heart rate now 174; Respiratory rate still 50; GCS 15
Evidence Gathered:
WAV radio transmission 005753 diverting crew to P1 transfer
WAV radio transmission 022303 updating dispatch child was sent straight to Children’s ward
WAV radio transmission 022712 crew requesting CAD number
WAV radio transmission 023146 Dispatch asking crew for IR1 as per DM instructions
Hospital complaint form
PRF 5663408
PRF 5663615
CAD SOE P1 Transfer
CAD SOE 111 call
Case Progress sheet
Record of conversation with T1
IR1 follow up enquiry email
Email requesting clinical assessment PRF
Email – crew’s response to Terms of Reference
G Hospital Exclusion Criterion
Clinical Bulletin
Delivery Manager Resource Log
Daily performance Review
EMAS inter-facility transfer policy
Performance Issues
• Performance Delivery Managers Resource Log notes N Division holding 10 x G2 and 2 x
urgent at 22:23
• A8 response for calls requiring 8 minutes attendance was 74.39% (target 75%)
• A19 response – requiring a vehicle to attend R8 call to transport patient within 19 minutes was
94.78% (Target 95%)
• G1 calls requiring face to face contact within 20 minutes was 76.85% (target 95%)
• G1 calls requiring face to face contact within 30 minutes was 81.38% (target 95%)
At 22:45 on 4/7/13 an automatic message was received from the 111 service. This was requesting a
R2 ambulance attend a child with “shortness of breath, tummy sucked in, palpitations”. This requires
a face to face response within 8 minutes. The Dispatcher checked Resource Allocation (Res/Alloc)
and notes that the nearest vehicle was 26 minutes away, but it was not classed as suitable to attend.
This vehicle contained a solo Emergency Care Assistant (ECA) only. This is not a clinically qualified
practitioner, and so would not be able to treat the patient. The Dispatcher acted correctly by sending
the Paramedic/Technician crew to this detail with a slightly longer eta.
On receipt, this call was opened by the Community First Responder (CFR) desk. Their role is to see if
there are any, appropriately trained, local volunteers who could provide a first response in the area.
When this call was received the CFR desk noted that this call was not suitable for a Responder. The
resource allocation (res/alloc) function was not used by the CFR Desk. Due to this the CFR Desk did
not allocate the Level 4 responder that was qualified to attend. The CFR’s eta was 6 minutes with an
approximate distance of 3 miles, and so this 8 minute response was achievable.
Crew arrived on scene with the patient 18 minutes after the call. The Dispatcher noted that there was
no R2 assessment available for this day. Due to this, a telephone Clinical Assessment Team (CAT)
could not be completed. This would have further assessed the patient’s condition, and provided
support to family till crew arrived.
Crew notes on the electronic Patient Report Form (ePRF) stated that the patient had been unwell for a
week. Patient was not his normal self that day, clingy to mother but was consolable. Crew also noted
that there was no Paediatric SATS monitor on the vehicle. Due to this they are unable to get an
oxygen reading from the patient.
Patient is described as “alert, conscious, good colour, nonproductive cough.” When spoken to the crew reiterated “there was no signs of tracheal tug or
intercostal recession at the time of assessment or on route to Grantham A/E.” That “Mother state(d)
patient had recession through night but none noted by crew on route to Grantham.” Crew made note
in ePRF of this comment by mother, but failed to state in the PRF it was not apparent in their
presence. The crew also stated that a patient with Tracheal Tug would have shown “nasal flaring, and
his posture would have been different. The child was happy to play and sleep on route to both G and
LC hospitals.” Crew also stated, that “the patient did not have a respiratory wheeze, therefore did not
fit into our nebulisation criteria.” When asked why G hospital was not pre-alerted to patient being on
way, they stated they did not believe the condition warranted it. Clinical assessment of the ePRF, by
LQM ----, states that the observations recorded “are within normal parameters for the age of the child.”
This statement supports the crews assessment that a Pre-alert was not required. ---- clinical
assessment is that a Pre-alert may possibly have been appropriate, but due to the lack of SATS
reading this point could not be confirmed in either direction.
At 00:58 on the 5/7/13 a 999 call was received from G Hospital. Request was for a Blue Light (P1)
transfer of the patient to AE at LC hospital. This was 1 hour and 15 minutes after the patient was
originally handed over. The original crew re-attended the patient, and transported him to LC with his
mother. ePRF for this transfer notes that patient was given a “further 2.5mg salbutamol to good
effect”. Oxygen levels (SATS) on arrival at LC Hospital was 95% on air. As patient maintaining his
own SATS the crew were told to take the patient direct to the Paediatrics ward by AE staff. Clinical
comparison by PB shows that the patient’s condition had deteriorated between the first and second
call.
On clearing this transfer the crew were contacted by the Control Room. The Delivery Manager JT,
requested that the crew complete an Incident Report form (IR1) for an inappropriate booking by G
Hospital, as the patient was deemed stable enough to go straight to a Paediatric ward. A P1 transfer
is only to be used when “time critical, life-saving intervention” is required. ---- clinical assessment was
that “the child was tachypnoeic (breathing rapidly) and struggling, but (he) was stable and I’m sure
discharged 24 hours later from (hospital).” Based on these findings the patient’s condition did not fit
EMAS criteria for a P1 transfer.
G Hospital asked why the patient was not taken directly to LC Hospital. EMAS policy is that the
patient is taken to the nearest AE. In this case G Hospital was 9.4 miles from the address patient was
collected from. LC Hospital was 39 miles from this address. The crew acted correctly in taken the
patient here. The patient’s condition did not fall under the exclusion criterion for the hospital. This
choice of hospitals has been assessed based on the ePRF data, and held to be a correct decision by
the crew.
All EMAS ambulances now carry Paediatric SATS probes as standard, as per Clinical Bulletin from
Medical Director, SD. Both crew members attended an Essential Education 2010/11 course with a
specific session on Paediatrics. This was based around the assessment of the sick child, and
included intercostal, sternal recession and tracheal tug. As well as the effects on respiratory
inadequacy and relevant management. In 2011/12 they both were issued the Essential Education
refresher workbook. This again mentions specifically assessment of breathing effort and looking for
recession.
Conclusion:
Why was a Community First Responder not activated to this call?
When the call was received the Community First Responder desk failed to do a resource allocation check.
Instead a note was just placed on the Computer Aided Dispatch message that this call was not suitable. Due to
this the Desk failed to allocate an appropriately trained responder to this patient. This was an incorrect action by
the CFR Desk and due to this an achievable R2 call was not attained.
Why was the hospital not pre-alerted?
Due to the lack of Paediatric Oxygen Probes (SATS) on the ambulance it cannot be fully ascertained if a prealert should have been placed. Based on the information available, P1 would have to use own judgement and
experience to decide if appropriate. The crew stated that they did not feel that the patient’s condition warranted a
pre-alert to AE. A clinical assessment of the observations by Locality Quality Manager (LQM), supports this. --states that “…the observations recorded (were) within normal parameters for the age of the child.”
Why was the patient taken to G hospital, and not LC Hospital?
The address the patient was collected from was 9 miles from G Hospital, but 39 miles from LC Hospital. It is
EMAS policy that 999 calls are taken to the nearest, appropriate, A&E. As the patient’s condition is not
contained within G Hospital Exclusion Criterion the crew acted correctly in taking to the nearest hospital.
What were the Paramedic’s observations on the PRF?
The Paramedics observations were:
1st observations: Heart Rate 120; Respiratory rate 28; GCS 15
2nd observations: heart rate 124; Respiratory rate 28; GCS 15
These have been clinically assessed as within normal parameters for a child of this age.
Does clinical assessment of the observations support the Paramedic’s treatment plan?
Yes. Clinical assessment of the observations raises no concerns with regards to the Paramedic’s treatment
plan.
Did the paramedic notice tracheal tug or intercostal recession? If not, what training are crews given to
identify this?
When interviewed, the crew stated that there were no signs of tracheal tug or intercostal recession at
the time of assessment or en-route to Grantham A&E.“ The patient’s mother had reported observing
intercostal recession through the night. The crew made note in the E-PRF of this comment by the
mother, but failed to state that intercostal recession was not apparent in their presence. Both crew
members attended an Essential Education 2010/11 course with a specific session on Paediatrics.
This was based around the assessment of the sick child, and included intercostal, sternal recession
and tracheal tug. As well as the effects on respiratory inadequacy and relevant management. In
2011/12 they both were issued the Essential Education refresher workbook. This again mentions
specifically assessment of breathing effort and looking for recession.
Were Oxygen Saturation rates taken? If so, what were they?
No Oxygen Saturations (SATS) were taken as there were no paediatric SATS probes on the vehicle. This is a
sensor placed on a digit that records oxygen levels within the red blood cells. Due to this, the crew monitored
patient’s colour, conscious state and breathing rate throughout both journeys. On arrival at LC the Hospital’s
monitor was used and SATS recorded at 95% on air.
Why was patient not given nebuliser, or O2, by paramedic?
The Paramedic states that “the patient did not have a respiratory wheeze, therefore did not fit into our
nebulisation criteria.” Oxygen was not given on route as the paramedic did not believe that the
observations indicated a need as patient was alert, with good colour, and a non-productive cough.
Patient was happy playing, or sleeping during the journey giving the crew no cause for concern.
Confirmation has been received that all EMAS ambulances now carry a paediatric SATS probe, and
was subject of a Clinical Bulletin by the Medical Director.
Did the observations support patient being booked as a P1 transfer – time critical, and immediately lifethreatening condition?
On arrival at LC A&E patients SATS were taken. They were 95% on air. As patient maintaining his
own SATS the crew, were told to take the patient direct to the Paediatrics ward by AE staff. On
clearing this transfer the crew were contacted by Control Room. The Delivery Manager ---, requested
that the crew complete an Incident Report form (IR1) for an inappropriate booking by G Hospital, as
the patient was deemed stable enough to go straight to a Paediatric ward. A P1 transfer is only to be
used when “time critical, life-saving intervention” is required. --- clinical assessment was that “the child
was tachypnoeic (breathing rapidly) and struggling, but (he) was stable and I’m sure discharged 24
hours later from (hospital).” Based on these findings the patient’s condition did not fit EMAS criteria
for a P1 transfer.
Recommendations:
Recommendation
Action
CAD Mail/E-,mail to all CFR
dispatchers regards to checking
Res/Alloc on all calls
CAD mail/Email to ensure all CFR understand the
need to use res/alloc on all calls. Re-iterate that
calls have been missed as not been checked for a
responder. It has been incorrectly assumed the
area does not have an appropriately skilled CFR.
All calls should have a CFR res/alloc check in the
SOE to evidence trail for none allocation: e.g.
Complaint not suitable.
Lead
Due Date
Evidence
21/9/13
Copy of CAD mail
FC/058/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Logged by:
Incident Location:
Witnessed an RTC, stopped to help. When EMAS arrived on scene, IMS
alleged that they tried to give a handover, FRV queried the skills of IMS &
complaint:
then told them to go
(15 working days)
29
August
2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of Why did the ECP refuse the clinical handover?
Investigation What was the reasoning for the ECP retaking a history of events from the patient?
(must include all
complainant
concerns) :
Why did the ECP move the patient’s limbs?
Yes both in person, by email and on the telephone
Expectations of Complainant: As above
FC/058/13
(EOC) on 29 May 2013 and the Patient Report Form (PRF) details.
Time
Events
13:52
Call 5578931 received into the EOC to attend a one vehicle Road Traffic Collision
(RTC) on the A38 north bound, north of A50.Call correctly Coded 29B03 Green2
(G2) with a 30 minute response.
Resource allocation (Res/All) list opened and 2431 First Response Vehicle (FRV)
P2 allocated to attend.
Patient a ---year old female. Oil and Debris, Police on scene.
Call Handler puts in notes ‘Technician on scene’.
Call Handler puts in notes ‘Technician requesting Fire, oil and debris on road’.
2431 FRV arrives on scene
Police informed Incident 356.
2431 FRV updates, confirms single patient RTC on A38 northbound just past
junction with the Hospital.
Back up Double Crewed Ambulance (DCA) required - Amber response
IMRS leave scene having completed their handover to 2431 RRV.
Dispatcher notes ‘Crew Required C Spine and board’ and also requests
attendance of Paramedic Team Leader.
DCA 3710 allocated to attend.
Dispatcher notes ‘Private ambulance service was on scene with the patient on
ECP arrival’.
3433 solo Paramedic Team Leader (PTL) allocated to attend.
DCA 3710 mobile to scene
PTL 3433 mobile to scene
DCA 3710 arrives on scene
PTL 3433 arrives on scene
DCA 3710 leaves scene conveys patient to hospital.
2431 also leaves scene
PTL 3433 leaves scene
DCA 3710 patient arrives at Hospital.
All resources marked clear of incident and call closed by Dispatcher.
13:53
13:54
13:56
13:57
13:58
13:59
14:00
14:00
14:04
14:08
14:08
14:09
14:11
14:14
14:28
14:29
14:33
14:39
15:47
Evidence Gathered:
• Sequence of Events (SOE) for Emergency Call 5578931.
• Patient Report Form (PRF) in relation to call 5578931.
• Voice recordings of call received into the EOC.
• Review of ePRF from Locality Quality Manager (LQM)
• Copy of Incident Reporting Form submitted.
• Record of Interview from ---.
A call was received into the Emergency Operations Centre (EOC) reference 5578931 asking EMAS to
attend a Road Traffic Collision (RTC). This was processed through the Advanced Medical Priority
Dispatch System and coded 29B03 Green2 (G2) with a 30 minute response. The caller stated they
were from Intrim Medical and Rescue Services (IMRS) and were a Technician crew.
A First Response Vehicle (FRV) was assigned to attend at 13:53hrs and arrived at the scene of the
incident for 13:58hrs. This is within the required 30 minute response time.
The FRV on scene requested the attendance of a Paramedic Team Leader (PTL) and for a Double
Crewed Ambulance (DCA) to attend confirming they would need to bring a spinal board with them.
The PTL is requested due to IMRS being on scene at the arrival of the FRV and the attitude of them
towards the FRV.
IMRS left the scene of the incident having completed a handover with the FRV. Notes on the PRF
from IMRS state the work carried out by them and handover issues. Information also shown from
IMRS not being happy over the Clinical assessment made by the FRV once the Patient was in their
care.
The Paramedic (PW) from the FRV confirms a verbal handover was given by the taller of the two
IMRS personnel, whilst the other held the Patient’s neck from behind. PW states the member of staff
completing the handover from IMRS was wearing laurel wreaths on his epaulettes and, came across
as intimidating by his ‘in your face’ attitude. --- asked IMRS who they were and what qualifications they
had as he had not met them before. He assumed they were high ranking officers from another service
and wanted to clarify this. On asking, the taller member from IMRS seemed to take offence at being
questioned and said something similar to ‘we can go’. --- told IMRS it was up to them if they wanted to
stay. At this the other member of IMRS let go of the Patient and walked away.
Due to the condition of the Patient, --- was left to support her by standing behind her holding her neck
to ensure no movement. He was unable to complete any observations as he was supporting the
Patient until the DCA arrived. At no point did PW ask the Patient to move her legs.
The PTL and DCA arrived on scene. The DCA took a limited Clinical Handover from the RRV then
prepared and conveyed the patient to Hospital. The DCA and FRV crew use a Spinal board to secure
the Patient.
The PTL travelled with the RRV to Hospital and an Incident Reporting Form was completed regarding
IMRS being on scene at the time of the incident along with their actions.
A justified reason is given at the top of the paper PRF for the crew not completing an ePRF. The PRF states the
system was down.
It is not clear if PRF is saying that there was c-spine/neck pain or not. Two sets of observations were completed,
although no BM, pain score (patient complaining of lower back pain) and pupillary reaction not assessed.
Lower back pain could be considered a distracting injury; however, without a pain score you are unable to
determine this which may have indicated the need for C-spine immobilisation.
Conclusion:
---- did not refuse the handover from IMRS. The PRF shows that IMRS were on scene at the arrival of the FRV.
It is standard practice for a Clinician to retake observations including some history of events to ensure they have
the full picture from the patient and can make a valid assessment for themselves. This guarantees that no
information has been missed prior to treatment being given.
It is not clear if the PRF is saying that there was c-spine/neck pain or not. Lower back pain could be considered
a distracting injury; however, without a pain score you are unable to determine this which may have indicated the
need for C-spine immobilisation.
The FRV --- did not ask the Patient to move her limbs. When IMRS left the scene ---- was left supporting the
Patient until the DCA arrived. Due to this support, --- was unable to complete or provide any other clinical
observations.
Recommendations:
1. Action: Communication to go to all Operational Staff explaining the need and use of Private
Providers. To explain they are clinicians and to obtain a handover as you normally would. To
explain they are an important part of the care process.
For:
FC/059/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Brief details of the PTS pt wants her wheelchair assessed to be carried in PTS vehicles. Had
complaint: an accident and told couldn't travel in it until assessed - see FC/211/12
Type of Complaint: Patient Care (Quality of Care)
Division/Area: # PTS Lincolnshire (PTS)
(15 working days)
(20 working days)
Staff involved
& Station:
PTS Control
Minor 1 – already been investigated by PALS, escalated to FC as patient not happy
Initial grading
with initial response.
& Rationale:
Scope of Why has chair not been assessed?
Investigation Is the chair suitable to be used on the Patient Transport?
(must include all
complainant
concerns) :
If chair not suitable for transport, what can be done so patient can attend her hospital
appointments?
31/7/13
Expectations of Complainant: Solution to transport issue
Immediate actions taken: N/A
FC/059/13
Date and Time
15/2/13 12:45
22/3/13
26/7/2013
Events
Patient Transport staff collected Patient from home address to hospital. A winch was
used to place the patient, in own wheelchair, on back of ambulance. On reversing
chair out of ambulance, the chair started to tip backwards.
Initial PALS investigation – recommends that the chair be assessed before further
transport for suitability. PTS records state this was done in March, and it was deemed
unsafe. There is no written report of this assessment and Patient states that this did
not occur, no one has come out to see her. Team Leader marked as attending is
currently off work.
Second letter of complaint received and escalated to FC. Patient has an appointment
20 August and needs chair assessing as soon as possible as she is cannot book
transport for till it is done.
Evidence Gathered:
PALS complaint proforma
Previous PALS complaint agreed course of action with Patient Transport Service (PTS) that the chair
be assessed. PTS manager states that Team Leader spoke to patient at the hospital, and was told
her own chair was not suitable. Patient recalls being told this, but states that the Team Leader did not
examine the chair itself.
Patient has travelled in the East Midlands Ambulance Service (EMAS) Chair supplied on one occasion
since this incident. She was very uncomfortable as the foot plate does not adjust. This position
resulted in pressure on her stoma and hernia.
During discussions with patient, it was ascertained that her own chair is not fitted with anti-tilt
stabilisers. Due to this there is a danger that crew would not be able to prevent her toppling out if
chair tilted again.
Have spoken with Wheelchair Services and arranged an urgent assessment of Patient’s chair. They
have confirmed it is crash tested, and will see if it is suitable for anti-tilt stabilisers to be fitted. The
chair is reported to be quite old, so Wheelchair Services will also assess whether it is more
appropriate to supply patient with a new chair instead. PTS manager has been advised of this, as has
patient. Both state that a new chair would be the best solution, and an agreement has been reached
where patient will travel in EMAS chair, if necessary, till her chair is organised. PTS manager has
been emailed to ensure that crew collecting her on next journey are aware this issue. They will try to
make her as comfortable as possible in the chair due to the foot rest problem.
Conclusion:
Why has chair not been assessed?
Team Leader attended the hospital, saw the chair and spoke with patient after the original incident.
Patient was advised at that time that the chair was not suitable for transport on the Patient Transport
vehicles. Patient recalls being told it was not suitable but was not aware of the chair being examined.
Is the chair suitable to be used on the Patient Transport?
No. It is not fitted with anti-tilt stabilisers to stop it toppling backwards on the ramp.
If chair not suitable for transport, what can be done so patient can attend her hospital
appointments?
Arrangements have been made for Wheelchair Services, from the hospital, to contact patient direct.
They will make an urgent assessment of her current chair. They will see if chair can be fitted with antitilt stabilisers and make any repairs necessary to make it safe. Due to the chair’s age they will look at
whether it needs to be replaced totally. Patient is happy to travel in EMAS wheelchair, if necessary,
whilst this is being put in place.
Recommendations:
PTS crew attending patient are to be made aware of the issue regards to the patient’s current chair. If
she is to be transported in EMAS wheelchair she is to be made as comfortable as possible with
consideration for the fact the foot plate does not adjust.
Action: Note to be placed on PTS Cleric system to make transport crew aware of what is being put in
place with Wheelchair Services and interim measures to be used.
For: PTS Manager
Evidence: Confirmation email of PTS entry with screen shot of Cleric Data
Date feedback given to complainant: 1/8/13
Response letter sent: 1/8/13
Formal Complaint Proforma Ref: Fc/060/13
Fc/060/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Patient was sectioned and transferred to -------------------- at -------------------------------.
He was restrained and nurse and police officer travelled with him.
Brief details of the It has subsequently discovered that he has sustained some injuries but
complaint: when this happened is not known. He has a fractured rib on right hand
side.
Does the attendant member of the crew witness anything during the
journey where injuries may have occurred.
Type of Complaint: Patient Care (Quality of Care)
(15 working days)
(20 working days)
Staff involved
& Station:
Moderate and rare 3 – escalated PALS to FC; enquitry for witness information
Initial grading
relating to nurse and police handling of patient; not directed at EMAS
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Did crew witness patient being restrained? If so, what did they see?
31/7/13 – email sent
Expectations of Complainant: Details of any actions witnessed
Fc/060/13
Date and Time
26/6/13 22:45
23:03
23:29
Exact time not
known
00:39
24/7/13
Events
999 call received – CAD 5644500. This detail was stopped and downgraded to an
urgent booking for admission to a seclusion room. ‘Patient has been restrained and
required monitoring on the way’. Police were noted to be on scene and would provide
an escort. Nursing assistant will follow in own car
Call is upgraded to a 999 call by the Dispatch Manager (DM). No note in detail as to
why call is upgraded back to a 999. Patient confirmed under section. Call was coded
as a G1 (35B00) call under standard protocol for upgraded urgent calls. Crew was
immediately assigned and were on scene by 23:10. This is within the 20 minute
response required for a G1 coding.
Crew left scene with Police escort 23:29. Patient was calm on arrival and in handcuffs.
He was placed on the stretcher and secured with safety belts. Crew arrived
destination 00:18.
Patient started kicking about, paramedic and police officer placed secure strapping
around his legs. Paramedic states no injuries occurred whilst patient was in their
presence. Nothing noted in PDF but did state Police and Nurse travelled in vehicle
with patient.
Crew marked clear of detail.
PALS complaint received and investigated:
Patient was sectioned and transferred to --------------------------- at ----------------------------.
He was restrained and nurse and police officer travelled with him.
It has subsequently discovered that he has sustained some injuries but when
this happened is not known. He has a fractured rib on right hand side.
Does the attendant member of the crew witness anything during the journey
where injuries may have occurred.
--- (Paramedic) states: “We attended this patient at -------------- after he had been restrained for some
time. Patient was sat on a sofa in handcuffs relatively calm. He was assisted
up by the Police and put on the stretcher where the safety belts were placed
on him.
During the journey we had to place extra restraints around his legs to stop him
kicking and injuring himself or others.
At no time while in our care could the patient have been injured”.
The Emergency Care Assistant in no longer employed by East Midlands
Ambulance Service NHS Trust
Any injury sustained to the patient was either done before or after the
ambulance crew had patient contact and not in their care.
1/8/13
--- spoken to by I.O. confirms previous statement to PALS as correct. Crew
unable to assist regards to information relating to injuries as described
Evidence Gathered:
CAD SOE 5644500
CAD SOE urgent detail
CAD SOE urgent upgraded to 999
Case progress sheet
PALS email 1
PALS email 2
PALS email 3
PALS email 4
PALS proforma blank
PALS proforma with investigation details
PRF request
Record of phone conversation with --Introducaiton Email to complainant
PRF
Crew arrived on scene to patient who was already handcuffed and sedated. Police and Nurse were
on scene. Patient was under section. Notes made the call state that patient had been restrained prior
to the Ambulance being requested.
Patient was calm whilst in the crew’s presence, excepting on one occasion. Patient began to kick out
whilst on the stretcher. Paramedic and Police Officer then used authorised leg straps to prevent
patient from continuing. Patient calmed down and no further incidents occurred.
Paramedic states that injuries did not occur in their presence and that they have no further information
to assist on the matter.
Conclusion:
Did crew witness patient being restrained? If so, what did they see?
No. The patient was handcuffed and sedated prior to the ambulance being called.
Patient was calm whilst in the crew’s presence, excepting on one occasion. Patient began to kick out
whilst on the stretcher. Police Officer used own authorised leg straps to prevent patient from
continuing. Patient calmed down and no further incidents occurred.
Paramedic states that any injury sustained to the patient was either done before or after the
ambulance crew had patient contact and not in their care.
FC/061/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? Yes
Previous reference: FC/001/13
Logged by:
Incident Location:
Patient had chest pain & abdominal pain. Paramedic said he wasn't
Brief details of the having a heart attack & refused to give him any pain relief. Waited over 2
complaint: hours for DCA to take him to hospital. Patient died from pancreatitis septic shock
(15 working days)
(20 working days)
Staff involved Paramedic
& Station:
Initial grading
& Rationale: FC5 – Catastrophic due to loss of life but rare event.
Scope of
Investigation
(must include all
complainant
concerns) :
Why there was there a delay of 2 hours and 4 minutes before an ambulance arrived on
scene?
Why did the solo Paramedic not contact the EOC and request or enquire into the DCA back
up?
Was the correct ambulance assigned for backup?
Why did Paramedic make patient walk to the ambulance?
Why did the Paramedic change his statement regards to the radio transmissions?
What action is to be taken by EMAS regards to the Paramedic’s change of statement?
How long has the P1 been a Paramedic?
What has been done to limit this issue re-occurring?
29/7/13
Paramedic to be disciplined for change of statement to Senior
Officer re Transmissions.
Immediate actions taken: None – prev HL (2nd investigation)
FC/061/13
Date and Time
16:00
15/3/2013 16:11
16:17
16:21 Approx
Events
Patient released from hospital after treatment and scan for liver condition.
Weather reported this day at 0.6 degrees.
Dispatcher1 (D1) takes over East Double Crewed Ambulance desk till 20:00 – due to
staff shortfall this is the third dispatcher for this desk on the shift, and was newly
trained.
D1 had training in class in March 2012; the mentoring period was then set up for
November with Dispatcher2 (D2), but was cut short by a few shifts.
It was then some time before D1 actually dispatched, other than to break cover. This
was one of D1s first solo shifts.
Duty Manager (DM) notes in Lincolnshire Resource Log (RL) currently holding 3 x P1
transfers. These are Blue light transfers requiring an 8 minute response from a Double
Crewed Ambulance from DPOW
999 call received – CAD 5400830. Male with Chest, Back and Abdo pain.
This was coded as an R2 call, requiring a response on scene within 8 minutes.
Dispatcher verbally passed FRV this detail.
This radio message has no date stamped onto the SOE for the Call so was not visible
on first investigation.
Examination of FRV Resource Log for the day, and comparing all logged radio
messages allowed it to be located.
Searches of the Storacall system located it as being passed at 16:13 – 4 minutes
before the 999 call was made.
16:21
16:20
17:19
17:25
17:26
17:52
17:53
In the call Dispatcher informs Paramedic1 (P1) that he will need to arrange backup as
this is a Chest Pain. No further communication radio transmissions are made between
Dispatch and P1 till 17:52 when P1 requests ETA on backup.
D2 dealt with 135 radio messages in the time of this call – one message every 86
seconds.
P1 was correctly assigned by D2 and arrived on scene at 16:25, this is within the 8
minute required response timescale.
RL Lincs states Trust invokes CMP 3 – 45 calls being held.
RL Lincs notes ‘Delays at DPOW A/E. Crews advise due to influx of resus patients
which has taken up a lot of nursing staff. Paramedic Team Leader (PTL) to be
dispatched as Hospital Liaison Officer (HALO) when clear current priority.
CAD generates an Incoming Message for the Dispatcher 2 stating that the FRV has
been at scene for over 60 minutes. This is a message that prompts the FRV
Dispatcher to welfare check the patient. It is a message that is not visible when
Dispatcher has other CAD details open on the screen. The call was opened, briefly by
Dispatcher 1, but no Resource Allocation (Res/Alloc) completed
Delays --- – no beds
FRV calls to control and Requests ETA for crew. Dispatcher 2 apologies for delay
stating DCA just clearing Grimsby – states problems with Resus holding up crews.
FRV makes no mention of patient condition in transmission.
Resource Allocation checked and ‘RED BACK UP’ entered in the log by Dispatcher 1.
Crew assigned with a 45 minute ETA. This was not the nearest vehicle available.
Check of the Res/Alloc at the time shows a crew with a 25 minute ETA. These were
mobile to a G2, lower category call, in the area and should have been diverted. Had
this been done backup would have been on scene 20 minutes earlier – approximately.
18:29
19:00
The only way for the Dispatchers to know that this Ambulance can be diverted is to
open up the relevant Call that the crew are currently on. The Res/Alloc does not say if
this crew is already on a red backup
Crew arrives on scene, contacts hospital for permission to give Morphine and leaves
with patient within 13 minutes. Time since original 999 call – 2 hours and 12 mins.
Patient’s wife arrives at PDOW A&E having travelled from Nottingham. Patient’s wife
arrives 26 minutes before the crew does.
Evidence Gathered:
WAV radio transmissions
WAV file 999 call
FC001 2013 Chronology
CAD SOE
Resource Log FRV and DCA
Case progress sheet
Call audit
Commentary Supporting Data
Daily performance Report
Capacity Management Plan
IO report HL 005 and FC001
Lincolnshire Resource Log
ePRF
Solo Responders Standard Operations Procedure
Dispatch Framework with auto backup
FRV Dispatch advice
Performance Data
Temp average temperature 0.6 degrees, Met office reporting Amber warning re heavy snow.
LC Divisional Performance
Red (within 8 minute response) 67.16% - target for Red calls is 75%
Red 19 (conveying vehicle to be on scene to Red call within 19 minutes) 88.06% - target is 95%
Green 1 (on scene within 20 minutes) 79.82% - target is 90%
Green 2 (on scene within 30 minutes) 79.82% - target is 90%
Green 3 (Clinical Phone Triage within 20 minutes) 100%
Green 4 (Clinical Phone Triage within 60 minutes) 90.16% - target is 90%
Environment
March 2013 was subject to heavy snow conditions throughout the UK, with reports of snow drifts and
treacherous driving conditions in the County. Comparison of calls, this date on the previous year, shows an
increase of 41%.
Paramedic (P1)
The initial investigation did not show any radio transmissions between D2 and P1 for this detail.
There was no trace of an automatic data entry which shows in the Call Sequence of Events (SOE) that the radio
was activated. When P1 was initially spoken to, he stated he recalled speaking with D2 about the backup, and
was told that one would be arranged. This P1 said from memory.
When P1 was shown the SOE from the call, P1 accepted that there was no automatic data entry supporting his
statement. Due to this P1 rescinded his statement, and stated that he must have misremembered what
happened.
Upon examination of the SOE, for the Fast Response Vehicle itself, it was discovered that there was a radio
message between D2 and P1 at 16:13. This call was listened to and found to be the recording of D2 diverting
P1 to this call. Within it D2 confirmed that backup would be automatically deployed to P1. This time stamp was
4 minutes before the 999 call was received. Due to this the CAD did not pick this recording up as part of this
incident, and so it was not located in the original investigation.
P1 was a Paramedic Team Leader (PTL) at the time of this call, now a Clinical Team Mentor, and has been a
paramedic since 1990. Previously that day, P1 had attended a call requiring backup in the same area. The
ambulance arrived on scene 1 hour 12 after being requested. D2 states traveling time for an ambulance, is
approximately 45 to 60 minutes, in good weather. P1 stated ‘It is not unusual to wait over an hour for back up in
rural LC.” P1 called up when the ambulance did not arrive 1 hour and 31 minutes after his arrival. This was now
outside the time scale he would have expected, so he contacted control for an ETA. The Solo Responders
Standard Operations Procedure does not include any requirement for P1 to call with an update on patient
condition from scene for an automatic backup.
Patient’s wife wished to know why her husband had been made to walk to the ambulance, considering his
condition. P1 states that ‘the patient had been walking to and from the toilet whilst waiting for the ambulance to
arrive and to walk to the waiting ambulance was little further, the patient was keen to get moving to hospital and
he was also very heavy, around --- stone or more in my estimation. He was haemodynamically stable so I saw
no problem in allowing him to walk to the ambulance.’ Checking the upper weight limit of the carry chairs,
supplied on the ambulances, the maximum weight limit is 18 to 19 stone (depending on which chair is available).
P1’s assessment places the patient at the upper weight limit, possibly exceeding it. Best practice in such a case
would be to allow the patient to walk if able to do so.
Dispatcher 1 (D1) East DCA Dispatcher
D1 had only recently qualified to dispatch. She is not a Dispatch officer, but is used to cover shortfalls of
Dispatch officers and to cover meal breaks. This was one of her first shifts running the desk without full time
supervision. D1 reports that when she took over the desk, at 16:00, there were already a lot of calls waiting to
be assigned and ‘serious delays’ at the DPOW hospital. D1 recalls these hospital delays had a severe effect
regards to covering calls in the North East of the county. Shortly after taking over the desk EMAS went into
Capacity Management Plan (CMP)3, and D1 believes that this may have been her first shift dispatching in CMP.
CMP 3 means EMAS was holding 45, or more, calls across the Trust. D1 has no memory of speaking with D2
regards backup for this incident.
Training for D1 started in March 2012, with mentoring in November organised with D2, a Senior Dispatcher.
This was cut short by several shifts, due to pressures on the service over Christmas. Class based training for
D1 was cut back by one day, and this was not re-scheduled. D1’s training, compared with other staff training for
dispatch, was short by 5 shifts of mentoring.
D1 was asked who she could obtain advice from if an experienced Dispatcher or Dispatch Manager (DM) is not
available. D1 stated that any questions would need to wait till one of them was free.
D1 was asked what could be done to make Dispatch Training more robust. She stated a thorough class based
training course, then mentoring to start within a month of the training course.
Dispatcher 2 (D2) Fast Response Vehicle Dispatcher
D2 was monitoring all jobs coming into County to see if a Fast Response Vehicle could be sent. This is a labour
intensive role that requires D2 liaise with both DCA dispatchers regularly, and deals with constant radio
messages from FRV staff. FRVs are single manned, so all communications need to be passed verbally when
the vehicle is mobile. The Dispatch advice for FRV Updates Procedure states “It is unsafe to send Mobile Data
Terminal (MDT- text style) messages to an FRV once the resource is mobile as they are unable to safely
acknowledge and read the message and maintain driving on blue lights and it is also not practical to slow down
or stop to read an MDT message and then continue on blue lights. Therefore no MDT message should be sent
to an FRV which is mobile to an incident.” During the timescale of this call, D2 dealt with 135 radio messages –
1 message every 86 seconds.
At 17:25 the Computer Aided Dispatch (CAD) generated an automatic message warning D2 that P1 had been on
scene for over 60 minutes. This is a message that would sit, with other outstanding messages, in the top left
hand corner of one of the dispatchers screen. When a Dispatcher opened up a CAD call it opens directly over
this message box. This means that when a call is open, dispatchers cannot see any messages outstanding.
When D2 spoke on the radio, at any time, he would have had to open the relevant call on CAD. Due to the
number of radio messages D2 dealt with, there would have been very limited time where D2 would have been in
a position to see the outstanding message queue.
When D2 assigned P1 to this call, D2 acknowledged that this was a call that would need automatic backup. This
is a requirement within the Dispatch of Planned Resources Standard Operating Procedure. D2 recalls telling D1
of the back-up request, but no warning note was placed on the CAD message indicating that Backup was be
required. D2 states D1 placed this request on a post-it note. At the time of this call, there was no set process for
formally logging backup requests on the desk. Since this incident, D2 has implemented a Back-up sheet that is
kept in the control room for future reference. As a Senior Dispatcher, he is now working with staff to ensure a
warning message is placed on all backup requests.
D2 states that he, and D1, should have checked Res/Alloc regularly so that a digital footprint of vehicles
available was placed in the CAD SOE. Upon examining the workload with a 41% increase in calls generated, it
is not believed that the dispatchers would have had the time to do extra checks without additional support at
such times. An entry in the Area Resource Log, by the Delivery Manager, notes that at 16:11 they were holding
3 x transfers from DPOW hospital to HRI. These are given an automatic coding of R2, and would have made a
substantial impact on the allocation of ambulances as they cleared for other details, and on backup requests in
the area.
With a substantial increase in calls received, it is not possible that D2 could have assisted D1 with mentoring
whilst in CMP 3. Every call coming into the County needs to be monitored by the FRV Dispatcher. Since this
incident, EMAS has ceased using an FRV desk in this area. The County is now split in three, with each
Dispatcher controlling one section. D2 feels this has had a substantial affect as it is a more manageable area to
control. Dispatchers now control all DCA and FRVs in their area, and so there are no longer this communication
issues between desks.
Conclusion:
Why there was there a delay of 2 hours and 4 minutes before an ambulance arrived on scene?
An error in communication occurred between the East Division Ambulance Desk and the Fast Response Vehicle
(FRV) Desk. This was due to a 41% increase in calls into the East Midlands Ambulance Service. There was no
additional support in place for the Dispatchers to assist with this increase.
Additionally, due to a staff shortage, a newly qualified Dispatcher was asked to complete one of her first shifts
without full time supervision. The FRV Dispatcher attempted to mentor her through this, but due to the incoming
workload this was not practical. This resulted in the patient having an excessive wait for ambulance transport to
hospital.
There was also three Blue Light Transfers from a City hospital. All were waiting for an ambulance at the time the
call to the patient was received. These calls require an ambulance to arrive on scene within 8 minutes, but none
were available at this time. This would have had a substantial effect on the ability of the Dispatchers to assign to
other calls.
Why did the solo Paramedic not contact the EOC and request or enquire into the DCA back up?
P1 is an experienced paramedic who is aware that it is not unusual to wait over an hour for backup in rural areas
of the County. P1 had had verbal confirmation from D2 that backup was being dispatched to him. There is no
requirement for P1, with in the Solo Responders Standard Operating Protocols, to call the dispatcher and alter
his automatic backup to any other level. When an FRV has been on scene for over 60 minutes an automatic
message is generated to ensure the patient is welfare checked by the Dispatcher. Due to the 41% increase in
calls this message was not noted by D2, and so the patient was not welfare checked.
Was the correct ambulance assigned for backup?
No. D1 assigned the first vehicle showing on the Resource Allocation (Res/Alloc) list as mobile, and available.
A nearer crew was mobile to a lower grade call, with a 25 minute eta. Had this crew been diverted they would
have arrived on scene 20 minutes earlier than the crew that attended. Delivery Manager confirms it is hard to
identify a crew that can be diverted in times of high demand using the Res/Alloc function.
Why did Paramedic make patient walk to the ambulance?
P1 stated that ‘the patient had been walking to and from the toilet whilst waiting for the ambulance to arrive and
to walk to the waiting ambulance was little further, the patient was keen to get moving to hospital and he was
also very heavy, around --- stone or more in my estimation. He was haemodynamically stable so I saw no
problem in allowing him to walk to the ambulance.’ Checking the upper weight limit of the carry chairs, supplied
on the ambulances, the maximum weight limit is 18 to 19 stone (depending on which chair is available). P1’s
assessment places the patient at the upper weight limit, possibly exceeding it. Best practice, in such a case,
would be to allow the patient to walk if able to do so.
Why did the Paramedic change his statement regards to the radio transmissions?
The initial investigation did not show any radio transmissions between D2 and P1 for this detail. There was no
trace of an automatic data entry which shows in the Call’s Sequence of Events (SOE) that the radio was
activated. When P1 was initially spoken to he recalled speaking with D2 about the backup, and was told that
one would be arranged. This P1 said from memory. When P1 was shown the SOE from the call, P1 accepted
that there was no automatic data entry supporting his statement. Due to this P1 rescinded his statement, and
stated that he must have misremembered what happened.
Upon examination of the SOE for the Fast Response Vehicle itself, it was discovered that there was a radio
message between D2 and P1 at 16:13. This call was listened to and found to be a recording of D2 diverting P1
to this call. Within it D2 confirmed that backup would be automatically deployed to P1. This time stamp was 4
minutes before the 999 call was received. Due to this the CAD did not pick this recording up as part of this
incident, and so it was not located in the original investigation.
What action is to be taken by EMAS regards to the Paramedic’s change of statement?
None. P1 made a correct statement when he was asked about the radio messages. He did this from memory.
When P1 was presented with the SOE printout he accepted that as the radio message was not there that he
must have mis-remembered the incident. It has since been proved that this radio message did exist, but due to
a technical issue it did not show up on the details of the call to this incident.
How long has the P1 been a Paramedic?
P1 has been a Paramedic since 1990.
What has been done to limit this issue re-occurring?
The FRV desk has been discontinued. Three Dispatchers now cover a third of the County each. This means
the same person deals with both the FRVs and the DCAs in the area. This removes the communication issue
that resulted in this incident. D2 has arranged for each desk to have a log that will be used to list all backup
requests. This will be filed and kept for future reference. Dispatchers are also being encouraged to use a
warning marker for backups, so that a digital footprint can be evidenced.
This excessive delay was caused by the Dispatchers failing to provide automatic backup as per policy. This was
due to a 41% increase in call volume due to extreme weather conditions, and insufficient support for the
Dispatch Team in times of high demand and multiple Blue Light transfers outstanding at time of this call. A new
Dispatcher was filling in to assist due to a staff shortfall, with one of the other Dispatcher’s providing her with
mentorship whilst he ran the FRV desk. No other Dispatch trained staff were available to work as Dispatch
Assistant to monitor calls incoming. It was not feasible for the Dispatchers to effectively monitor all calls in these
circumstances. This resulted in a communication error, and hence the delay in backup attending the patient.
Recommendations:
Recommendation
A review support
needed for Dispatch
Teams in times of CMP
or extreme weather
conditions.
Action
Review of support requirements
of Dispatch Teams needs to be
undertaken. Each desks
specific needs should be taken
into consideration with view to a
tailored action plans. They
need to ensure effective
working practices when under
high demand due to CMP levels
or extreme weather conditions.
A working group of experienced
Dispatch officers, and
Managers, should be actively
involved in this process.
Lead
SDM
Due Date
01/01/14
Evidence
Copy of report
More robust Dispatch
training required
A specific and robust training
program needs to be
constructed for all Dispatch
Trainees. It should outline
specific requirements that are
signed off by a Dispatch Mentor
before the trainee completes
ANY solo shifts. This should
contain a mixture of classroom
activities and active dispatch
work within a stated time scale.
The programme should
consider Area specific issues
that apply to only certain desks.
This training course should be
mandatory on all occasions
before solo shifts are
authorised.
The Solo Responders SOP
needs to be amended to clarify
the automatic backup protocol
within this SOP. This should
outline the actions of the
Dispatcher and the FRV in such
circumstances. Establish how
Red and Amber backup
requests from other FRV affect
Training
Team
01/01/14
Copy of training
programme
Governance
01/01/13
Copy of the amended
SOP
Auto backup addition
into the Solo
Responders SOP
the automatic backup priority.
Consider a requirement that
once patient has been
assessed the FRV should
contact control and establish
backup level as regards to Red,
Amber, Green and none.
Formal Complaint ProformaRef:FC/063/13
FC/063/13
Date Received: 05 August 2013
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Their reference:
Logged by:
Incident Location:
Delayed response to a --- year old child that was fitting.
complaint:
Date for Investigation conclusion: 28 August 2013(15 working days)
Date to post response letter: 03 September 2013(20 working days)
Deceased? No
Staff involved BBEOC AE
& Station:
Initial
Minor 4 – unsatisfactory patient experience but likely to happen again
grading&
Rationale:
Why did the ambulance take 27 minutes to attend?
Scope of Why would the Call Taker not comment on how long it would be?
Investigation Was there a nearer ambulance at local Hospital that could have been used?
(must include all
Were any Community First Responders available to assist?
complainant
concerns): What improvements are the services planning to rectify such issues?
Intro letter, 2 phone messages left
Expectations of Complainant: Explanation of delay, actions being taken to remedy these.
The Investigation Officer’s Report FC/063/13
Date and Time
7/7/13 02:56
04:03
05:11
07:01
08:00
08:14
08:16
08:19
08:24
08:25
08:41
10:17
13:08
Events
Lin Resource Log (RL) notes CMP 4 continuing. Service level 57% on 277 calls.
Lin RL notes dropping to CMP 3
CMP 3 cancelled
Lin RL notes Hb crew no vehicle available as night duty not returned
Community First Responders (CFR) desk sends out text to all volunteer responders.
This is request for anyone available to log on to contact control due to high demand in
the area
999 call received – CAD 5669624. Call is to a --- year old male “fitting. Vomited during
the night”. Call was coded as a R2 – face to face contact required within 8 mins.
Crew assigned showing distance to call 8.47 miles with a 17 minute eta. This was the
closest resource.
Dispatcher notes for Out of Performance reason: 2 x Sp crews already out. Shortfall
of 2 staff. 07/19 DCA shortfall in Sp. Hb day crew had just been asked to go to Sp for
cover as they had just got their vehicle, but only just leaving Hb.
Clinical Assessment Team listening to call – state call is not appropriate for triage – call
to continue as R2
Crew diverted to R1 call – higher priority call. Dispatcher action correct
nd
2 crew assigned showing distance of 10.95 miles with eta 16 minutes. These were
the next closest to this call and correctly assigned by Dispatcher
Crew arrived on scene – 27 minutes after call received. Patient transported to BP
hospital.
st
Delivery Manager (DM) places additional notes in Out Of Performance reason: 1
nd
crew diverted to R1 in Sp. 2 crew dispatched from Bou. CFR off line
CMP 4 re-instigated
Evidence Gathered:
Performance
A8 - calls requiring attendance within 8 minutes, at 62.03% (target 75%)
A19 – vehicle able to transport patient to attend A8 calls within 19 minutes, at 87.31% (target 95%)
G1 – face to face contact within 20 minutes, at 63.13% (target 95%)
G2 – face to face contact within 30 minutes, at 67.7% (target 95%)
EMAS had been in CMP 3 and 4 on before and after this detail.
Calls this day show an increase of 15.21% on R1/2 calls, and 42.74% on G1 calls on the previous
week.
The local area was experiencing a high demand. Whilst crew was mobile to this detail, another 6 x
999 calls were in progress in the vicinity.
At 08:14 on the 7 July 2013 a 999 call was received to a child fitting and vomiting during the night.
The call was taken through the Accredited Medical Dispatch System to ascertain the condition of the
patient. This was given an R2 coding. This requires that a response arrive on scene within 8 minutes.
A crew was immediately assigned with an ETA of 17 minutes, as no other vehicles were available
closer. The local ambulance station had a shortfall of one Double Crewed Ambulance, and the other
two ambulances were already on scene at other calls. The Delivery Manager notes that none the
volunteer First Community Responders (CFR) were on duty that morning.
At 08:24 the crew was diverted to a higher priority, R1, call in the area. The Dispatcher then reassigned the next nearest crew to this detail. This crew had an ETA of 16 minutes. The action taken
by the Dispatcher was correct and complied with Dispatch Protocols for higher coded calls.
During the call the Emergency Medical Dispatcher (EMD) stayed on line with the caller, to give support
and assistance till the crew arrive on scene. The call was also monitored by a member of the Clinical
Assessment Team. The EMD was not able to give the caller information regards to the time scale till
the ambulance will be on scene. This is a strict protocol under the AMPDS system as to give an
estimated time of arrival (ETA) “gives false expectations” to the caller as the crew could be diverted at
any time. Due to this the EMD acted correctly by not providing an ETA to the caller.
The second crew arrived on scene 27 minutes after the call was received. This was 19 minutes
outside of the required target for R2 calls. Checks on the Sequence of Events, which is a
computerised log of all actions relating to this call, show that the correct vehicles were assigned. No
other options were available to the Dispatcher for this call. Whilst crew was mobile to this call another
6 x 999 calls were in progress in the area.
East Midlands Ambulance Service (EMAS) instigated different levels of the Capacity Management
Plan up till 05:11 that day. This means that the numbers of calls coming into EMAS were of such a
volume, that they outstripped the resources available to respond effectively. At 08:00 a generic text
went out to all CFR asking anyone available to log on duty to assist. This indicates that, although
EMAS was no longer in CMP, the volumes of calls incoming were still having a knock on effect
regards to attending calls. Information obtained from the Met Office show that from “…6th to 24th,
(temperatures) exceeding 30 °C on several days.” This hot weather placed additional pressures on
the Ambulance Services, and may account for a large proportion of the call increase of 15% in R1/2
calls (8 minute response required), and 43% in G1s (20 minutes response required).
Conclusion:
Why did the ambulance take 27 minutes to attend?
The United Kingdom was in a heat wave, with temperatures exceeding 30 degrees. Due to this there
was a substantial increase in calls to the service (15% for R1/R2 calls requiring an 8 minute response,
and 43% on G1 calls requiring a 20 minute response). At times throughout the day, the number of
calls outstripped East Midlands Ambulance Services (EMAS) ability to respond. At the time this call
was received, two local ambulances were already on scene at other calls. The nearest available
ambulance was deployed with a 17 minute eta. A further, higher priority call was received and this
crew had to be diverted. The next available vehicle was then assigned to this patient. The ambulance
arrived 27 minutes after the call to the patient was received, so was 19 minutes outside the target for
such a coding. The actions of the Dispatcher were correct.
Why would the Call Taker not comment on how long it would be?
The Emergency Medical Dispatcher (EMD) is prohibited from giving callers indications of when the
ambulance will arrive. This is strictly governed by the AMPDS, as to do so would give false
expectations to the caller. The crew mobile to this patient could be diverted to a higher priority call at
any time till crew showing on scene with the patient. The EMD acted correctly in not giving the caller
this information.
Was there a nearer ambulance at the local Hospital that could have been used?
No. At the time of this call there were no nearer ambulances than the ones that were assigned. The
local station had a shortfall of one double crewed ambulance that day. The other two ambulances had
gone out to calls in the area, and were no longer available to attend. The nearest ambulance was
correctly assigned to this detail.
Were any Community First Responders available to assist?
No. At 08:00, a page was sent out to all Community First Responders in EMAS. This was to inform
them that EMAS was receiving a high level of calls, and asked any available to log on duty. When the
call to this patient was received there were no Community First Responders logged on in the area.
What improvements are the service planning to rectify such issues?
The EMAS Trust Board approved “Being the Best” plans at its meeting on 25 March 2013, and at that
meeting said they would spend the next three to six months developing the plans, i.e. identifying the
most suitable areas for the stations to be located.
For the new 2012/13 financial year, EMAS has successfully negotiated additional funding from the
organisations that pay us to provide a level of emergency service i.e. the Clinical Commissioning
Groups. This additional investment means that we are now actively recruiting more frontline
colleagues to our service, extra to the 140 new frontline staff announced in March 2013.
We are working hard to improve Turnaround times with our colleagues at the hospitals. We will
continue to make good progress and to deliver quality clinical care to people in an emergency
situation.
Recommendations:
No recommendations
FC/064/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
How Received: Email
Their reference:
Logged by:
Incident Location:
Ambulance crew allegedly banged the patient's foot when wheeling her
out to the ambulance. On examination in A&E her left big toe had the nail
complaint:
'ripped off'.
Division/Area: # A&E Leics & Rutland (A/E)
(15 working days)
03
September
2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Minor
How did the patient sustain the injury to her toe?
23 August 14:00 hrs voicemail
Immediate actions taken: Crew statements taken
FC/064/13
for call reference 5718527 on 26 July 2013
12:09
12:10
12:10
12:12
12:16
13:04
13:10
13:23
14:17
16:25
new call received call reference 5718527 on behalf of a female patient who is
unresponsive
call is on behalf of a --- year old female who is conscious and breathing. Call is coded
as an eight minute emergency.
resource 4041, double crewed ambulance (DCA) is allocated to the incident.
resource 4041 mobile to scene.
resource 4041 arrives on scene.
resource 4041 leaves the scene with the patient.
resource 4041 arrives at the hospital with the patient.
CAD message: patient has gone into Resus.
crew of resource 4041 hand patient over to hospital staff and call clear.
crew of resource 4041 are unable to get through on the IR1 reporting line and are
returning to base to complete a paper Untoward Incident form.
Evidence Gathered:
Crew statements
CAD report
Electronic Patient Report Form (e-PRF)
Statements from staff at the Care Home
Handling of emergency call: the call was correctly coded as requiring an eight minute emergency
response. The responding resource arrived on scene seven minutes after receipt of the emergency
call.
Statements from members of staff at the Residential Home: the two members of staff who were in
attendance at the Residential home advised that on arrival the ambulance crew were taken upstairs to
the patient and they began to undertake basic and advanced life support procedures. The patient was
agitated and this made it difficult to insert a cannula but this was eventually done. The patient also
kept removing her oxygen mask. After the ambulance staff had undertaken their initial observations
the female member of staff advised that she would go back to the ambulance for the stretcher but the
care home staff advised her that it would not fit in the lift so she fetched the carry chair. The patient
was lifted from her bed and placed into the chair and then covered with a blanket and strapped in. As
she was being moved the Manager of the home noticed that the patient’s feet were not on the footrest
and so the Manager supported the patient’s feet on the journey to the ambulance. When the crew
arrived at the ambulance they moved the patient into the vehicle and started to transfer her to the
ambulance stretcher. At this point a member of the care home staff noticed that the big toenail on the
patient’s left foot was hanging off and dripping blood. The member of staff also stated that the female
ambulance crew member stated “look we’ve caught her foot”. The care home staff members then left
the patient in the care of the ambulance crew. Later in the day the patient’s daughter telephoned to
ask what had happened to her mother’s toe and she stated that the hospital staff were under the
impression that the ambulance staff had stated the injury must have been sustained at the care home.
The care home staff stated that the injury did not occur while the patient was under their care.
Statements from attending crew: the crew members had a good recollection of the incident and
advised that they were attending a female patient with a low level of consciousness, low blood sugar
(the patient is an insulin dependent diabetic) and the possibility of left ventricular failure. A full set of
observations was taken and due to the patient’s time critical condition it was imperative to get her to
hospital as soon as possible. The crew were assisted by a GP who arrived shortly after they did, and
interventions were performed including cannulation and the administration of Glucose and
Furosemide. They moved the patient to the ambulance by carry chair as the stretcher would not fit in
the lift. As they were transferring the patient onto the ambulance stretcher they noticed that the
patient’s left big toenail was hanging loose and bleeding. The crew examined the area and bandaged
the toe, and then they proceeded under emergency conditions to the Leicester Royal Infirmary with a
pre alert call placed to advise the hospital staff of their impending arrival. As part of their handover to
hospital staff the ambulance crew did advise of the injury to the patient’s toe.
The crew do not remember knocking the patient’s foot while they were transferring her, but would like
to pass on their sincere apologies if they did inadvertently cause the injury. Neither crew member can
recall saying that they had caught her toe but they do recall remarking that the injury was present. The
patient was time critical and the crew’s priority was to get her to hospital as soon as possible. They did
complete a report for an untoward incident before the end of their shift detailing the injury to the
patient’s toe.
Conclusion:
The ambulance crew do not recall catching the patient’s toe while they were transporting her, but they
would like to pass on their sincere apologies if the injury was caused while they were caring for her.
The patient was very poorly at the time and the crew were focused on getting her to the hospital as
soon as possible so she could receive specialist medical attention.
Recommendations:
There are no recommendations to be made on this occasion.
Date report sent to Investigation Manager for approval: 2 September 2013
FC/065/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 22 August 2012
Patient Name:
Deceased? No
Their reference: FC/189/12
Logged by:
Incident Location:
Brief details of the Patient collapsed. Very unhappy that she wasn't taken directly to the
complaint: stroke unit. Was FC/189/12 - new questions
(15 working days)
(20 working days)
Date to post response letter: 04 September 2013
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Moderate
To answer the additional queries relating to the incident raised by the complainant.
Last contact made 18 October 2013
Expectations of Complainant: Answers to additional queries raised.
Date OSM/PTL/Manager informed: LQM and CP 16 September 2013
Immediate actions taken: Additional statement from Paramedic
FC/065/13
Date of Incident 22 August 2012
Chronology developed from CAD SOE 4881021
The chronology for this incident is detailed in the original report under ref. FC 189 12.
Evidence Gathered:
CAD report
Patient Report Form (PRF)
Statements from attending crew
Clinical Opinion from Divisional Locality Quality Manager (LQM)
Handling of emergency call: the call was assessed as requiring an emergency response within eight
minutes. The solo responder arrived nine minutes after receipt of the call. On this occasion the target
timeframe was missed by one minute. After the solo responder requested back up the first available
vehicle was allocated to attend the incident and this arrived 14 minutes after the request was made.
Responses to additional questions raised by complainant.
In addition to the formal responses dated 25 February 2013 and 24 April 2013, the complainant has
asked for a number of additional questions to be addressed, and these are detailed below.
Do you hold any further documentation generated from the events of 22 August 2012?
No, the records relating to this incident consist of the Patient Report Form (PRF) and the Computer
Aided Dispatch (CAD) sequence of events (SOE) which have already been sent to ---------.
You state that the ambulance crew quickly ruled out electrocution as a cause of my wife’s collapse. On
my arrival, I was told by the Paramedic that my wife was suffering from shock/stress. However I note
from the PRF that it is recorded that my wife was not talking and under a lot of stress but the initial
clinical assessment is ticked as “calm”. This appears contradictory. Also, if the Paramedic suspected
that my wife would not be accepted by Nottingham City Hospital, could a call not have been made to
the hospital to check acceptance? Do you have a policy or guidelines relating to this?
The Paramedic undertook a 12 lead ECG to help with his possible diagnosis of electrocution, but he
could not rule this out entirely and it remained a possible cause for the patient’s condition. The initial
assessment of calm was recorded as the patient was not showing signs of panic or distress. In respect
of making a call to the City Hospital, the Paramedic had undertaken a FAST test which he judged to
be negative, and he felt that the most appropriate destination for the patient would be the QMC as
there was still a possibility that electrocution was the cause of the patient’s condition.
You state that my wife was not suffering from any right-sided weakness on initial examination. Given
that my wife remained with the ambulance crew for some time before transfer to hospital, and that it
was apparent to me on arrival at home at about 15:30pm that my wife was indeed suffering right-sided
weakness, should this form not be subject to further review and another assessment made,
particularly as the Paramedic remained with my wife from 14:47 until 16:30? What is your policy on
completion of PRF’s? Please explain who completed the PRF?
The Paramedic has stated that a second FAST test was carried out before the patient was transferred
to hospital, with the same result as the first test. The completion of the PRF is often undertaken by
both crews as observations and assessments are done, and this was the case on this occasion. The
first set of observations was undertaken by the Paramedic, and it was his decision to request back up
and transport the patient to hospital. The majority of the form was completed by the back-up crew.
You state at point 3 of your letter that the Paramedic stated in interview he was told to wait for my
return home? Who told him to wait and why? Would you provide me with the minutes of this interview?
I told the Paramedic I would not get to my home until about 15:30 so they did know how long it would
take for me to arrive and I queried why they had to wait also.
The Paramedic recalls that he thought the request to wait for the patient’s husband was made by a
friend who had arrived and that he should arrive in the next few minutes. The decision was taken on
this basis and because the patient’s condition was assessed as stable.
Have you carried out a serious untoward incident report/ root cause analysis in relation to these
events?
A serious incident report was not completed on this occasion as the complaint was handled under our
formal complaints procedure. Analysis of the findings was carried out as part of the complaint
investigation.
What are your target timeframes in relation to arriving at the scene of the incident and transferring to
hospital? Did you meet the target in relation to my wife’s incident of 22 August 2012?
The call on behalf of the patient was assessed as requiring an emergency response. The Trust’s
target for these calls is to have a response on scene within eight minutes in 75% of cases and within
19 minutes in 95% of cases. The Paramedic arrived on scene nine minutes after receipt of the
emergency call. In respect of the back-up crew this is dispatched to the scene as soon as an
appropriate vehicle becomes available, based on the priority under which this has been requested and
other emergency demand. The back-up resource was requested under the highest priority and this
arrived 14 minutes after it had been requested.
Please let me know the qualification and experience of the Paramedics who carried out the diagnosis
of my wife’s condition.
The Paramedic has been with the ambulance service for 13 years and he has been a Paramedic for
six years.
I should like to bring to your attention my dissatisfaction with the attitude of the Paramedics on 22
August 2012. I pointed out to the Paramedics that my wife was not moving on her right hand side.
Their response was that my wife was “fine” and was doing this “on purpose”. The implication was that
my wife was attention seeking and that her condition was not critical. I do not believe any effort was
taken to diagnose her. It was only due to my insistence that my wife was eventually transferred to
hospital.
There was no intention on the part of any of the ambulance crew to suggest the patient was seeking
attention. In respect of the decision to take the patient to hospital, this was taken by the Paramedic
when he requested back-up and this was well in advance of the patient’s husband arriving home.
Clinical opinion: the information gathered in relation to this incident has been reviewed by the
Divisional Locality Quality Manager with the following observations being made:
• The on scene time is excessive given that the back-up crew were requested as an emergency
response to transport the patient to hospital
•
•
•
•
The recording of the patient’s inability to talk should have resulted in the FAST test being
positive.
The Paramedic had decided within 25 minutes of arriving on scene that the patient would be
travelling to hospital. Given this decision the delay in waiting for the patient’s husband to arrive
home should not have been allowed.
The patient spitting out water should have raised the concern that she may have lost her ability
to swallow/her gag reflex, which should have raised a concern relating to a possible stroke.
Given the comment above about the patient being FAST positive, a call should have been
made to the Berman ward at City Hospital to verify whether the patient should have been taken
there. However, as electrocution was still being considered as a possible cause, it is likely that
they would have been instructed to take the patient to QMC initially.
Conclusion:
Clinical opinion in relation to this patient has concluded that the patient assessment should have
established that this patient was FAST positive. A call should have been made to Berman ward,
although it is likely the patient would still have been directed to the QMC due to the possibility of
electrocution.
Recommendations:
The following recommendations will be implemented as a result of this incident.
Action: Reflective practice to be completed by all members of staff.
For:
Deadline: 30 November 2013
Evidence: Reflective practice document completed and held on personnel files.
Action: Completion of 2013/2014 Essential Education for both members of the back-up crew.
For:
Deadline: 30 November 2013 to book date for attendance.
Evidence: Completed essential education record.
Action: Clinical supervision to be arranged for all members of staff including a discussion of this incident.
For:
Deadline: 30 November 2013
Evidence: Record of clinical supervision completed and held on personnel files.
Action: Audit of Patient Report Forms (PRF’S) for all members of staff on a minimum of 10 PRF’s.
For:
Deadline: 31 January 2014
Evidence: Result of PRF audits completed and held on personnel files.
FC/2013/067
Date Received: 15/8/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 6 August 2013
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
Dialysis patient had fallen. Wife states crew were abrupt and did not
check patient over before moving. Wife wanted patient to go to QEKL but
complaint:
crew insisted on PBH.
Type of Complaint: Crew Attitude
Division/Area: Lincolnshire
(15 working days)
12/9/13
(20 working days)
Staff involved
& Station:
Initial grading Low 4 – crew attitude likely to happen again
& Rationale:
Scope of Why did crew not attend the hospital requested by patient’s wife?
Investigation What arrangements were made for the patient’s dialysis?
(must include all Do Emergency Crews get training in people skills, and in how to reassure
complainant patients and relatives?
concerns) :
Email 18/8/13
Expectations of Complainant: Explanation and response
Date OSM/PTL/Manager informed: None
FC/2013/
Date and Time
6/8/13 05:57
05:59
06:04
06:44
07:15
07:26
Events
CAD 5745153 – 999 call received to --- year old male who has fallen and not alert.
Call coded R2 – requires on scene response within 8 minutes
Crew arrived on scene
Crew left scene
Crew arrived hospital
Crew clear hospital
.
Evidence Gathered:
Conflict Resolution Training lesson plan
CAD SOE
PRF
WAV 999 call
Staff Training
P1 - Attended EE 2nd October 2012, Conflict Resolution Training completed 16th February 2010 and
IPR completed July 2013
T1 - Attended EE 23rd October 2012, Conflict Resolution Training completed 10th June 2011 and IPR
completed August 2013
On 6/8/13, at 05:57 a 999 call was received to a ---- year old male who had fallen with a head injury.
The call was taken through the Advanced Medical Dispatch System. The call was coded requiring an
8 minute on scene attendance. Crew was assigned and arrived on scene with this timescale.
Patient’s wife was particularly concerned as to why the patient had not been taken to QEKL as she
had requested. The patient was due there for his dialysis treatment that morning, and his wife wanted
to know why her request was not acted on. The attending Technician (T1) was spoken to with regards
to the hospital choice of PHB. T1 states that the patient had a “significant head injury with bogginess
over the eye” and was “fading in and out”. Due to this the head injury had to take priority over the ongoing dialysis treatment. This required that the patient be taken to the nearest A&E department. T1
stated that PHB was 20 minutes away from the address, as opposed to QEKL at 40 minutes. This
was further compounded, T1 said, by on-going road works and diversions when heading to QEKL
which made PHB the only option for a trauma injury of this nature. Upon arrival at PHB, the crew
informed staff of the Dialysis appointment. PHB staff then contacted QEKL. Arrangements were then
made arrangements for the patient to be transported to QEKL once the head injury was treated, and
patient was stable.
The patient’s wife additionally raised concerns regards to training EMAS staff receive regards to
reassuring family, and using people skills. All staff attends induction training that includes active
listening, helpful attitude, empathy and positive body language. They are also taught skill with regards
to preventing and de-escalating conflict with others. Additionally to this, EMAS is incorporating a
behaviour and attitude module into its current Essential Education programme for 2013. It is required
that all staff attends this training.
Conclusion:
Why did crew not attend the hospital requested by patient’s wife?
The attending Technician (T1) was spoken to with regards to the hospital choice of PHB. T1 states
that the patient had a “significant head injury with bogginess over the eye” and was “fading in and out”.
Due to this the head injury had to take priority over the on-going dialysis treatment. This required that
the patient be taken to the nearest A&E department. T1 stated that PHB was 20 minutes away from
the address, as opposed to QEKL at 40 minutes. This was further compounded, T1 said, by on-going
road works and diversions when heading to QEKL. This made PHB the only option for a trauma injury
of this nature.
What arrangements were made for the patient’s dialysis?
Upon arrival at PHB, the crew informed staff of the Dialysis appointment. PHB staff then contacted
QEKL. Arrangements were then made for the patient to be transported to QEKL once the head injury
was treated, and patient was stable.
Do Emergency Crews get training in people skills, and in how to reassure patients and
relatives?
All staff attends induction training that includes active listening, helpful attitude, empathy and positive
body language. They are also taught skill with regards to preventing and de-escalating conflict with
others. Additionally to this, EMAS is incorporating a behaviour and attitude module into its current
Essential Education programme for 2013. It is required that all staff attends this training.
Recommendations:
None
Date feedback given to complainant: No phone number
Description and Consequences Report
Unique Reference: 2013 FC/2013/068
Type: Delayed Response To Green 2
Category: Transport (Ambulance And Other)
Incident Date: 06/08/2013
Source: Letter
Written or Verbal: Written
Acknowledgement Date: 15/08/2013
Date Agreed: 11/09/2013
Final Contact Date: 29/08/2013
Initial Call Coding:
Green 2
Area/Divisional:
EOC Nottingham
Base:
GP Surgery
Patient Outcome:
Unknown
Summary: Delayed Response To Child
Case Type: Formal Complaint
Case Details: Doctor called for an Ambulance for a Child Patient within the surgery. Delayed response in attending to the
Patient which the Doctor finds unacceptable
•
Why was there a delay in the Ambulance Service responding to the Patient?
•
Is it normal practice for Ambulances to be diverted because a Doctor is with the Patient therefore
causing delay?
TOR agreed by:
Date: 14/08/13
Crew Stood Down:
No.
•
Staff support and involvement:
Paramedic – EE date: 17/05/12. IPR date: May 2013
Paramedic – EE date: 03/05/2012. IPR date: 20/09/2012
ECA – EE date: 15/11/2012. IPR date: 27/09/2012
Healthcare Decisions Panel (HDP) referral: No. None clinical incident.
Being Open
Initial Contact Date: 14/08/2013.
Timeline of Events
Taken from calls 5746235, 5746263 and 5746304 received in to the Emergency Operations Centre (EOC) on 6 August
2013.
Time
Event
6 August 2013 Incident Number 5746235
16:35
16:37
16:38
16:52
16:54
16:58
17:07
17:09
17:11
17:13
17:21
17:36
17:37
17:37
17:43
17:55
17:59
18:26
18:46
First call 5746235 received into the Emergency Operations Centre (EOC) and processed through
the Advanced Medical Priority Dispatch System (AMPDS).
Dispatcher accesses Resource Allocation (RES/ALL) function. No resource allocated at this point.
Call processed correctly by Call Handler and coded incorrectly as 26A10 Green 4, 1hour call back
response. Correctly upgraded to Green 2, 30 minute face to face contact response.
Second call 5746263 received into the EOC. Processed through AMPDS by Call Handler and gains
Incorrect call coding of 26O01 Green 4.
Call Handler confirms there is a Defibrillator on site with trained personnel.
Second call 5746263 correctly stopped by Dispatcher as a duplicate to first call 5746235.
Third call 5746304 received into the EOC. Processed through AMPDS by the Call Handler and gains
correct coding of 26C01 Green2, 30 minute response.
RES/ALL function accessed by Dispatcher and job allocated to First Response Vehicle (FRV)3734
(CL).
Third call 5746304 correctly stopped by Dispatcher as a duplicate to first call xxx.
FRV 3734 arrives on scene.
Dispatcher accesses RES/ALL function, no further resources available.
Dispatcher accesses RES/ALL function, no further resources available.
Dispatcher accesses RES/ALL function, Double Crewed Ambulance (DCA) 9114 assigned to attend
job.
FRV 3734 on scene advises Dispatcher Red response now required by back up crew DCA 9114.
DCA 9114 arrives on scene with Patient.
DCA 9114 leaves scene to Hospital.
FRV 3734 calls clear from this job.
DCA 9114 arrives at Hospital.
DCA 9114 calls clear from this job.
The First call 5746235 was made by the Doctor’s Receptionist and received into the Emergency Operations Centre (EOC) at
16:35hrs.
This call was processed through the Advanced Medical Priority Dispatch System (AMPDS) and gained a Green 4 (G4) 1 hour
Clinical Assessment Team (CAT) call back. As the call was from a Healthcare Professional, this was upgraded to a Green 2
(G2) 30 minute face to face response. Although coded incorrectly as 26A10, the correct coding of 26A08 would have
achieved the same response.
At the same time as the call being processed 16:37hrs, the Dispatcher accessed the Resource Allocation function (RES/ALL)
to see any available resources that are free to attend the detail. No vehicle was available to be assigned.
A second call 5746263 was received from the Doctor’s Receptionist into the EOC at 16:58hrs. This was processed through
AMPDS by the Call Handler and incorrectly coded as a G4, 1hr CAT call back. Processed correctly, this would have achieved
the same disposition of the original call of G2. This call was then closed correctly by the Dispatcher as a duplicate to the
first call 5746235.
Although the Call Handler asked if there was a Defibrillator on site, this was not allocated to the job.
By 17:07hrs, a third call was being received into the EOC. This call was made by the Doctor’s receptionist. The Call Handler
processed the call through AMPDS and gained the correct response of G2, 30 minutes face to face contact. As this was a
duplicate to the first call, it was correctly closed by the Dispatcher at 17:11hrs.
The Dispatcher accessed the RES/ALL function at 17:09hrs and assigned a First Response Vehicle (FRV) to attend the
incident which; arrived on scene with the Patient four minutes later at 17:13hrs. This FRV arrived on scene 38 minutes
after the first call, 8 minutes over the target time of 30 minutes.
From 17:21hrs to 17:37hrs, the Dispatcher accessed the RES/ALL function three times in an attempt to send a Double
Crewed Ambulance (DCA) to assist the FRV. On the third attempt at 17:37hrs, a DCA was assigned. At the same time, the
FRV on scene advised that the DCA should travel as a Red Response meaning, they should travel as back up with lights and
sirens.
The DCA arrived on scene at 17:43hrs and conveyed the Patient to Hospital for 18:26hrs.
The FRV called clear from this detail when the crew conveyed at 17:59hrs and the crew, at 18:46hrs once the Patient has
been transferred to Hospital care.
Information provided by the Fleet Administration Team shows there was a shortfall of vehicles on the day this incident
occurred. 13 of the 49 Ambulances due to be used on the 6 August 2013 were off road and unusable. This is a shortfall of
27% compared to when up to full capacity.
Conclusion
There was a delay in responding due to other calls and their resources being fully committed in attending to, or being
diverted to higher priority emergencies/backups. On the day of this incident, there was also a shortfall of Ambulances in the
area equating to 27% of the fleet.
No Ambulances were diverted from this call once allocated and, having a Doctor on scene with a Patient does have an
impact on the response time. The first available resource was sent to the surgery which was a First Response Vehicle. This
arrived on scene 38 minutes after the first call, missing the response time required by eight minutes.
Although the second call was coded incorrectly, this did not have an impact on the response time. The Call Handler should
have upgraded the call to Green 2, which was the same response time as the first call.
The calls were prioritised as appropriate. When calls are received into the Emergency Operations Centre (EOC), they are
coded using a nationally defined set of priorities based upon the information given over the telephone. The calls are assessed
and prioritised in order of clinical need. At the time we received the calls into the EOC, the information given did not
require an immediate 8 minute Ambulance response and instead, was allocated as a 30 minute response.
Although the patient has been assessed by a Medical Professional; when taking a call on the 999 line, we always re-assess
the patient to ensure the most appropriate response is being given.
Calls are prioritised using the Advance Medical Priority Dispatch System. AMPDS is a set of questions relating to a Chief
Complaint used to rule out priority symptoms. Once questions are answered, AMPDS gives the most appropriate response
at that time ensuring more immediate life threatening or time critical patients are responded to first.
When a call is received into the EOC on the 999 line, the call handler will ask a series of questions about the
Patient to establish the priority of the response that is required.
The series of questions asked will be dependent upon various factors including the Chief Complaint of the
patient, age, sex etc.
In order to send the most suitable response, it would have been appropriate to ensure all of the patients’ Chief
Complaints such as Chest pain, Difficulty in Breathing or Unconscious, were presented at the time of making
the 999 call. By providing a diagnosis, this does not always allow the Call Handler to ask the most appropriate
questions as there are often no or little symptoms provided.
By providing facts and information about the patient, they will receive the correct response from the outset.
Action: EMDs to have feedback with regards to incorrect coding of their calls
For:
Deadline: 24/09/13
Evidence: Copy of Report
Action: Surgery staff invited to observe in EOC.
For:
Deadline: 24/09/13 – Completed, invited by response.
Evidence Gathered
Sequence of Events from calls 5746263, 5746304 and 5746235.
Copies of Voice Recordings for call 5746263, 5746304 and 5746235.
Call Audits for calls 5746263, 5746304 and 5746235.
Information provided by Fleet Administrator.
Resource Log for Emergency Operations Centre Duty Manager.
Copy of Electronic Patient Report Form.
Date report sent to Investigation Manager for approval:29/08/2013
Date feedback given to complainant: Tried via telephone 29/08/13, surgery busy
Patient or relative willing to be approached for their ‘story’ for the EMAS board? Have you asked? Why? Why not?
What did they say?
FC/042/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 1/6/13
Patient Name:
Deceased? No
How Received: Telephone call
Their reference:
Logged by:
Incident Location:
Patient was on holiday at holiday park and had 3 young children
with him. He was suffering great pain and a bystander called 999 on
his behalf (and looked after the children). The crew arrived and just
kept telling him to get up. They thought he was drunk.
He was manhandled into the ambulance and has suffered bruises on
his arms as a consequence. The crew eventually apologised to the
complaint:
bystander and advised he was having a heart attack. The black
haired member of the crew treated him 'like shit'.
He does not want this to happen to anyone else.
The bystander will be a witness if required.
Type of Complaint: Crew attitude
Division/Area: Lincolnshire
6/9/13
13/9/13
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading Moderate 6 – unlikely to reoccur but possible mismanagement of patient care
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Was the call handled correctly?
Did the coding issue delay attendance to the patient?
Why did the crew approach the patient in this manner?
Why did they apologise to the witness for their manner?
Why did the patient have bruises under his arm from being moved?
Why did they change their story?
Why did crew lie when the change was identified?
Was it appropriate to make the statement “you should be grateful we saved your life”?
Phone call and letter
Expectations of Complainant: Wants an apology from the crew and the manager
Fc/042/13
Date and Time
1/6/2013 18:21
18:23
18:24
18:35
18:59
19:02
20:46
Events
999 call received to a --- year old male with abdominal pain.
Crew assigned
Call is coded G2 – requiring EMAS to be on scene within 30 minutes
Crew automatically books on scene
Crew call control and request the new number for the PPCI at LC hospital.
Crew marked as leaving scene
Crew clear hospital.
Evidence Gathered:
WAV Recordings of Radio Transmissions
WAV recording of 999 call
CAD SOE
999 call audit
PALS proforma
Record of conversation
Call Handling: On the 1 June 2013, a 999 call was received to a male in the street with abdominal
pains. This call was taken through the Advanced Medical Dispatch System (AMPDS) and assigned a
code requiring the crew arrive on scene within 30 minutes.
This call has been audited and given an 81% compliance score. The target score is 90%. The
Emergency Medical Dispatcher (EMD) failed to fully verify the address of the incident as the call was
made on a mobile phone. During the call the patient was established as having erratic breathing.
This was not identified by the EMD and so the protocol chosen, abdominal pain, was incorrect.
Assessment of the call shows that the Dispatch Code of a 30 minute response was correct for the call,
so the use of an incorrect protocol did not affect the on scene attendance time required to the patient.
Service Delivery: A crew was assigned to the call, and arrived on scene within 14 minutes, achieving
the required response time. The call was originally coded as an abdominal problem, but the crew
assessed the patient and identified the patient as having a heart attack (MI). The crew made
arrangements for the patient’s children to be cared for, and then took him immediately to the LC
Catheter Suite for an emergency Primary Percutaneous Coronary Intervention (pPCI).
Crew Attitude: The original complaint was dealt with as a PALS matter, but due to unanswered
patient concerns it has been escalated to a formal complaint. In the original report by Team Leader
(RH) it was assessed that the patient’s medical treatment “was to the highest level and to the correct
pathway”. Both crew members expressed sadness that the patient felt that he had been badly treated.
This was because the patient had thanked them at the hospital.
The patient raised concern that the he was being treated as if he was drunk initially. This is believed
to have been due to the crew asking the patient if he had been drinking. The crew state that there
was a clinical need to establish this information before administering morphine. This is an essential
question to ensure that there is no undue interaction with the medication.
The Technician, who drove the patient to hospital, has been spoken to with regards to the escalation
of the complaint. This was to discuss the patient’s concerns with the crew’s initial attitude when they
arrived on scene. The Technician confirms that when they arrived on scene that patient was on the
grass “writhing in agony”. The Technician states he spoke to the patient in an abrupt manor, but that
this was so he could get the patient’s attention as he was in too much pain to respond. Once in the
ambulance, they were able to fully assess the patient’s condition and ascertained that he was having a
heart attack. They then updated the member of public outside the ambulance, and ensured that the
patient’s children were cared for whist they went to hospital. The patient has confirmed he was happy
with the crew arranging this care for his children. During the conversation with the member of public,
the crew apologised in case their manner had been abrupt..
The patient reported bruising under his arms, and states these were caused by the crew moving him
onto the stretcher. The crew stated “on arrival at scene, the patient was on the grass and the
ambulance pulled onto the verge very close to the patient. The stretcher was taken to his right hand
side, from where he was able to use his right arm and push to standing with little assistance from both
crew members.” They further stated, during the original investigation, that “at no point throughout the
journey was the patient manhandled, and was only touched in order to take BP measurement,
cannulate and administer medication. On leaving Lincoln PPCI, the patient thanked us for our
assistance.” The Team Leader was spoken to regards to the bruises, and states that the patient
underwent a Primary Percutaneous Coronary Intervention (pPCI) procedure at the hospital. This is a
specialised treatment that both unblocks the coronary artery and widens the narrowed area at the
same time. This reduces the possibility of more heart attacks or strokes. Team Leader states that this
procedure can result in some bruising due to where the catheter is placed, and due to some
antiplatelet drugs used at the time. This cannot be substantiated as the cause to the bruising
reported.
The Technician has confirmed he was the one that made he made the comment “the patient should be
grateful because we saved his life”, not the Team Leader. The Technician would like to offer his
apologies regards to any offence this statement may have caused. This was not his intent, and he is
sorry that his manner was taken in this way by the patient and member of public. Initially, the patient
was under the impression that this comment was from the Team Leader. In the closing statement of
the original report the Team Leader has written “I believe the crew should be thanked for the treatment
they provided as this undoubted saved the patient’s life”. This was not a comment by the Team
Leader supporting the crews initial manner with the patient, but regards to the quality of the clinical
care given when it was identified the patient was having a heart attack. At no point has there been
any concerns regards to the patient’s medical treatment by the crew. The Team Leader’s intention had
been to re-enforce the quality of clinical care given only.
The patient has been spoken to, and it has been explained that an apology from the crew will be
included in the letter from the CEO. The patient has also been informed about the training the crew
will be attending.
Conclusion:
Was the call handled correctly?
No. The Emergency Medical Dispatcher (EMD) did not verify the address correctly as the call came in
on a mobile phone. Additionally, the EMD used the Abdominal Problem protocol, not breathing
problem protocol/
Did the coding issue delay attendance to the patient?
No. The call was handled on the wrong protocol - Abdominal Pain as opposed to Breathing Problems.
The call has been audited and both calls would have resulted in a 30 minute timescale. This would
not have impacted on the Dispatchers actions, or delayed the crew arriving with the patient.
Why did the crew approach the patient in this manner?
Discussions with the crew indicate that when they arrived the patient was on the grass “writhing in
agony”. The Technician stated that he used a firm manner with the patient to get a response from
him. The crew were informed that they were attending an Abdominal Problem. It is not possible to
ascertain if the coding effected in the crew’s initial manner.
Why did they apologise to the witness for their manner?
The crew stated that once they had moved the patient into the ambulance they were able to assess
him in private. Before they left with the patient they exited the vehicle to explain to the passer by what
was happening, and ensured that the patient’s children were being cared for. This was in agreement
with the patient. Whilst there, they apologised for their initial manner, as they felt it may have come
across as abrupt, this was not their intention. Their aim had been to try to take control of the situation
so that they could assist the patient, and apologise if this caused offence.
Why did the patient have bruises under his arm from being moved?
The crew states that they did not man handle the patient. That the “stretcher was taken to his right
hand side, from where he was able to use his right arm and push to standing with little assistance
from both crew members.” They do not believe these actions would have caused the bruising under
the arms. The patient was cannulated and BP was taken in the ambulance, but this is not believed to
be the cause of the bruises. The Team Leader was spoken to regards to the bruises and states that
the patient underwent a Primary Percutaneous Coronary Intervention (pPCI) procedure at the
hospital. This is a specialised treatment that both unblocks the coronary artery and widens the
narrowed area at the same time. This reduces the possibility of more heart attacks or strokes. Team
Leader states that this procedure can result in some bruising due to where the catheter is placed and
because of anti-platelet drugs used at the time. This cannot be substantiated as the cause to the
bruising reported.
Why did they change their story?
On discussion with the Technician it was apparent that the crew did not initially perceive that the way
they spoke to the patient caused concern. It was not until they had the perspective of a third party
that they realised the effect their manner had caused. This was not an intentional change of story by
the crew, but an acceptance that the third party had no reason to make comment on their behaviour
unless it was not appropriate.
Why did crew lie when the change was identified?
As was stated above, the crew did not perceive that their behaviour had caused upset. When
informed of the facts, they re-evaluated their behaviour. They now accept that their attempt to control
the situation may have caused offence, and have apologised for any distress this may have produced.
Was it appropriate to make the statement “you should be grateful we saved your life”?
No. The Technician has confirmed he said thist. It was not his intent to upset anyone, and he is sorry
that his manner has caused this offence to the patient and member of public.
The patient was concerned about the Team Leader making a similar statement in the original report.
The Team Leader has written “I believe the crew should be thanked for the treatment they provided as
this undoubted saved the patient’s life”. This was not a comment by the Team Leader supporting the
crews initial manner with the patient. This was regards to the quality of the clinical care given when it
was identified the patient was having a heart attack. At no point has there been any concerns regards
to the patient’s medical treatment by the crew. The Team Leader’s intention had been to re-enforce
the quality of clinical care given only.
Recommendations:
Recommendation
Action
Crew to attend next
available Essential
Education course 2013
Crew to attend EE
training with
behaviour and attitude
component. Special
consideration to
empathy and
understanding of the
Lead
Due
Date
31/12/13
Evidence
Email
confirmation of
attendance
patient during a 999
call.
Unique Reference: FC/2013/070
Type: Attitude Of Staff
Category: Attitude Of Staff - Operational
Initial Call Coding: Green 2
Base:
Source: Telephone Call
Written or Verbal: Verbal
Final Contact Date:
Area/Divisional: Leicestershire
Patient Outcome: Patient still in Hospital
Summary: Crew attitude
Case Details: Crew attitude towards Doctor, Patient and Patient’s Husband whilst in the Doctor’s surgery
Why did the crew question the abilities and diagnosis of the Doctor?
What was the reason the crew chastised the Husband for not calling 999 himself?
In general, why did the crew feel it appropriate to come across as arrogant and non-chalont throughout their
visit?
TOR agreed by:
Date: 14/08/2013
Crew Stood Down:
No.
•
Paramedic (P1), EE date: 6 March 2013 IPR date: Completed full appraisal 3 August 2012, completed PDR
section July 2013.
Paramedic (P2), EE date: 31 May 2012 IPR date: Completed full appraisal 12 October 2012.
Healthcare Decisions Panel (HDP) referral: No – Non clinical complaint with regards to crew attitude.
Being Open
Initial Contact Date: 14/08/2013
Timeline of Events
Taken from call 5760610 received in to the Emergency Operations Centre (EOC) on 12 August 2013.
Time
Event
Unknown
10 Days previous Patient suffered a fall.
17:23
Call received into the Emergency Operations Centre (EOC)
17:24
Call entered as ‘head injury 64yof’ and processed through the Advanced Medical Priority
System (AMPDS). Correctly coded by Call Handler as 31C02 Green 2 (G2) a 30 minute
response.
Dispatcher accesses Resource Allocation (RES/ALL) function and correctly assigns job to
First Response Vehicle (FRV) 4033.
Dispatcher accessed RES/ALL function and correctly allocates Double Crewed
Ambulance (DCA) 4810 to detail.
4033 Stood down by Dispatcher from attending detail due to 4810 attending.
4810 DCA arrives at scene of incident.
4810 DCA leaves scene of incident with Patient on board.
17:24
17:25
17:26
17:42
17:54
18:13
18:59
An Emergency call was received into the Emergency Operations Centre (EOC) at 17:23hrs. This call was put
through to the Doctor who was with the Patient.
The Call Handler processed the call through the Advanced Medical Priority Dispatch System (AMPDS) and
gained the correct coding for the call of Green 2, 30 minute response based on the information supplied by the
Doctor.
A Dispatcher accessed the job whilst being processed and correctly assigned a First Response Vehicle (FRV) to
attend. Two minutes later at 17:26hrs this FRV was stood down as a Double Crewed Ambulance (DCA) were
now able to attend.
The crew of the DCA arrived on scene with the Patient at 17:42hrs. They found the Patient to be sat in the
waiting room of the Doctors surgery and, not in the Doctors room as they thought would be the case given the
presenting condition.
Information gained from a statement taken from the Doctor states the Patient was struggling to walk. Within a
few minutes of discussion with the patient and her husband, the Doctor knew that this lady had almost inevitably
suffered from some form of intracranial (within the skull) haemorrhage.
The Doctor picked up the phone for immediate Ambulance assistance, within a few minutes of the patient being
in her room. During this time whilst on the phone, the Patient appeared to be extremely drowsy, but was
rousable; and could talk when spoken to. She was able to maintain her own airway.
Whilst waiting for the Ambulance, the Doctor was waiting with the patient in the waiting room of the surgery. The
patient’s husband and the Doctor had managed to help the lady into the waiting room – a conscious decision
that was made, with the view that; this lady was clearly very unwell. Should this patient’s condition rapidly
deteriorate, the Doctor would be able to shout for help and have senior colleagues on hand within seconds. The
Doctor’s consultation room is slightly further away, and the Doctor would have problems getting people’s
attention quicker; and calling for help.
On arrival of the ambulance, the Paramedic crew seemed to saunter into the waiting room, up to the patient and
Doctor. The Doctor introduced herself and proceeded to handover the patient to them. The Doctor’s existence or
handover received no acknowledgement from the Paramedic crew.
The Doctor continued with the normal handover. At this point one of the Paramedics spoke to the Patient’s
Husband in a manner which left him bewildered. He had taken his wife to the surgery and we being questioned
as to why he did not call 999 in the first place. The Doctor believes this added further stress to the Patient’s
Husband.
In readiness for moving the Patient, the crew implied she should walk to the Ambulance. The Doctor states it
was clear the Patient was becoming hemiplegic (lost the use of one side of her body) and was unacceptable that
the crew should not arrange for the Ambulance carry chair. They then asked if the Surgery had a wheelchair
instead of using their own equipment.
This incident took place in a Surgery waiting room with other Patients and staff present. Comments were made
by the crew such as ‘So you called a 999 ambulance, and left the patient unattended in the waiting room, with no
trained medical professionals around’.
The Doctor approached the Ambulance Crew when the Patient was on the Ambulance to ask their names. It
took four attempts to gain a name.
After speaking with the crew, it is said there was no Doctor on scene with the Patient when they arrived on
scene. The Patient was found to be sat alone in the waiting area. When the crew asked the Patient’s Husband
what had happened, he did not know. At that point, the Doctor returned to the Patient.
A brief verbal handover was received from the Doctor . It is remembered that the Patient had banged her head
10 days earlier and in the last 24 hours the Patient had deteriorated. She now had right hand side weakness and
was deteriorating rapidly.
P1 mentioned to the Husband about the decision for not calling 999. This was not to chastise but in a
friendly/welfare manner as it was clear the Patient was ill and he had been struggling to move her. P2 does
remember telling the Husband that if either he or his Wife were as poorly as this, they should ring 999. This is
something that P1 says to most Patients when they haven’t called for an Ambulance and it may be the best
course of action. P1 states it was not said in a manner meant to condescend.
The Doctor mentioned that a chair would be required. P2 asked how the Patient had got into the Surgery to see
how rapidly the Patient had deteriorated. This question seemed to be met with some defence from the Doctor
who stated along the lines of ‘obviously he dragged her in here’. The Patient had been moved from the Doctors
room to the reception. P2 was wondering how the Patient had got there. This was not asked.
Whilst the Doctor was talking with P2, she did so in a manner that reduced P2’s personal space. P2 remembers
moving away from the Doctor.
P1 does not remember asking if there was a wheelchair in the surgery that could be used. As the Patient had
weakness, it is stated P1 would not normally use the Surgery equipment as it would make it harder for transfers
onto the vehicle.
P2 collected the carry chair from the Ambulance and then P2 moved the Ambulance whilst P1 was preparing the
Patient to be moved. The Ambulance was moved as close to the Surgery doors as possible.
Whilst P2 collected the chair, P1 asked the Doctor why the Patient had been left in the waiting room when she
had an obvious reduced Glasgow Coma Score (GCS). The Doctor did not seem happy to be questioned
however, P1 felt it appropriate as she was unable to gain full information with the Patient being in full public view.
When the Patient was on board the Ambulance, the Doctor approached the rear of the vehicle with another
unknown Male and demanded that P1 get off. P1 refused to do so as was treating the Patient and knew she
needed time critical treatment. The Doctor wanted the name of P1 which was given. P2 was not asked for her
details however, did give the call sign of the vehicle which was on the back of the Ambulance. P1 remembers
giving her name details and referring to the call sign number.
Information from the Acting Medical Director shows the Doctor in the surgery retains Clinical responsibility of the
Patient until they handover care to the Clinician on scene. If the Doctor makes a judgement that the Patient is
safe to be left alone, then that is their clinical decision.
It is documented on the PRF that the crew were concerned as to why the Patient was sat in the Waiting Room
on their arrival with no Doctor present.
Conclusion
The crew did not question the ability or diagnosis of the Doctor. On entering the Surgery, the crew have made an
assumption that the Patient was left alone and allowed this to hinder their communication with the Doctor.
A reminder is always given to Patients by the crew to call 999 in circumstances when a Patient is as poorly as
this. When asking the Husband why he had not dialled 999, the crew were trying to remind the Patient that the
service was there. The crew state this was not meant to cause distress to the Husband.
Whilst in attendance, the crew carried out the task of gaining information and transferring their Patient as best as
they could. Being in the Surgery meant there was little privacy for the Patient. The crew are very conscientious in
their work and apologise if they came through in a manner that seemed to be arrogant or nonchalant.
Action: Both crew members to have attended or be booked on to attend the Essential Education for 2013/2014
to ensure knowledge is up to date.
For:
Deadline: 17/09/13
Action: Staff to be made aware that although a Patient may be in the waiting room when the Ambulance arrives,
it is not for them to judge the situation and a clinical decision has been made by the Doctor on scene for them to
be left alone to wait for the crew to attend.
For:
Evidence: Copy of report
From the Clinical Governance Group meeting held in August 2013, there is to be an introduction in 2014 to
monitor Crew Attitude. This will ensure persistent staff members who are reported, can be monitored.
Evidence Gathered
•
•
•
•
•
•
Sequence of Events from call 5760610.
Statement from Complainant.
Statements from both crew members.
Copy of Electronic Patient Report Form.
Voice recording of call received into the Emergency Operations Centre.
Email regarding Clinical Governance Group intro of Crew Attitude Survey.
Patient or relative willing to be approached for their ‘story’ for the EMAS board? Have you asked?
Why? Why not? What did they say?
PALS Form
PALS/0302/13
FC/2013/070
Section A: To be completed on receipt of concern
Enquirer Name:
Correspondence
Address:
Response required:
Enquirer phone no:
Enquirer category:
Type of concern:
Date of incident:
Description:
Incident Location:
Patient Name:
Patient Address:
Patient phone no:
Patient Deceased:
Date Received:
Date due back:
PALS Coordinator:
Initial grading:
Area:
Service Delivery:
Purchaser:
Investigator:
Staff involved & Station:
How Received:
Acknowledge date:
Logged by:
Enquirer is patient? No
Not stated
Letter
Email
Phone
Mobile:
(delete as required)
General Public (Enquirer)
Driving (Other)
03 July 2013
Member of the public driving towards a 90 degree blind corner,
with solid white lines in the middle of the road, when an
ambulance on lights & sirens came round the bend on her side
of the road whilst overtaking another car.
Ambulance heading into Upper Broughton on A606.
CAD5660007
N/A
No
10 July 2013
05 August 2013
Moderate
Leicestershire/Rutland
# A&E Leics/Rutland (A/E)
*A&E Leicestershire
letter
12 July 2013
Liz
PALS/0302/13
Section B: The Investigating Officer’s Report
Chronology of 4734 Double crewed ambulance received a call to a cardiac arrest at:
Events: 14:01 they were in Upper Broughton
14:01 mobile
Arrived on scene at 14:19
Left scene at 15:21
Arrived at LRI 16:50
Clear at 17:22
Investigation Why did the ambulance cross double white lines on a blind bend?
Report: I have spoken to the crew (Paramedic and ECA).
The Paramedic was driving at the time, he recalls receiving the call and is
aware of the stretch of road we are referring to. He states that as he
approached the bend the driver in front travelling in the same direction
immediately put his brakes on, on the bend and stopped. Andy pulled out
wide from the stationary vehicle in order to give himself a clearer view as it is
a tight bend. Our driver claimed the exemption of crossing double white lines
as the vehicle in front was stationary (therefore travelling less than 5 miles per
hour which is the excemption).
has confirmed this incident.
Conclusion answering the
scope of the
concern
Unfortunately our driver had no choice but to take evasive action from hitting
the back of the car which had erratically stopped on the bend. I have spoken
to the driver about exemptions under blue light conditions. The driver states
he had blue lights and sirens going to warn other motorists ahead.
Section C: Action Plan to be completed by Investigating Officer
Has the potential future risk of
recurrence been identified:
If yes what?
Action:
Deadline:
Who is taking responsibility for
implementing the action?:
Concluded:
Learning Identified:
Service Improvements Identified:
Action:
Deadline:
Concluded:
Learning Identified
Section D: Sign off to be completed by the PALS Coordinator
Date returned to PALS
Coordinator:
Response/actions by PALS
Coordinator:
27/06/2013
27/5/2013
Deceased? No
Letter from ULH Complaints Department
Lead In Joint Complaint
Their reference:
FC/2013/072
Date Received:
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident:
Patient Name:
How Received:
Logged by:
Incident Location:
Patient’s asked for him to go to Peterborough Hospital, but was told
Brief details of the he had to go to Pilgrim Hospital Boston (PHB). Is it not a patient's
complaint: right to choose which hospital the Ambulance attends?
CAD 5574231
Type of Complaint: Customer Care
Division/Area: East
17/9/2013
24/9/20134
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading Minimum 3
& Rationale:
Scope of
Investigation Why did crew take patient to BPH, not to PCH as per family request?
(must include all
complainant
concerns) :
Was the Paramedics action correct in this matter?
None – detail handed over
Staff involved informed: Email – 01/09/2013
FC/2013/072
Date and Time
27/5/2013 09:49
09:50
09:51
10:03
10:34
11:04
Events
999 call CAD 5574231 received. --- year old male fallen off of motorcycle, possible
collar bone injury.
Crew assigned showing 10 miles from call, ETA 15 minutes.
Call coded G2 (29B01) requiring arrival on scene within 30 minutes.
Crew automatically logs on scene. 30 minute response achieved.
Crew book mobile to hospital
Crew book clear of the detail
Evidence Gathered:
CAD SOE 5574231
Google map screen print
Complaint Form
Email P1
At 09:49 a 999 call was received to a --- year old male who had fallen off a motorcycle. Notes
stated a possible collar bone injury. A crew was assigned with an ETA of 10 minutes. Call was
taken through the Advanced Medical Dispatch System and given a G2 coding. This requires
that an on scene attendance within 30 minutes. Crew arrived on scene within 14 minutes, so
timescale achieved.
Complaint received from the hospital outlines that Patient’s wife specifically asked crew to take
her husband to PCH. Paramedic (P1) has been spoken to, and has confirmed response in
writing. P1 did not have access to the Patient Report Form so was completed from memory
only. He recalled that the patient had broken his shoulder, and something else. P1 stated it
was something possibly dangerous, like rib injury as well. P1 explained to Patient’s wife that
PBH was geographically closer (PBH 16.7 miles versus PCH 19.7 miles). P1 stated he
“explained (to the) lady that the (PBH) is closest, and if something happened on the way to
(PCH) I could not justify why I went in there with this patient, she argued patient choice should
be preferred, and I explained her that is true but not with traumatic injuries like her husband
had, I have explained to her and nicely apologised for not taking him in (PBH) and told her I
understood she had bad experience with (PCH) before with herself.” P1 then stated he went to
see patient’s wife after handing over the patient as “she was upset, apologised again, and again
explained reasons, also told that even if we don’t have these rules regards nearest hospital and
(if) I took him to (PCH) and something happened on way I would feel really upset and guilty to
not take him somewhere closer. She looked like she accepted that and I wished her and her
husband all the best.”
On examining the road layout from the location of the accident to PBH and PCH, the route to
PBH is straight up one main A road. Even though there is only a 3 mile difference between the
two hospitals, the direct route of PBH made it a shorter traveling time than PCH. The crews
actions were correct in attending the nearest A&E with a traumatic injury.
Conclusion:
Why did crew take patient to BPH, not to PCH as per family request?
P1 explained to Patient’s wife that PBH was geographically closer (PBH 16.7 miles versus PCH
19.7 miles). P1 stated he “explained (to the) lady that the (PBH) is closest, and if something
happened on the way to (PCH) I could not justify why I went in there with this patient, she
argued patient choice should be preferred, and I explained her that is true but not with traumatic
injuries like her husband had, I have explained to her and nicely apologised for not taking him in
(PBH) and told her I understood she had bad experience with (PCH) before with herself.” P1
then stated he went to see patient’s wife after handing over the patient as “she was upset,
apologised again, and again explained reasons, also told that even if we don’t have these rules
regards nearest hospital and (if) I took him to (PCH) and something happened on way I would
feel really upset and guilty to not take him somewhere closer. She looked like she accepted that
and I wished her and her husband all the best.”
Was the Paramedics action correct in this matter?
Yes. On examining the road layout from the location of the accident to PBH and PCH, the route
to PBH is straight up one main A road. Even though there is only a 3 mile difference between
the two hospitals, the direct route of PBH made it a shorter traveling time than PCH. The crews
actions were correct in attending the nearest A&E with a traumatic injury.
Recommendations:
None
Patient or relative willing to be approached for their ‘story’
for the EMAS board? Have you asked? Why? Why not? What did they
say?
20/8/13
None
31/7/13
Deceased? No
Letter
Their reference:
FC/073/13
Date Received:
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident:
Patient Name:
How Received:
Logged by:
Incident Location:
complaint:
Passer-by was assisting --- yom who had fallen off a kerb. Paramedic
drove slowly along road with lights on, nearly missing patient, failed to ask
if anyone witnessed the accident, failed to offer comfort for patient and
wife. Passer-by states paramedic did not examine the knee of the
patient.
Attitude and treatment
EAST
Type of Complaint:
Division/Area:
10/9/13
17/9/13
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Askin, Laurie (P)
Minimum 4 – passer by perception regards care – likely to happen again
Why did Paramedic drive along the road slowly with his blue lights on?
Why did Paramedic not ask if anyone witnessed the fall?
Why did Paramedic not physically support the patient when taken to the back of the
car?
Why did the Paramedic not physically comfort patient and his wife?
Introduction letter
FC/073/13
Date and Time
31/7/13 14:11
14:12
14:13
14:18
14:38
14:51
Events
999 call received CAD 5731278 to a --- year old male collapsed in the street. A Fast
Response Vehicle (FRV) was assigned to the detail with an ETA of 2 minutes at
0.84 miles distance. Caller stated patient had head injury post fall, in and out of
consciousness,
Call coded as 17D03 – R2 requiring face to face contact within 8 minutes
Note placed in CAD that off duty Community First Responder on scene with the
patient.
Radio Transmission between FRV and Dispatch – confirming only location is Street
name, location within street not known.
FRV arrived on scene within the 8 minute target
Radio communication between FRV and Control – patient taken to own car with
graze on knee.
Call closed by the Dispatcher – marked as Patient Treated On Scene
Evidence Gathered:
WAV file radio transmissions
PRF
CAD SOE
At 14:11 on 31/7/2013 a call was received to a male who had fallen in the street. No exact
location was given. A Fast Response Vehicle (FRV) was assigned. The call was taken through
the Advanced Medical Dispatch System (AMPDS) and was given a coding that required an 8
minute response and the FRV arrived within that timescale. As no specific location was given
the FRV arrived with blue lights on, but then had to reduce speed so that the driver could
visually search the area for the patient safely.
As complaint has been raised by a member of the public no comments can be made regards to
the treatment of the patient, or to any questions the attending Paramedic may or may not have
asked. To do so would breach Patient Confidentiality and Data Protection Legislation. Evidence
obtained from the Patient Report Form (EPRF) indicates that the Paramedic was able to obtain
all information that he required from the patient and his wife.
Conclusion:
Why did Paramedic drive along the road slowly with his blue lights on?
As no specific location was given the FRV arrived with blue lights on, but then had to reduce
speed so that the driver could visually search the area safely in order to locate the patient.
Why did Paramedic not ask if anyone witnessed the fall?
Evidence obtained from the Patient Report Form (EPRF) indicates that the Paramedic was able
to obtain all information that he required from the patient and his wife.
Why did Paramedic not physically support the patient when taken to the back of the car?
This question cannot be answered as it may breach Patient Confidentiality and Data Protection
to do so.
Why did the Paramedic not physically comfort patient and his wife?
This question cannot be answered as it may breach Patient Confidentiality and Data Protection
to do so.
Recommendations:
None
Response letter sent: 2/9/13
say?
Deceased? No
Their reference:
FC/074/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
How Received:
Logged by:
Incident Location:
complaint:
Patient was taken to Boston Pilgrim Hospital following cardiac arrest, and
then on to Lincoln County Hospital. Breathing tube was not put in place
and patient’s wife has been advised by a Consultant at Lincoln County
Hospital that this compromised his breathing. The patient’s wife also
wants to know what care her husband was given at Boston Pilgrim
Hospital and what happened on the journey between Boston and Lincoln.
Care management
Lincolnshire
Type of Complaint:
Division/Area:
19 September 2013
Staff involved
& Station:
Initial grading Moderate
& Rationale:
Scope of Why was a breathing tube not put in place?
(15 working days)
(20 working days)
Investigation
(must include all
complainant
concerns) :
What treatment did the patient receive at Boston Pilgrim Hospital?
What happened on the journey between Boston and Lincoln?
ULH 22/08/2013
Immediate actions taken: Statements taken from all attending crew members.
FC/074/13
Chronology of Events: Taken from the Computer Aided Dispatch (CAD) sequence of events
(SOE) for call reference 5681156.
22:12
22:13
22:13
22:14
22:17
22:21
22:56
23:00
23:00
23:07
23:08
23:30
23:46
new call received, call reference 5681156, on behalf of a patient who has
collapsed.
resource 7130 solo responder allocated and mobile to the incident.
Call coded as 09D01, cardiac or respiratory arrest/death, ineffective breathing.
Call allocated a Red1 eight minute response. CAD message: you are responding
to a patient in apparent cardiac (respiratory) arrest. The patient is a --- year old
male, who is unconscious and breathing. Ineffective breathing.
resource 7110, double crewed ambulance, allocated and mobile to incident.
resource 7110 leaves scene with patient.
resource 7110 arrives at Boston Pilgrim Hospital with the patient.
CAD message: 7130 reports that patient is back with them and they are heading
to Pilgrim for stabilisation then possibly on to Lincoln County.
doctor at Pilgrim hospital administers medication to patient. Crew then begin the
journey to Lincoln County Hospital.
resource 7130 calls clear from scene.
patient administered medication en route to Lincoln County Hospital.
patient handed over to hospital staff at Lincoln County Hospital.
Evidence Gathered:
CAD report
Statements from attending crew members
Handling of emergency call: the emergency call was allocated a Red 1 eight minute response.
The first clinician on scene arrived five minutes after receipt of the emergency call, meeting the
target on this occasion.
Statements of attending crew members: The first member of staff on scene advised that he
had been dispatched to a cardiac arrest and he was aware that a backup crew were also en
route. On arrival the patient was in cardiac arrest and chest compressions were being
performed on him.
The back-up crew arrived four minutes after the solo responder Paramedic, and after a number
of attempts to shock the patient’s heart, the ambulance personnel achieved return of
spontaneous circulation. A 12 lead ECG was undertaken which indicated a heart attack. One of
the ambulance crew contacted the Heart Centre at Lincoln County Hospital (LCH) who advised
that the patient should first be taken to Boston Pilgrim hospital. This was so the patient could be
assessed before transfer to Lincoln County Hospital and also when the initial contact was made
there was on-one available to formally accept the patient at LCH. The ambulance crew received
a phone call from LCH accepting the patient as they arrived at the hospital in Boston.
A pre alert call was placed to Boston Pilgrim Hospital. However when the ambulance crew
arrived at the hospital one of the crew had to go in and fetch a doctor out to the ambulance
vehicle, so the patient could be examined on board to save time. The doctor confirmed that the
patient had suffered an acute myocardial infarction, and he administered a dose of
Fondaparinux which is used to prevent deep vein thrombosis. The ambulance crew then began
the journey to Lincoln County Hospital.
En route to the hospital the patient became combative, and under advice from the Heart Centre
at Lincoln County Hospital he was administered medication containing Diazepam which calmed
him again. On arrival at Lincoln County Hospital the patient was handed over to staff at the
Heart Centre.
In respect of the patient not being intubated, the member of staff who was attending him
established the patient’s airway was clear and intubation was not necessary. There was no
advice to intubate the patient given to the ambulance crew by the doctor who examined him at
Boston Pilgrim Hospital.
A clinical review of the incident by the Divisional Locality Quality Manager has found that the
medical interventions performed on the patient were appropriate to his presenting condition. If
the attending clinician has established the patient’s airway is clear then intubation is not always
necessary. The decision to leave the patient on the vehicle at Boston Pilgrim Hospital was taken
to make the assessment there as quick as possible, and the pre alert call was intended to
speed up the process also so the onward journey to Lincoln County Hospital could be
completed.
Conclusion:
The decision not to intubate the patient was considered to be appropriate as the attending
clinician had established the patient’s airway. He was left on the vehicle on arrival at Boston
Pilgrim Hospital in order for a rapid assessment of the patient to be completed. During the
transfer to Lincoln County Hospital the patient became combative but this was resolved with the
administration of appropriate medication.
Recommendations:
say?
SI Criteria:
Incident Date:
Care Management Concern
16 June 2013
deceased
Base:
Patient Outcome:
Source:
FC/075/13
Harm Rate:
Level
Area/Divisional:
Nottinghamshire
5
–
Patient
EOC HP
Patient Deceased
Report Submission Date: 5 November 2013
Extension: Possible breach in submission due to annual leave and access to staff.
An Ambulance was called for a patient having suffered a suspected fall. Whilst a responder was on
scene, chest pain was confirmed to Control. There was a delay in getting further resources to the patient
who went into Cardiac Arrest on scene. The patient had been on the floor for 1hr 45 minutes. The patient
later died at Hospital.
1.
2.
3.
4.
5.
6.
Establish whether the 999 call was handled and coded correctly
Establish whether dispatch protocols were correctly followed
What was the resource capacity within this area for the incident date?
What were the demands on our ambulance resources at the time of this call?
What was the clinical assessment of this Patient?
What was the treatment of this patient from first resource arriving on scene to handover at
hospital?
TOR agreed by:
Date:
Locality Quality Manager (LQM) and Service Delivery Manager (SDM)
Email 09 September 2013 and 12 September 2013
Crew Stood Down:
No, delay issue from EOC.
Staff Education and Support
Desk Officer (DO), HP EOC.
Desk Assistant (DA), HP EOC.
Team Leader Paramedic (P).
EE Date: 1 November 2012. PDR Date: 16 August 2012.
EE Date: 2 October 2012. PDR Date: 14 August 2012.
EE Date: 4 October 2012. IPR Date: September 2013.
EOC staff given support by Duty Manager (DM) and PAM Assist (Occupational Health) details for selfreferral.
Being Open
A call was made on 05 September 2013 to the Patient’s Daughter by the Investigation Officer. The
Daughter was informed that an internal investigation is being conducted and the timescales involved.
Upon conclusion, a written response to the complainant will be provided explaining the full outcome,
actions and learning from the investigation.
Timeline of Events
Date and Time
16 June 2013
13:11
13:12
13:12
13:12
13:13
13:15
13:15
13:26
13:31
13:32
13:43
13:56
13:56
14:17
14:26
14:28
14:30
14:33
14:34
14:35
14:38
14:42
14:45
14:48
14:57
14:57
14:57
14:58
15:06
15:06
15:18
15:34
Event
Call received into Emergency Operations Centre (EOC), ‘gentleman fallen over on
the drive – not conscious’.
Resource Allocation (RES/ALL) function access by Dispatcher
Double Crewed Ambulance (DCA1) allocated
Community First Responder (CFR) Dispatcher (CFRD) accesses RES/ALL
function.
Nothing allocated and exits job.
Call coded by Call Handler as 31C02 Green 2 (G2) 30 minute response.
Dispatch Officer (DO) accesses call and correctly diverts DCA1 to Red 2 call.
CFRD accesses RES/ALL function and allocates CFR to detail with ETA 4 minutes.
CFR arrives on scene with Patient.
DO accesses RES/ALL function nothing allocated.
DO accesses RES/ALL function, DCA2 allocated.
DCA2 correctly diverted to attend a Red2 call.
Update from CFR, ‘Patient seems stable. His SATS on arrival were low but are
now normal. Patient is still outside on the floor and has got chest pains’.
DO accesses RES/ALL function and correctly allocated First Response Vehicle
(FRV) to detail.
FRV arrives on scene with Patient.
Update from FRV on scene, ‘Amber response’, crew required. Updated by
Dispatch Assistant (DA).
Patient cannulated by FRV using 18g cannula in right wrist. Successful at first
attempt.
Oxygen administered through nasal cannula at 2litre per minute.
DO accesses RES/ALL function and allocates DCA3 to detail to attend as ‘Amber
Response’.
Update from scene, ‘Upgrade to Red Response’. Updated by DA.
FRV administers 400mcg GTN.
FRV administers 2.5mg Morphine flushed with 10ml sodium chloride
FRV administers 50mg Cyclizine due to nausea.
DO diverts DCA3 to call Red2
DA accesses RES/ALL function and correctly re-assigns DCA3.
Update entered by DO to say ‘cardiac arrest in progress’.
Advance Life Support (ALS) commenced by FRV.
Oropharyngeal Airway (OPA) inserted.
DCA3 arrives on scene.
Defibrillator shock given 200joules.
Patient intubated, successful at first attempt.
DCA3 leaves scene with Patient towards Hospital.
DCA3 arrives at Hospital with Patient.
Following a call audit, the Emergency Medical Dispatcher (EMD) coded this call incorrectly processing it
via the unconscious/fainting protocol instead of falls. The response received due to the incorrect coding
was Green 2(G2), a 30 minute face to face response time. The same response time may have been
achieved had falls been selected and a more appropriate line of questioning would have been available
using the falls protocol.
Based upon the rules of case entry within Advanced Medical Priority Dispatch System (AMPDS) the chief
complaint is selected in order of priority, taking in to consideration: scene safety, mechanism of injury and
medical symptoms. There were no scene safety issues to consider so in this instance the EMD incorrectly
took the medical symptoms of the patient as priority, instead of addressing the mechanism of injury. This
resulted in the inappropriate selection of the unconscious/fainting protocol.
Community First Responders (CFR) basic level are only authorised to attend a limited range of patient
conditions. This does not include trauma incidents. A fall is classed as a trauma incident and would not
have enabled a CFR to be allocated in line with the CFR Dispatch Criteria
Following the incorrect coding of the call the CFR was correctly allocated as the call now fell within the
range of patient conditions they can attend. The CFR was on scene with the patient within 14 minutes of
the call being received. This is within the 30 minute response time target for the G2 call.
After being with the patient for 30 minutes, the CFR updated the Emergency Operations Centre (EOC).
The patient was said to be stable with low saturation levels (SATS) on arrival which had returned to
normal. However, the patient was now experiencing chest pains. At the same time 13:56, the Dispatch
Officer (DO) accessed the Resource Allocation (RES/ALL) function and assigned a First Response
Vehicle (FRV) to attend which is correct in line with the Deployment of Planned Resources Standard
Operating Procedure (SOP).
On arrival with the patient the Paramedic carried out an Electrocardiogram (ECG); the Paramedic
indicated this reading to be ‘OK’. From this reading the request for an amber response for a conveying
resource, would imply the Paramedic had no immediate concerns for the patient condition. An amber
response required a conveying DCA to attend under emergency conditions, but allowed the resource to
be diverted to a cardiac arrest call whilst en route.
The allocation of DCA3 at 14:33 was to progress as an amber response. At 14.34 the Paramedic
requested a red response as the patient had deteriorated. A red response at the time of this incident
required that the conveying DCA attend under emergency conditions and is not available to be diverted to
any Red calls whilst en route.
At 14:45, the Dispatch Officer (DO) responsible for allocation and decisions made by the desk incorrectly
diverts the DCA3 to attend a Red 2 response. Whilst the red response has been made, the job will still
show on the dispatcher screen as G2. Three minutes later at 14.48 the Dispatch Assistant (DA) notices
the error and re-assigns DCA3 back to the initial red response request.
At the time of this incident occurring, the DO was a DA acting up to the DO role in order to cover meal
breaks for the Divisional desk. The DO had been through the training procedure within EOC for the DO
role. There is no formal signing process to prove a DA is competent in DO duties.
Whilst preparing the patient to travel, one of the DCA3 crew contacted the nearest Catheter Laboratory
18 miles away. At this point the patient then went into Ventricular Tachycardia (VT) cardiac arrest. The
Catheter Laboratory advised taking the patient to the nearest Emergency Department (ED) which was 15
miles away.
The crew had made the patient’s family aware they would be travelling to the Catheter Laboratory;
however as no member of the family travelled with the patient, the decision to travel to ED post arrest was
not conveyed to the family. The crew correctly conveyed the patient to the nearest ED, whilst the family
travelled to the Catheter Laboratory at a different location 18 miles away.
On arrival at the ED the patient was making some respiratory effort and had a cardiac output.
A review of the electronic Patient Report Form (ePRF) by the Clinical Team Mentor identified that on
arrival of the FRV the Patient was alert with a Glasgow Coma Score (GCS) of 15. His respiratory rate was
normal, along with his skin temperature and colour. The patient was said to be anxious and it was
unknown if there had been a loss of consciousness for the duration he was unattended.
The ECG taken by the Paramedic at 14: 25 showed episodes of Ventricular Tachicardia (VT) and an
irregular heart rate of 142 beats per minute. All other observations taken were within limits/normal with
the exception of a pain score 07/10 for which Morphine was correctly administered. There were no
concerns for the care provided to this patient by the attending crew.
Information gained Performance Management Information Team (PMIT) identified there were shortfalls in
the Divisional area; three FRVs were abstracted due to back fill shortfall and one an ECP due to sickness
all of which are solo responders/paramedic roles. Vehicle off Road (VOR) accounted for the loss of a
further FRV at 11:55hrs. This shortage of FRV and solo responder resources would impact on DCA
availability to convey patients whilst attending to calls in place of FRVs. Add here whether the shortfalls
had been covered via VAS/PAS
The Duty Manager (DM) resource log shows the DO requested assistance from the DM between 14:15
and 15:00. This request for assistance relates to the volume of resources accumulating and requiring
resource allocation. The Duty Manager confirmed support was given through the dispatch desk meal
break period due to high demand within Division for resource allocation.
Conclusion
The 999 call was coded incorrectly by the Emergency Medical Dispatcher (EMD).
From the dispatch coding achieved by the EMD, the protocols followed by the DO were in accordance
with the Deployment of Planned Resources SOP.
There were shortfalls within the Divisional area on incident date. Four FRVs were unavailable due to back
fill shortfalls and sickness. A further FRV went VoR mid shift accounting for a further loss
.
All resources were attending to or backing up other crews on emergencies at the time this call was
received. After the FRV had requested a DCA conveying response, the next available resource was
allocated.
Clinical assessments were made of the patient on arrival of the CFR and FRV as documented on the
electronic Patient Report Form. All treatment given to the patient was based upon the presenting
condition. The CFR administered Oxygen prior to the arrival of the FRV to increase the patient’s Oxygen
saturation levels. As the patient complained of chest pain he was correctly cannulated and given
Morphine along with Cyclazine. Prior to this the FRV had given Glyceryl Trinitrate (GTN) spray to alleviate
the pain with no success.
The patient went into cardiac arrest at 14:57 and Cardio Pulmonary Resuscitation (CPR) was undertaken.
Defibrillator Shocks were administered six times between 14:57 and 15:33 with Adrenaline and
Amiodarone also given. DCA3 arrived at Hospital with the patient by 15:34 and handed over to the ED.
Root Cause
The Emergency Medical Dispatcher coded the call incorrectly taking the patient’s medical condition over
the method of injury.
The call was incorrectly coded allowing a CFR to attend.
The CFR did not request an upgrade of call based on the Patient’s new presenting condition.
The Patient presented to the FRV with a GCS of 15.
Divisional resource shortfalls due to back fill.
No procedure in place for auto upgrade of a call when a CFR is on scene.
Recommendation
Dispatchers
to
enter
into
the
occurrence
book
when on shift or
covering
meal
breaks.
CFR Dispatchers to
verbalise
if
a
Patient is unwell
rather than just
altering warnings to
Dispatchers.
Dispatch
Desk
training for DO to
be formalised to
ensure
documentation
of
training completed.
Protocol in place for
backing up a CFR
when on scene.
EE
to
completed.
be
PDR
to
completed.
be
Communication to
family
if
end
location for Patient
changes and no
one travelling.
Action
Lead
Due Date
Evidence
Desks
to
be
communicated with
to ensure correct
logging procedures
followed.
20/12/13
Copy
of
email/communication sent
to Dispatchers.
Communication to
go to all CFR
Dispatchers
to
ensure message is
received.
20/12/13
Copy
of
email/communication sent
to CFR Dispatchers.
20/12/13
Copy
of
implemented
training plan documents
and sign off sheet.
Actioned
Copy of the updated
Deployment of Planned
Resources SOP.
Formal process for
training to be put in
place for DA/DO
training
with
documents
to
support.
Update
to
the
Deployment
of
Planned Resources
SOP.
All staff to be
booked on to and
complete 2013/14
EE course.
PDR
to
be
completed by EOC
staff.
Crew to contact
EOC
to
inform
family if end location
of Patient changes.
Efforts to be made
by EOC to inform
family.
Booked
by
01/12/2013
01/01/2014
01/01/2014
Email evidence of booking
and attendance supplied
by
Organisational
Learning.
Email
evidence
of
completion
by
Organisational Learning.
Copy
of
Clinical
Update/Email bulletin to
EOC Dispatch staff.
Members of staff new in post still requiring on-going support after their mandatory training period has
ended.
Evidence Gathered
Call Audit
Copy of electronic Patient Report Form (ePRF)
Record of Verbal Interviews
Clinical Review of ePRF
Resource log for Divisional Desk and DM
Sequence of events
Email of process from DM
Statistical information from Fleet
Type: Delayed Response For Urgent
Source: PALS Office
Final Contact Date:
Harm Rate: Moderate
Base: EOC Control HP
Risk Rate and Score:
Area/Divisional: EOC Control HP
Patient Outcome: At home
Summary: Delay In Transport
Case Type: Formal Complaints
Case Details: Urgent Ambulance booked by Doctor to transport Patient to Hospital. Significant delay over the two
hours time slot requested.
• Why was there a delay in responding to the Patient?
• Why was the caller always asked whether he wanted to upgrade when the decision should belong to the
Doctor?
• Why did Control say they had spoken to the Doctor when this hadn’t happened?
Crew Stood Down:
No. Delay call, non- clinical
Staff support and involvement: Emergency Medical Dispatcher, EE date: 02/07/12, PDR date: 25/06/13
Assistance provided by Team Leader MP. Referred to PAM assist if required.
Healthcare Decisions Panel (HDP) referral: No. None clinical incident
Being Open
Timeline of Events
Date and Time
Event
19 August 2013
12:03
16:22
18:10
18:15
18:17
19:17
Capacity Management Plan put into place.
Two hour ambulance requested from NEMS to transport to Queens Medical Centre.
Patients GP rang for ETA to Patient’s address.
Call made to surgery to confirm out of time. Asked for extension. Not confirmed as given.
Incorrect notes left by Call Handler to say more time has been allowed.
Call received from Patient’s friend asking for ETA. Advised high number of emergencies
and to call 999 if Patient deteriorates.
Second call received from Patient’s friend asking for ETA.
Third call received. Patient now getting weary as ready for bed.
Call received from Nurse on B3 requesting ETA of Ambulance.
Call correctly upgraded by Call Handler from Urgent to Green1, 19 minute response.
Dispatcher accesses Resource Allocation (RES/ALL) function, no resources available.
Dispatcher accesses RES/ALL function, no resources available.
Dispatcher accesses RES/ALL function and correctly allocates Double Crewed Ambulance
(DCA) 8329 to attend detail.
DCA 8329 leaves scene with Patient towards Hospital.
Patient arrives at Hospital with DCA.
19:58
20:35
21:37
21:59
21:59
22:02
22:10
22:13
22:22
22:46
22:53
23:19
20 August 2013
00:01
00:02
DCA 8329 clear from this detail.
Call closed correctly by Dispatcher.
Prior to this call being received, East Midlands Ambulance had invoked their Capacity Management Plan (CMP)
levels 1&2. This procedure is designed to manage demand and resources during high call volumes where the
supply of the Ambulance Service resources is insufficient or, potentially insufficient to meet the clinical demand of
Patients. CMP actions are in place to maximise responses to the most seriously unwell patients. CMP level 1&2 do
not affect the out of time Urgent process.
An Urgent Ambulance booking was made at 16:22hrs from the Nottingham Emergency Medical Services (NEMS)
team. This was to be with the Patient for within two hours.
At 18:10hrs the Patient’s GP called the Urgent booking line to ask how long it would be before the Ambulance
arrived with the Patient and was advised we were still in time, were busy and; would be there as soon as possible.
The GP mentioned the Patient was ill and suffering from Cancer.
A call was made by a Call Handler at 18:15hrs to the GP surgery to confirm that the Ambulance would not be with
the Patient within the two hours agreed. The Call Handler asked if an extension could be given. The GP receptionist
stated the Patient was aware there is a delay and were advised to call 999 if the Patient got worse before the
Ambulance arrived. The Call Handler incorrectly noted that more time had been allowed to attend the Patient. This
had not been agreed.
The Patient’s friend rang the Urgent booking line to ask for an ETA at 19:17hrs. The Call Handler apologised for the
delay and explained this was due to the high number of emergencies being received. The caller did state the GP
had advised to call 999 if the Patient got worse before the Ambulance arrived.
A second call was received from the Patient’s friend at 19:58hrs asking for an ETA. The friend was told that due to
the amount of 999 calls, EMAS had not been able to allocate a response. The friend was concerned as the Clinic
the Patient was booked into was waiting for him. The Call Handler apologised for the delay. The friend was told if
the Patient deteriorated in any way to call 999 where the Patient can be re-assessed at any point.
By 20:35hrs, the Patient’s friend called on a third occasion. He stated the Patient was getting weary as should be in
bed by now. The friend was again told that due to the large number of emergencies, we did not have a crew to
send and to call back on 999 if the Patient gets worse. The friend stated he was getting nowhere and it wasn’t up
to him to decide if a 999 Ambulance was needed, and hung up the phone.
A Nurse from Ward B3 Queens Medical Centre rang the Control room at 21:37hrs to enquire to when an
Ambulance would be sent to the Patient. The Nurse was told an extension had been granted by the GP. The Nurse
stated the Patient and Patient’s friend were not aware of this and the Patient had not had his evening medication
due to waiting on the Ambulance. The Nurse was told the next available Ambulance would be sent.
One of the Call Handlers monitoring the Urgent bookings made the Clinical Assessment Team (CAT) aware of this
job at 21:59hrs. It was agreed to upgrade this to a Green 1 (G1) 19 minute response.
The Dispatcher accesses the Resource Allocation (RES/ALL) function five times between 21:59hrs and 22:22hrs in
an attempt to assign a Double Crewed Ambulance (DCA) to this detail. On the fifth attempt, a DCA 8329 was
assigned.
The DCA 8329 arrived on scene with the Patient at 22:46 and transported him to Hospital. The DCA was clear from
this details at 00:01hrs 20 August 2013.
At 00:02hrs on the 20 August, the call was correctly closed down by the Dispatcher.
Conclusion
There was a delay in responding due to incorrect information being noted by a Call Handler when speaking with
the GP receptionist.
A note was made by the Call Handler that the option to extend time prior to arriving with the Patient had been
granted by the Doctor. This was not the case. The Call Handler had spoken to the Doctor’s receptionist and no
further time was granted at this point.
Due to the time the Patient was waiting, a welfare call should have been made by the Clinical Assessment Team
(CAT). As the extension was recorded as granted, this did not happen.
Had the call been upgraded in line with the Out of Time Urgent SOP, the Patient would have received a Green1
(G1) response. This means the Ambulance would have gotten to the Patient sooner.
When a caller who is with a Patient calls into the Emergency Operations Centre, they are reminded to call back on
999 if the Patient’s condition deteriorates before the crew arrive. A caller does not have to be medically trained. As
they are with the Patient, they will know whether the Patient is getting worse ie lowered level of consciousness. It
is these circumstances that would allow for a call to be re-assessed and, if appropriate an Ambulance sent on a
priority response.
When calls are received into the EOC they are prioritised dependent upon the clinical need of the Patient.
Although the call had not been upgraded as per the SOP, there was no immediate medical need reported to make
this call an Emergency.
Action: EMD to have further training and support around the correct process for contacting GPs and upgrading
Urgent calls.
For:
Deadline: 13/11/2013 due to planned staff sickness
Evidence Gathered
Sequence of Events from calls 5777219 and 5777980
Copies of Voice Recordings for call 5777219 with ETA calls
Resource Log for Emergency Operations Centre Duty Manager
Copy of Capacity Management Plan v7.2
Copy of Urgent Upgrade SOP
Patient or relative willing to be approached for their ‘story’ for the EMAS board? Have you asked? Why?
Why not? What did they say?
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
FC/2013/077
Deceased? No
Logged by:
Incident Location:
Delayed response to a CVA
complaint:
Type of Complaint: Service Failure
Division/Area: EAST (BBEOC)
16/9/2013
23/9/2013
Their reference:
(15 working days)
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
BBEOC A&E
Moderate 6 – distress at service issue possible to happen again
Was the call correctly handled?
Scope of Was there a delay in the ambulance arriving with patient?
Investigation If there was a delay, what was the cause?
(must include all
Was a Community First Responder available to attend the patient?
complainant
Did delay have impact on the golden hour?
concerns) :
Intro letter + 3rd party permission form
Date OSM/PTL/Manager informed: No
Staff involved informed: No
FC/2013/077
Date and Time
29/7/13
13:09
13:13
13:37
13:39
13:58
13:59
14:00
14:03
14:07
14:08
14:10
14:34
14:42
14:58
15:04
15:06
15:29
16:00
Events
RTC requiring 3 Crews, Helicopter and Community First Responder Doctor on
flyover A# South of NWK
Resource Log (RL) notes thunderstorms in the County
RL – LCH breaching handover 30 minutes – Team Leader attending hospital
Reports of thunderstorm over area
CAD 5726657
999 call received. --- year old male suffering a stroke from Event Private Ambulance
crew
Fast Response Vehicle (FRV) assigned from NWK base with 20 minute ETA (12.63
miles). Community First Responder (CFR) assigned.
Call coded G1 (28C01U) – requiring on scene attendance within 20 minutes
CFR stood down as no reply to phone calls
RL notes lightning strike close to control room affecting telephones – quickly
restored
FRV diverted to suspected cardiac arrest
Double crewed ambulance assigned with 42 min ETA (distance 20.79 from LC)
CAD 5726747
nd
2 999 call received for patient – coded R2. Res/Alloc shows crew mobile to detail
already is the closest.
Crew arrives on scene: 47 minutes after assignment
Crew leaves scene with patient
Control pre-alerts LCH resus: 49M, left sided weakness. BP 150/83; SATS 86;
Pulse 77; BM4; ETA 40 minutes; Fast Positive; GCS 15
LCH marked as informed
Crew arrives LCH A&E
Crew clear LCH
Evidence Gathered:
CAD SOE 5726540 (serious RTC in vicinity)
CAD SOE 5726657 (1st 999 call)
CAD SOE 5726747 (2nd 999 call)
East Resource Log
North Resouce Log
PRF 5726657
WAV file 999 call 1
WAV file 999 call 2
Trust Performance Data
Call Handling: At 13:58, a 999 call was received to a --- year old male suffering with a
suspected Stroke. The call was made by a Private Ambulance Service that was working at an
event. The call was taken through the Advanced Medical Priority Dispatch System (AMPDS)
and was given a coding of G1. This requires an on scene response of 20 minutes from the
Trust.
The Training Team Manager was asked about response timescales allocated to different calls,
and how they are established. The Manager states “Representatives from the Department Of
Health review all the codes used by AMPDS, allocate a response and create a national
database for the UK ambulance service Trusts.”
In this case, based on the information
provided by the caller, the patient’s condition was deemed as not immediately life threatening so
given a National code with a 20 minutes response target. The call was assessed as coded
correctly by the Auditing Team.
The Dispatcher checked the Resource Allocation (Res/Alloc) at 13:59. This is a computer
function that allows the Dispatcher to see what vehicles were available to attend this detail. The
Dispatcher correctly assigned the nearest resource, a Fast Response Vehicle (FRV) with an
ETA of 20 minutes. The FRV would have arrived within the required time scale, but had to be
diverted to a R1 call at 14:08. This was a correct action by the Dispatcher as outlined in the
Dispatcher’s Framework, Section 10.13 - “The first dispatched resource must always be stood
down and diverted to a higher priority call e.g. a resource running on G1/G2 should be diverted
to Red 1 and 2…”
The Dispatcher then assigned an ambulance from LC, with an estimated time of arrival of 42
minutes. The Res/Alloc has been checked, and the Dispatcher chose the correct vehicle to
attend this detail as no other nearer vehicles were available at that time.
The Community First Responders (CFR) desk attempted to assign a CFR shown on duty, but
was unable to raise them on the phone. CFR desk were unable to utilise any other responders
in the area as none were logged on, other than the Doctor attending a serious Road Traffic
Collision (RTC) in the area.
At 14:34, a second call was received to this patient. This was coded as a R2 call. This call was
audited as correctly coded. Dispatcher completes a Res/Alloc which shows the vehicle already
on way to this patient is the closest to the patient and is correctly assigned to the detail
Crew arrives on scene at 14:42. This was 44 minutes after the call was received. This was a
24 minute late response to the patient. Due to this delay, the Trust failed in its Duty of Care to
this patient.
Service Issues: Prior to this call, reports of a serious RTC were received. This was within 10
miles of this address, and required multiple vehicles including the Air Ambulance. This had a
serious effect on the number of vehicles available to attend the stroke call. Due to this, with the
FRV diverted to an R1 call, there were no other crews in the area that were closer than the one
assigned.
At 13:39, the Air Ambulance reports unable to take off due to the weather conditions at the
RTC, and at 14:07, the East Control Room suffered a near lightning strike causing problems
with the phones. Such weather conditions would have had an adverse effect on crews
attempting to get to calls in a timely, and safe, manner. Additionally, LC Hospital was reported
as having delays of up to 30 minutes which resulting in crews being unavailable for calls for a
longer period.
Patient care: Clinical assessment of the Patient Report Form (ePRF) raised no concerns
regards to the treatment of the patient by the crew. The Clinical Team Mentor (CTM) states the
crew “clearly showing that they recognised (the) patient was time critical and reacted
accordingly”, and that they made good time in transporting the patient to the nearest treatment
centre.
The patient’s family has specifically asked about how this delay would impact on the “Golden
Hour”. This relates to the first hour after symptom onset in which medical treatment to prevent
irreversible internal damage and optimize the chance of survival is most effective. The CTM
stated that the patient was transported to hospital within the timescale outlined by the National
Institute for Health and Care Excellence (NICE) of 3 to 4.5 hours. The CTM further states that
“even though the patient was still at hospital in time to be treated the fact remains that the
longer the delay in treatment the greater the risk of a poorer outcome increases.” As the onscene attendance to this patient was 24 minutes outside the timescale required the Trust failed
in its Duty of Care to this patient.
Conclusion:
Were the calls correctly handled?
Yes. Both calls were audited as correctly handled, and given the appropriate response level.
Call 1 was coded within 20 minute response required. Second call received a code requiring an
8 minute response as the patient was reported to have deteriorated.
Was there a delay in the ambulance to arriving with the patient?
Yes. The first call was given a 20 minute on scene response required by the Trust. This was
not met, with the ambulance arriving 24 minutes later than the response time for a coding of this
type.
If there was a delay, what was the cause?
Prior to this call, reports of a serious Road Traffic Collision (RTC) were received. This was
within 10 miles of this address and required multiple vehicles, including Air Ambulance. This
had a serious effect on the ability of the Trust to attend this call within the required timescale.
Reports at the time show that a thunder storm was in the area. This was causing difficulty in the
Helicopter taking off, and lightning strikes hit close to the East Control Room. Such weather
conditions would have had an adverse effect on crews attempting to get to calls in a timely, and
safe, manner. Additionally, LC Hospital was reported as having delays of up to 30 minutes for
releasing crews so reducing the number of available resources to attend outstanding calls.
Was a Community First Responder available to attend the patient?
The Community First Responders (CFR) desk attempted to assign an on duty CFR but was
unable to raise them on the phone. CFR desk were unable to utilise other responders in the
area as none were logged on, other than the Doctor attending the RTC.
Did delay have impact on the golden hour?
Yes. The Golden Hour relates to the first hour after symptom onset in which medical treatment
is most effective. Clinical Team Mentor (CTM) states that “The overall time from the onset of
symptoms to arrival at the correct hospital and handing over the patient was 1 hour 35 minutes,
which is within the time for the patient to still be able to receive treatment. Which NICE
(National Institute for Health and Care Excellence) guidelines and local hospital policy states
treatment should be within 3 - 4.5 hours from onset of symptoms.” That even though the patient
received treatment within the timescale outlined by NICE “the fact remains that the longer the
delay in treatment the greater the risk of a poorer outcome increases.”
Due to a 24 minute delay, the Trust failed in its duty of care to this patient.
Recommendations:
None
say?
Deceased? No
Their reference:
FC/2013/078
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Logged by:
Incident Location:
2nd letter received with further questions regards: Pt with back pain.
Unhappy with FRV attitude, lack of examination, diagnosis, and referral to
complaint:
GP.
(15 working days)
Date for Investigation conclusion: 02 September 2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Minor 4 Patient care issue that is unlikely to re-occur.
1.
Should the first Paramedic have carried out a full examination?
2.
Was it correct for the Paramedic to refer you to the GP?
3.
Was if correct for the Paramedic to leave you to make a decision, should I
wait for more pain killer from the GP, or get in his ambulance with only entonox gas
4.
Should the first Paramedic have called for assistance so you could be
transported to hospital after having stronger pain killer as there would be a second
Paramedic?
5.
Should the second Paramedic have been deployed to your house sooner?
6.
Given the fact the Ambulance Service is aware of my condition, should they
have sent a two man crew?
7.
Should the second Paramedic have carried out a full examination? That he
should not have said that stronger pain killers would not be available in hospital,
that you would not get an MRI till Tuesday?
8.
Was it correct that you and your partner had to push for another
Ambulance so I could get to hospital?
9.
Was it correct for the second Paramedic to ask his control for an
Ambulance on a non-urgent call?
Letter with Subject Access Form
Fc/078/13
Date and Time
3/5/13 07:28
07:51
13:48
14:35
15:16
15:23
16:24
19:35
19:50
19:54
21:12
21:17
21:39
Events
111 send through call on the Automatic system: 5517583 requesting a G2,
emergency transport request within 30 minutes. Patient in agony; cannot get out of
chair; lower back shoulder, legs and left side of face. Numbness in cheeks.
Single crewed Ambulance assigned to the call, driven by P1. Arrived on scene at
08:13 hours – outside of the G2 response time. P1 left scene at 09:20 – detail
closed as Treated on scene, and referred to GP for additional medication
Call received to a major RTC on A46, approximately 20 miles for patients address.
Detail requires 6 EMAS vehicles to attend, with last vehicle clearing scene at 16:42.
One EMAS vehicle receives damage and is taken off line.
999 call to address for back problems – CAD 5518408 . This was taken through the
AMPDS system and coded G4 – to send to EMAS Clinician for triage.
999 call to address for male with back problems – CAD 5518497 . Patient
requesting ETA on TAS call. This Coded G3 which is a Triage call back.
TAS spoke to the patient call and created CAD 5518547.
ECP was assigned to CAD 5518547 at arrived scene at 16:35. ECP remained on
scene for 9 minutes, no PRF completed, ECP states no examination of patient
completed, no supporting documentation.
Welfare check request not completed at 18:45; Dispatcher now checks Resource
Allocation (Res/Alloc) and crew assigned to attend the patient – no blue lights.
999 call to male with back pain – CAD 5519065.
Performance Delivery Manager’s Log Reports: CAT Team welfare checking holding
calls
Crew arrive on scene and transport the patient to the hospital. Urgent collection was
total of 4 hours and 37 minutes.
Performance Delivery Manager’s Log Reports: R1 triage suspended to assist with
Triage backlog.
Performance Delivery Manager’s Log reports:
26 uncovered 999 calls holding; 11 G3/4 Calls awaiting triage and 7 out of time
urgents across EMAS. Capacity Plan (CP3) implemented
Evidence Gathered:
SOE CAD Call 1
SOE CAD Call 2
SOE CAD Call 3
SOE CAD Call 4
SOE CAD Call 5
SOE CAD Call 6
Letter Complaint
EMAS Daily Performance Review
Call 1 WAV file
Call 2 WAV file
Call 3 WAV file
PRF Call 1
Performance Delivery Managers Resource Log
Lincs Resource Log
PRF Call 3
Email LQM re 2nd RRV attendance
LQM response to 2nd RRV attendance
EMAS Clinical Record Keeping Policy
Performance Review
East Midlands Ambulance Service (EMAS) was under performing on all categories of calls. There was an
increase in calls of 9.76% on previous week across the board. Response times to Red calls, requiring 8
minute response was 72.9% (below 75% required); G1 performance was 80.58% (should be 95%); and
G2 performance was 82.04% (should be 85%).
Capacity Plan (CP) 3 implemented at 21:39: 26 uncovered 999 calls holding; 11 G3/4 Calls awaiting
triage and 7 out of time urgent calls across EMAS.
Serious RTC in Lincolnshire Division, 20 miles for patients address, requiring 6 resources at attend. Last
unit clearing at 17:00, Delivery manager noted this as effecting response to other details.
At 08:20 on Friday, 3 May 2013, Paramedic (P1) attended patient for on-going back pain
problem. P1 completed observations and administered entonox. Patient spoke with P1 and
with own GP. A care plan was established for the GP to call back later to monitor patient’s pain
level. Patient signed to say that this was acceptable. P1’s actions have been clinically
assessed by a Clinical Team Mentor (CTM) and found to be correct.
P1 gave patient all facts and information needed so that the patient could make informed
decisions regards to his own treatment. As there were no doubts about the patient’s mental
capacity, it is a legal requirement that P1 abides by the treatment decisions made by the
patient.
At 14:35, first 999 call was received for the patient. This was taken through the Advanced
Medical Priority Dispatch System (AMPDS) and coded as suitable for further triage by an EMAS
Clinician (CAT) within the hour. Clinician spoke with patient, within 50 minutes of this call, and
assessed his condition. CAT upgraded call to a G2 call, ambulance required within 30 minutes.
Due to a serious Road Traffic Collision in the area, an Ambulance was not available to attend
within this timescale. The Dispatcher assigned an Emergency Care Practitioner (ECP) to this
call. It is not standard procedure to deploy an ECP to a call requiring an ambulance to attend for
transport. Due to this it was not appropriate for one to be assigned until it became evident that
no crew would be available for some time. On arrival ECP states he was informed by the patient
an ambulance was organised already. ECP remained on scene for 9 minutes and there is no
record that the patient was examined.
ECP cleared scene and an ambulance was requested for within 4 hours, and that patient be
welfare checked if not collected within 2 hours. Records have been searched and there is no
trace of a PRF for the ECP visit. As there is no PRF there is no evidence to show if this was an
appropriate response to the patient. Section 3.2 of the Clinical Records Keeping Policy states
that PRF is to be completed ‘…by all personnel for each patient attended…’ and a ‘…form
should be generated whenever a vehicle arrives on scene at an incident.’
EMAS is an emergency service and only keeps basic history on any calls they attend. They do
not place digital flags on addresses unless it is for serious scene safety issues, or for when a
patient has a serious life threatening condition.
At 21:12, ambulance arrives on scene to collect patient on the urgent booking. This is 37
minutes outside of the 4 hour timescale requested by the ECP. No welfare check was
instigated at the 2 hour mark. A note was made in the Performance Delivery Managers
resource log that CAT were completing welfare checks, but this patient was not noted as
checked, nor was the computer log opened in this timescale. Capacity Management Plan (CP)
3 was instigated at 21:39 as demand on EMAS services outstripped the services available
resources.
Conclusion:
1. Should the first Paramedic have carried out a full examination?
Full sets of observations were completed by the paramedic, and entonox administered. The
actions of this Paramedic were clinically assessed and found to be correct.
2. Was it correct for the Paramedic to refer you to the GP?
As was stated in the original letter the care plan instigated was completed after discussions with
the patient and his GP. Referral to a GP was the correct course of action for a condition longstanding and on-going.
3. Was if correct for the Paramedic to leave patient to make a decision, should he wait for
more pain killer from the GP, or get in the ambulance with only entonox gas?
Yes. There were no issues about patient’s mental capacity. It is the Paramedic’s duty to give the
patient informed choices only. The decision regards treatment options must be the patients, as
stated by law.
4. Should the first Paramedic have called for assistance so you could be transported to
hospital after having stronger pain killer as there would be a second Paramedic?
No. The Paramedic completed full observations and contacted patients GP whilst on scene. The
Paramedics actions were appropriate in this matter, and the patient signed the Patient Report
Form agreeing to this course of action.
5. Should the second Paramedic have been deployed to your house sooner?
No. At this time we had a transport only request from our Clinical Assessment Team. This
required that a Double Crewed Ambulance be sent, not a solo Paramedic. Unfortunately, as was
stated in the original response, a serious road traffic accident in the area meant no double
crewed ambulances were available. When it was apparent this issue would not resolve quickly
the Dispatcher acted correctly by requesting an Emergency Care Practitioner (Paramedic 2)
attend as a temporary measure.
6. Given the fact the Ambulance Service is aware of patient’s condition, should they have
sent a two man crew?
No. The ambulance service is an emergency service and respond based on medical need only.
EMAS do not monitor peoples on going health issues, and are commissioned to attend life
threatening emergencies. Standard protocols are applied to all calls, as was with this patient’s
call. A single ECP was sent on the second call because a serious Road Traffic Collision in the
area delayed a crews attendance, as per point above.
7. Should the second Paramedic have carried out a full examination? That he should not
have said that stronger pain killers would not be available in hospital, that patient would
not get an MRI till Tuesday?
Yes. As was stated in the original response, the second Paramedic failed to complete an
examination of the patient. Additionally, he failed to complete a Patient Report form regards to
attending the patient. Due to this the second Paramedic has had an official note placed on his
record of service.
Regards to questions about medication and MRI’s, Paramedic 2 provided information regards to
hospital procedures based on his knowledge to ensure that the patient had sufficient information
to make an informed decision on his treatment options.
8. Was it correct that patient and partner had to push for another Ambulance so patient could
get to hospital?
No. Unfortunately, the nature of an emergency service is that it cannot be predicted regards to
numbers, or types of calls, at any given time. In this case a serious road traffic accident had to
take priority over the patient’s call. This involved patients with life-threatening emergencies that
needed multiple vehicles to attend.
9. Was it correct for the second Paramedic to ask his control for an Ambulance on a nonurgent call?
No. As was stated, by failing to complete a Patient Report Form it is not possible to support the
second Paramedics request for a non-urgent booking. All actions by EMAS staff must be
evidenced to show appropriate actions utilising this form. As the Paramedic did not do this a note
has been placed on his file.
Recommendations:
None additional to original report
say?
Type: Patient Care Issue
Source: Letter
Written or Verbal: W
Date Agreed: 20/09/2013 – extension
agreed
Delays Incurred
Reason for Delay: new issues to be investigated
New Agreed Date: 15 October 2013
Reported as Patient Safety Incident: N
Harm Rate: N/A
Base: Patient's House
Extension: XX
Green 2
Risk Rate and Score: 0
Area/Divisional: Patient's Home
Patient Outcome: Discharged 12/07/2013
Summary: Alleged Poor Care Management
Case Details: Patient found disorientated at a neighbour’s property. On arrival the ambulance personnel
established that the patient required no medical attention and he was assessed as having capacity.
Patient’s sister and brother attended the scene and insisted that patient be sectioned. They were advised by
ambulance and Police personnel that this was not possible; the brother became aggressive and confrontational.
The patient was eventually taken to hospital as a place of safety as the relatives would not agree to assume
responsibility for him. Following the incident an Acknowledgement of Responsibilities Agreement (ARA) was
issued to the patient’s brother in respect of his actions on scene and a complaint was subsequently received in
response.
When he was contacted to dicuss the complaint the patient’s brother advised that his main concern was that when
the ambulance crew handed the patient over at the hospital the involvement of the Crisis Team in respect of the
patient was not highlighted. The complainant also questioned the validity of the ARA and he requested a retration
of the document and an apology.
• Was the patient handover at the hospital adequate?
• Why was the ARA issued against the patient’s brother?
TOR agreed by:
IO and complainant
Date: 3 September 2013
Crew Stood Down:
No. Crew actions considered appropriate.
Healthcare Decisions Panel (HDP) referral: No.
Being Open
Initial Contact Date: 3 September 2013
Consent Required: No Consent Date:
Timeline of Events
Date and Time
Event
11/07/2013
20:47
New call received, call ref.5680997, on behalf of a male patient shaking violently, like cold,
asthma patient.
Resource 4931, solo responder, allocated to incident.
Despatch code 10C01, chest pain, abnormal breathing, allocated to incident, Red 2 eight
minute response. Resource 4931 mobile to incident.
Resource 4931 arrives at the scene.
Resource 4615, double crewed ambulance, allocated and mobile to incident.
Resource 4615 arrives on scene.
CAD message: Relatives have arrived on scene and are verbally aggressive, Police are on
scene.IR1 (Untoward Incident report) to follow and crew are to complete a vulnerable
adult referral. Relatives have advised that they are going to make a complaint.
Resource 4931 calls clear from the scene. Resource 4615 leaves scene with the patient.
CAD message: when patient’s brother and sister turned up they were very nasty and
abusive towards the solo responder and crew. The brother of the patient wanted the
patient sectioning despite the patient having capacity.
CAD message: Control and solo responder were not aware that this patient carries a risk as
he was not at his home address. The name of the patient was entered as the solo
responder had booked on scene and she had not come across the patient before so did
not know that the patient was a risk. The patient lives at --------------------------------------- and
has a warning as not suitable for lone responders.
Resource 4615 arrives at hospital with the patient.
Resource 4615 hands patient over to hospital staff.
20:48
20:49
20:50
21:13
21:16
21:32
21:57
22:05
22:18
22:39
23:43
Handling of emergency call: the call was allocated a Red2 eight minute emergency response, and the first
responder arrived on scene three minutes after receipt of the emergency call.
Care of the patient – the Paramedic who was first on scene advised that when she arrived a Police officer was
already in attendance with the patient who was in a house near his own home, having been taken in by the
occupants after he had been observed in the garden looking disorientated and shaking violently.
The Paramedic undertook a full set of observations which were all within normal ranges apart from a slight
increase to his heart rate which was assessed as being a result of his earlier disorientation and distress. The
Paramedic then spoke to the patient’s sister who had just arrived on scene and advised her that the patient did not
wish to travel to hospital. The patient confirmed this and the Paramedic and the Police officer both agreed that he
had the capacity to make this decision.
The patient’s sister began to escort him back to his home which was nearby in the same close. However, as she
was doing so she had a conversation with her other brother and she then returned to demand that the patient be
sectioned under the Mental Health Act. The Police officer explained that as the patient had capacity and he was
not in a public place he could not be sectioned under the Act.
The Paramedic and the Police officer questioned why the patient’s sister thought he should be sectioned and going
to hospital and she replied that he was confused. At this point the back up crew arrived and the Paramedic began
to update them on the situation; the patient’s brother also arrived.
The brother had previously been identified as the patient’s main carer. He immediately became confrontational
(tone of voice) and demanded that the patient be sectioned and taken to hospital, and again it was explained that
in the circumstances it was not appropriate to section the patient. The attending member of staff on the back up
crew again asked the patient what he wished to do and he advised that he wanted to return home to take his
medication.
A conversation took place between the Police officer, the ambulance staff and the patient’s relatives. The patient’s
brother expressed his intention to lodge a complaint regarding the incident. The relatives also raised concerns that
the patient would be discharged in Peterborough on his own at some point, and the Crisis Team at the hospital
should be notified if he was taken there.
The Police Officer left briefly to have a conversation with a colleague and shortly afterwards the ambulance
personnel came out of the property with the patient, who now stated that he was happy to travel to hospital. The
relatives were asked if they were going to accompany the patient and they advised that they were not. The
patient’s brother had a further conversation with the Police Officer which became heated.
The attending member of staff on the back up crew could not be sure if the Crisis Team had been referred to
during the handover with hospital staff. To date the Patient Report Form (PRF) has not been located by the clinical
audit department although the member of staff confirms that one was completed and handed over at the hospital.
The hospital have confirmed that there are instructions on the patient’s hospital records to notify his brother if he
is due to be discharged and this did happen on this occasion in the early hours of 12 July.
Conclusion
Care and treatment of the patient – The initial assessment of the patient was that he was not suffering from any
medical problem on the day of the incident once his distress and disorientation resulting from the circumstances in
which he found himself were resolved. However the decision to take him to hospital as a place of safety was taken
as his relatives appeared unwilling to take responsibility for his ongoing care.
Validity of the ARA – the evidence provided by the members of staff and the Police Officer confirms that the
issuing of an Acknowledgement of Responsibilities Agreement is appropriate following the incident on 11 July
when EMAS staff attended the patient.
Date Resolved: 15 October 2013
Grade: Moderate
Status: Resolved
Letter Date: 15 October 2013
There are no recommendations on this occasion.
Evidence Gathered
CAD report
Statements from attending crew and Police officer
The investigation has been approached in a fair, open and transparent manner without prejudice to any individuals concerned
and has sought to establish the facts surrounding the incident, the decisions made during the incident and to be objective
throughout. The results published will ensure both positive and negative findings will be shared, along with any lessons
identified.
The investigation methodology was to first establish the facts into the incident and draw up a chronological sequence of events
of the Trusts involvement starting from receipt of the first emergency call on behalf of the patient to the point at which the
patient arrives at hospital. The methodology for gathering data will be specific to each investigation.
Deceased? No
FC/064/13
Complainant Name:
Telephone Contact:
Correspondence
Address:
Date of incident: 8 October 2012
Patient Name:
Their reference:
Logged by:
Incident Location:
Brief details of the Patient waited over two hours for a backup ambulance to transport her to
complaint: hospital
Type of Complaint: EOC delay
Division/Area: EOC Northamptonshire
(15 working days)
Date for Investigation conclusion: 17 September 2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
N/a EOC delay
Minor
Why did the patient wait over two hours for an ambulance?
28/08/2013 NGH
Immediate actions taken: CAD report reviewed
FC/080/13
Chronology of Events: taken from the Computer Aided Dispatch (CAD) sequence of
events (SOE) for call reference 4996368/4996434.
12:04
12:06
12:30
12:31
12:40
12:54
14:04
14:05
14:25
14:31
14:32
14:42
15:07
new call received on behalf of a --- year old female suffering from vomiting
and shivering.
call assessed as requiring a return call from NHS Direct within 60 minutes.
call received from NHS Direct passing the call back with a request for an
ambulance under emergency conditions within eight minutes.
resource 0632, solo responder, allocated and mobile to the incident.
request placed by the solo responder for ambulance back up, cold
response.
St.Johns ambulance allocated to the incident.
ambulance mobile to incident.
ambulance arrives on scene.
Solo responder calls clear from scene.
ambulance leaves scene with the patient.
ambulance arrives at the hospital.
ambulance crew hand patient over to hospital staff.
Evidence Gathered: CAD report
Handling of emergency call: The call was originally assessed as requiring a call back within
60 minutes. When NHS Direct called back 26 minutes later, the patient’s condition had
worsened and the response was upgraded to an emergency eight minute response. The solo
responder arrived ten minutes after the call was upgraded, missing the eight minute target but
achieving the 19 minute target.
Response to emergency call: when the solo responder had arrived and assessed the patient,
he requested a cold back up as the patient’s condition was not immediately life threatening. Due
to the demand for emergency responses a resource did not become available until 14:05 hrs,
which was two hours and one minute after receipt of the emergency call. As the request for
back up specified cold response higher priority calls would be attended first.
Conclusion:
As the patient’s condition was stable the request for back up was made on a cold response
basis, and higher priority calls were attended first.
Recommendations:
say?
Type: Inappropriate Actions
Category: Transport - Ambulance And Other
Source: PALS Office
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
.
Reported as Patient Safety Incident: Y/N
Harm Rate: xx
Act
Base: Public Place
Extension: none
Red 2
Area/Divisional:
Patient Outcome:
Protected under Data Protection
n/k
Summary: CAD Ref: 5751390
Case Details: Enquirers son attempted suicide by jumping off a bridge over the M1
Son has now spoken to enquirer and has explained the following:
The ambulance crew were joking the whole time and displying unprofessional behaviour.
A crew member took down his pants and flicked his penis and said 'yes he'll live'.
The air ambulance arrived but one of the crew members stopped him travelling in the air ambulance saying that
'that's what he' want'.
The patient is very upset about this.
• Why did the crew make untoward comments?
• What was the reason for the crew touching the Patient’s penis?
• Why was the Patient not conveyed by Air Ambulance?
Crew Stood Down:
No. Crew questioned by Consultant Paramedic into actions taken.
•
(P1). Skill Level: Team Leader. EE date: 22 August 2013. IPR date: No record.
(P2). Skill Level: Paramedic. EE date: 13 August 2013. IPR date: June 2013.
(T1). Skill Level: Technician. EE date: 3 September 2013. IPR date: No record.
(P3). Skill Level: Paramedic. EE date: No record. IPR date: Nor record.
Doctor (D1)
Trainee Doctor (D2)
Support provided by Consultant Paramedic and referral to PAM details given if required.
Healthcare Decisions Panel (HDP) referral: Yes
Being Open
Consent Required: Yes
Consent Date: sent out 6/9/13
Timeline of Events
Date and Time
Event
19:17
19:19
19:19
19:20
19:21
19:26
19:27
19:30
19:37
19:48
19:51
19:57
20:05
20:13
20:38
21:11
Call received into Emergency Operations Centre. Person jumped off bridge over the
motorway.
Dispatcher accesses Resource Allocation (RES/ALL) function and allocates First Response
Vehicle (FRV) 8631 to detail.
Call coded incorrectly by Call Handler as 17D01J Red2, 8 minute response.
Dispatcher accesses Resource Allocation (RES/ALL) function and allocates Double Crewed
Ambulance (DCA) 8420 to attend.
Helimed Dispatcher accesses RES/ALL function and allocates Air Ambulance Helimed 54
(HM54) to attend.
DCA 8420 shows auto on scene.
FRV arrives on scene with Patient.
DCA 8420 arrives on scene with FRV.
HM54 arrives on scene with Patient.
Helimed Dispatcher asks if HM54 will be transporting as no crew available for landing site.
DCA 8420 conveys Patient to Hospital.
Call made by Doctor as a pre-alert to Hospital.
FRV 8631 call clear from this detail.
DCA arrives at Hospital
HM54 calls clear from this detail.
DCA calls clear from this detail.
A call was received into the Emergency Operation Centre to say a person had jumped off a bridge over the
motorway.
The Dispatcher correctly assigns First Response Vehicle (FRV) 8631 with a Paramedic Team Leader on to attend. At
the same time, the call is incorrectly coded through the Advanced Medical Priority Dispatch System (AMPDS) and
gains a 17D01J Red2, 8 minute response. If coded correctly, this would have been 17D05 Green 1 (G1) 19 minute
response.
A double crewed ambulance (DCA) is assigned to attend at 19:20hrs with the Air Ambulance Helimed 54(HM54)
also assigned to attend at 19:21hrs.
Information provided by the crew on the DCA shows that P1 from the FRV was on scene when the DCA arrived.
The timings show the DCA on scene first due to the auto at scene function being triggered. There was an off duty
nurse also in attendance immobilising the Patient via the head, details of who were not gained.
On arrival with the Patient, the crew state he was squealing with a Glasgow Coma Score (GCS) of 15. P1 from the
FRV completed a primary survey of the Patient and obtained Intra-venous (IV) access . The Patient had a
suspected pelvic injury and was administered 10mg of Morphine as well as being put in a pelvic splint.
HM54 arrived on scene at 19:37hrs after both sides of the carriageway had been closed to allow for their landing.
HM54 had a crew of one Doctor, one trainee Doctor and one Paramedic.
When on scene with the Patient, one of the Doctors D1 continued to examine the Patient on the road. The crew
confirm the Doctor did look down the Patient’s underpants due to the Pelvic injury. When the Patient asked ‘what
are you doing’, the Doctor confirmed ‘I am checking for bleeding’. This was from the Patient’s penis and could have
indicated internal injury to the Patient.
D1 then administered further drugs to the Patient including Ketamine as the pain was still present in the Patient.
At the time of the treatment taking place, the road was closed to the public and the Patient was fully clothed. The
persons present were the Ambulance Staff, Police and; a few lorry drivers within hearing distance who had
stopped due to witnessing the incident.
The Patient was transported on a scoop stretcher by the crew in the DCA with both of the Doctors also travelling.
He was conveyed at 19:51hrs and arrived at Hospital, the nearest trauma centre by 20:13hrs. The distance
travelled was approximately eight miles.
HM54 could have conveyed the Patient however, they would have needed another DCA at the landing site to take
the Patient to the Hospital. It was confirmed by the Helimed Dispatcher there were no other crews at that time
available for the transfer which would have caused a delay in Patient care. HM54 did fly to the landing site for
retrieval of the Helimed crew after their handover at Hospital.
None of the crew in attendance remember making inappropriate comments. It is stated that they were too busy
attempting to treat a critically ill Patient to do so. They did not hear anything untoward whilst in attendance.
Comments were made by Doctors from HM54 at what a good job all of the crew in attendance had done.
Attempts have been made to contact the Doctors involved with this incident, to date no response has been gained
to collaborate witness statements.
Conclusion
No untoward comments were made towards the Patient. The crew were busy treating the Patient and did not
have time to do anything other than provide care. It is stated there were other people within a distance that could
be heard talking and; it could have been another person who made a comment.
The road was fully closed to allow HM54 to land on the carriageway. Due to this and the Patient being fully
clothed; there were no dignity issues.
In order for the Doctor to ascertain the extent of the Patient’s injuries, he touched the Patient’s penis and checked
for bleeding. Doing this allowed the Doctor to see if there were any internal injuries. This is normal process.
It was quicker to take the Patient to Hospital by land due to potential delays waiting for a transfer crew.
When the Air Ambulance is in attendance at an incident, an assessment is made by the senior member of staff as
to the best method to convey the Patient to Hospital. At this incident it was deemed quicker to transfer the Patient
by land in the DCA with the Doctors also present. Had the Patient been transferred by HM54,on landing at the
secondary site which is not at the Hospital; another crew would have been required to take the Patient the rest of
the journey by land causing further delays.
None
Evidence Gathered
Sequence of events from call 5751390
Record of verbal interview from DCA
Voice recording from HM to ED
Voice recording from HM Dispatcher to HM
Copy of PRF
identified.
Director and or any other delegated managers and specialists; on occasion it may be appropriate to include staff involved with
the incident. The panel is convened to identify the root cause(s) and associated contributory factors of the incident. The RCA
members must agree on the recommendations arising from this investigation to prevent and/or minimise recurrence and
Their Ref: 2013-14 (049)
Type: EOC Issue
Category: EOC/CAT Callback Issue
Source: Email
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Private Residence
Extension: XX
XX
Area/Divisional:
Patient Outcome:
XX
Summary: 2013-14(049) Delayed Response- Stroke Pt
Case Details:
Why was ---------------- advised to replace the handset and wait for someone to call back, particularly when she said
she had already been advised by the OOH Doctor to call a 999 ambulance?
Is it normal process for such calls to be further triaged by an EMAS Doctor, despite the fact the call had already
been triaged by the OOH Doctor?
Is there a system in place whereby such patients can be flagged "at risk" on the EMAS system, to prevent such
delays in future?
• Why did the caller need to wait for a call back after already speaking with an Out of Hours Doctor?
• Is the normal process for the Clinical Assessment team to call back too?
• Can ‘at risk’ patients be flagged to prevent delays?
Crew Stood Down:
No. None clinical EOC query
•
Emergency Medical Dispatcher(EMD), EE date:20 September 2012. PDR date: 3 July 2013.
Support provided by EMD Team Leader and information regarding PAM assist given if required.
Healthcare Decisions Panel (HDP) referral: No – None clinical incident
Being Open
Consent Required: No Consent Date: N/A
Timeline of Events
Date and Time
Event
10:46
10:46
10:46
10:47
10:47
10:48
10:50
10:51
11:01
11:02
11:02
11:03
11:03
11:06
11:07
11:08
11:10
11:29
12:10
12:45
13:13
Call received into the Emergency Operations Centre from Patient’s Wife.
Dispatcher accesses Resource Allocation (RES/ALL) function. Nothing assigned to detail.
Dispatcher accesses RES/ALL function and assigns Double Crewed Ambulance (DCA)7630
to attend.
Problem established by Call Handler as ‘off legs, nausea’ and coded correctly as 26A03
Green 4 Clinical Assessment Team (CAT) call back.
DCA 7630 stood down from detail due to categorisation of call.
Call passed to CAT to await call back and assessment.
Call accepted by CAT onto their waiting list.
CAT team call back made to Patient’s wife.
Call upgraded by CAT member to Green 2 (G2) 30 minute face to face response.
Dispatcher accesses RES/ALL function. Nothing assigned to detail.
Dispatcher accesses RES/ALL function and assigns DCA 7317 to attend.
Dispatcher accesses RES/ALL function, no further vehicle assigned.
Dispatcher accesses RES/ALL function, no further vehicle assigned.
Dispatcher accesses RES/ALL function and allocates First Response Vehicle (FRV) 7311 to
attend detail.
FRV 7311 diverted to another detail and stood down from attending this call.
DCA 7317 leave with Patient towards Hospital.
DCA 7317 arrive at Hospital with Patient.
DCA 7317 calls clear from this detail.
Call number 5806122 was received into the Emergency Operations Centre at 10:46hrs. The caller stated to the Call
Handler that she had dialled 111 and been advised to ring for an Ambulance. As this call came via the 999 line, it
was processed via the Advanced Medical Priority Dispatch System (AMPDS).
The Patient had a stroke about three years ago, woke up late, was sweating, staggering and feeling sick. This was
recorded on the Computer Aided Dispatch (CAD) system after being processed through AMPDS as ‘off legs, nausea’
and processed correctly by the Call Handler to achieve a Green4 (G4), one hour call back from the Clinical
Assessment Team (CAT). As there were no sudden onset of symptoms for a stroke, this was managed via the ‘Sick
person’ protocol.
A Dispatcher correctly accessed the Resource Allocation (RES/ALL) function and assigned a Double Crewed
Ambulance (DCA) 7630 to attend the incident.
As the call was coded correctly by the Call Handler, this was going to be triaged by one of the CAT to allow them to
gather further information about the Patient.
Due to the coding of G4, the Dispatcher correctly stands down the DCA 7630 from attending.
At 10:51hrs, a member of the CAT contact the Patient’s wife who was the original caller. The CAT Clinician correctly
processes the caller through their system after asking a series of questions. From the information gained by CAT,
an informed decision is made to send an Ambulance as a Green 2 (G2) 30 minute face to face response.
Between 11:02hrs and 11:03hrs, the Dispatcher accesses the RES/ALL function three times. On the fourth attempt,
a DCA 7317 is assigned to attend.
The Dispatcher assigns a First Response Vehicle (FRV) to attend at 11:08hrs. At 11:10hrs this is correctly diverted to
a higher priority emergency call.
DCA 7317 arrived on scene with the Patient at 11:29hrs and after checks and observations were made, left for
Hospital at 12:10hrs.
The DCA 7317 with the Patient, arrived at Hospital for 12:45hrs.
At 13:13hrs, DCA 7317 calls clear from this detail.
Conclusion
The call was coded correctly by the Call Handler based upon the presenting condition of the Patient.
As the 111 service had asked the Patient’s Wife to ring 999 for an Ambulance, the 999 call had to be processed in
accordance with Ambulance Service protocols. The disposition is then based upon the information gained by the
Call Handler. Had the 111 service telephoned or transferred the details to the Ambulance Service, there may not
have been a need for a further Clinical Assessment to take place as it would be clear the Ambulance was required
and, the Patient had already been triaged.
To ensure the most appropriate response is given to a Patient, the CAT Clinician will call back an address and
gather information. This ensures they have all of the details required to make an informed decision and send the
appropriate response in the timeframe that is deemed suitable based upon the condition of the Patient.
East Midlands Ambulance Service do have a system in place to ‘flag’ vulnerable or at risk Patients however, to
ensure the most appropriate response is given to a Patient when dialling 999, it is imperative that all presenting
symptoms are given to the Call Handler. This information will ensure the highest priority response is given.
Recommendation
111 Service providers
to be made aware of
our processes if a
caller is asked to ring
999 themselves.
Action
Lead
Training memo to go
to 111 staff
Due Date
Evidence
29 November
2013
Copy of training memo
disseminated to 111 Lincs
Staff.
Evidence Gathered
Sequence of events for call number 5806122
Call audit for call 5806122
Call audit for CAT call back
Call recordings for call 5806122 and CAT call back
Patient or relative willing to be approached for their ‘story’ for the EMAS board? Have you asked? Why?
Why not? What did they say?
Type: Delayed Response
Category: Transport (Ambulance And Other
Source: Telephone Call from Family
Written or Verbal: V
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
32B03 (G2)
Patient Outcome:
XX
Summary: Delayed Response - Stroke Pt
Case Details: Pt lives in assisted living flats, 1 mile form the hospital. They rang 999 as pt was having a stroke. It
took over 2 hours for an ambulance to arrive. They were told that there were no ambulances available, but if the
pt got worse to ring 999 again. The police attended as CFR and had to clear the patient's airway whilst they were
waiting for an ambulance.
• Establish what was Trust told regards to the patient’s condition
• Ascertain if all calls correctly handled
• Ascertain what line did the calls come in on
• Establish if the Trust response outside required times. If so, by what timescale
• Determine if the Trust informed during the calls that the patient had had a stroke
• Determine why caller told no ambulance available
• Clarify why family were not given remote access by the Lifeline Control
•
•
DO
Healthcare Decisions Panel (HDP) referral: N/A
Timeline of Events
Date and Time
Event
8 September 2013
12:06
999 call received to concern for safety of a --- year old female from Lifeline centre. Not
able to gain access to property. Lifeline answers “don’t know” to all questions.
12:08
Community First Response (CFR) desk checks resource allocation (res/alloc)
Call coded 32B03 – G2 requiring response within 30 minutes
12:10
Dispatcher checks res/alloc.
12:11
Dispatcher notes in Out of Performance report (OOP): “Holding several calls; no resources
available; no CFR or PAD in area; severe staffing shortages in South. CMP (Capacity
Management Plan) 1 & 2 in place”
12:15
Capacity Management Plan 1 &2 instigated
nd
12:27
2 999 call received. Can’t get into patient’s room – concern for welfare. Call from Family
member. Patient is believed collapsed, warden off duty for the weekend. All answers
from Family member as “Don’t know”. Care line saying they cannot give family access to
the property. EMD tries to locate keys, recommends that LL give family remote access
12:28
Call coded 32B03
12:36
3 999 call - Careline calls back – don’t know what is happening in the apartment and no
one has arrived yet. Concern for safety on urgent line – advised to call on 999 if they felt
patient has deteriorated
12:37
Note in Computer Aided Dispatch for first call: Care Line called for ETA
12:47
4 call Police call on 999 line. Attending at request of LL.
12:49
Note states Police have been called by Careline and on way – police advises CMP 1
rd
th
th
12:58
5 call 999 call received from Police stating entry gained, patient laid on floor and choking
on own vomit
13:00
Coded 11E01 – R1 requiring response within 8 minutes
13:00
Fast Response Vehicle (FRV) assigned on first call
13:00
Dispatcher manually upgrades the call to R1
13:01
FRV mobilises to the detail
13:01
Dispatcher updates OOP report: “Second call 11E01”
13:05
Police Message Number 277
13:06
FRV arrives on scene
13:13
Crew assigned to detail
13:14
Dispatcher notes “Back up Red Response --- year old male choking vomit collapse”
13:14
Crew mobilises to detail
13:17
Crew arrives on scene
13:44
Crew leaves scene
13:48
Crew arrives at hospital
On the 8 September 2013 a 999 call, was made to the Trust at 12:06. This call was from a Lifeline Control regards
to a concern for safety for a --- year old female. The Lifeline Centre were unable to give any details to the
Emergency Medical Dispatcher (EMD), answering unknown to all questions. At no point did Lifeline inform the
EMD the patient was having a stroke. This was coded a G2 response requiring on scene attendance within 30
minutes. The call was audited as correctly handled.
At 12:27 a second 999 call was received. This was from a family member stating she had a concern for safety for
the patient. The caller could not gain entry to the flat as the Warden was off duty. At no point during the call was
the EMD told that the patient may have had a stroke. The family member stated that she had spoken to Lifeline.
The Lifeline Control had informed her that they could give remote access to the Ambulance, but they were not
giving that remote access to family member on scene. The EMD advised the family member to re-contact Lifeline,
and obtain access to the property so she could go into the patient. This would allow a proper assessment of the
patient as no information regards her condition was currently known. The EMD then, correctly, provided the caller
with the authorised Capacity Management Plan (CMP 1&2) speech. This advises the caller that the level of calls
being received are outstripping the number of resources that the Trust has to respond. This call has been audited
as correctly handled, and was assigned a G2 code.
At 12:36 the Lifeline Control Room called the Trust on the Urgent Line. They requested an ETA for an ambulance.
The EMD correctly informed them that we currently unable to provide an ambulance due to the level of calls
currently being received, complying with the Capacity Management Policy. The EMD then advised the Lifeline
Control Room to call 999 if the patient’s condition had worsened so that she could be reassessed.
At 12:47, Police make a 999 call to the Trust regards the patient. The Police were enquiring regards to an ETA for
this patient as they had had a call requesting they attend to gain entry. The EMD advised that Police that no
vehicle had been assigned at that stage, and advised them of the Capacity Management Speech. This call was
audited as correctly handled.
At 12:58 a second call is received from Police. Access has been made to the patient, who is reported to be semiconscious and choking on own vomit. This call is correctly assigned an ECHO code. This is the highest response
level available, and requires the nearest available vehicles be immediately assigned to the call. This requires an on
scene response of 8 minutes. A Fast Response Vehicle is assigned and arrived on scene within 6 minutes. A crew
was then assigned to the patient as per Solo Responders Policy regards to a single person attending an ECHO code.
The crew arrive on scene at 13:17, within the required 19 minutes timescale for this level of call.
Total length of time take to arrive on scene to this patient was 60 minutes. This is 30 minutes outside of the
required response for a G2 call. A clinical assessment of the PRF shows that the crew took correct treatment of the
patient regards to a stroke diagnosis. The patient was treated on scene for 27 minutes and the transported to an
appropriate treatment centre as per the Stroke Pathway bulletin.
A search of the computer records show no other calls to this address before 12:06. The Lifeline Control centre has
confirmed that they placed the first call just after 12:00 and that the Family member was on scene at the time.
Lifeline were asked why they did not let the family member into the flat so she could access her Grandmother.
Lifeline states that they are not allowed to give access to the property without speaking to the resident
themselves. Due to this Lifeline refused family’s request to access the patient reported to be in a collapsed state.
Between 12:10 and 13:00 the Dispatcher completed no Resource Allocation checks. This is where the Dispatcher
checks a function where they can establish which vehicles are available in the area to deal with this call. This is a
breach of the Dispatch Deployment Framework which requires the Resource Allocation is checked regularly.
Dispatcher did note in the detail that the Division was holding several calls, no Community First Responders in the
area and “severe staffing shortages in the area.
Conclusion
The first call was received at 12:06. The Lifeline Centre has confirmed that was when they called. There were no
concerns raised, during any of these calls, that the patient had had a stroke. The callers were not able to get into
the property so it was not possible to ascertain the patient’s condition. Due to this the calls were coded as a 30
minute response as the answer to most questions was “not known”. All calls to the patient have been reviewed
and audited as correctly handled.
During the second call, the Emergency Medical Dispatcher (EMD) spoke with patient’s family member regards to
her gaining access to the property through the Lifeline Control Centre. This was so the family member could
establish what the patient’s condition was. The Lifeline Centre refused to grant access to the family member. The
Lifeline Control has confirmed they will not grant access to family members unless voice contact is made with the
resident. The Lifeline Control does not have an exemption for situations such as this call.
All calls, excepting one, were received on the 999 line. A call was received on the Urgent line from Lifeline
requesting an ETA for the ambulance. The EMD correctly advised Lifeline to call back on a 999 line if your mum’s
condition had worsened. All EMD’s correctly issued the Trust’s Capacity Management Speech to all callers. This
notifies the caller that a large number of life threatening calls are being received, and an ambulance will be sent as
soon as one is available.
Total time from the first call to the Trust arriving with the patient was 57 minutes. The 30 minute timescale
required to attend your mother was not met. The Delivery Manager’s Resource Log notes that Capacity
Management Plans (CMP) 1 and 2 had been instigated at this time. This means the Trust was holding multiple
calls, with demand outstripping its resources available to attend. The Control Room Service Delivery Managers are
currently reviewing processes, for these times of high demand, to ensure all outstanding calls can be monitored
effectively. Due to this the Trust failed in its duty of care to this patient.
Date Resolved:
Status: Unresolved
Grade: Moderate
Letter Date:
Recommendations
Dispatcher to be
given guidance
regards Dispatch
Framework
Action
The Dispatch Officer should
receive guidance on the
Dispatch Framework by
their Duty Manager. Time
should be provided for the
Dispatcher to read through
the document and be aware
of its contents
EMD’s to be advised
re Hot Transfer to
clinician
Training Team to message
all EMD’s and advise them
that when call received for a
collapse behind locked
doors G2 they should
consider Hot Transfer of call
to CAT. This will allow a
clinician to establish any
previous medical history
which indicates the need to
upgrade the call
immediately
Lead
Due Date
02/11/13
Evidence
Copy of email
confirmation from
DM
31/12/13
Copy of message –
action completed
11/10/13
Evidence Gathered
Call audits
Lifeline response
CAD SOE’s
WAV call recordings
PRF reviews
PDM RL
Graded R1 0012 was closer than FRV mobile to G2 call. Not diverted. ?due to length of time call outstanding: came in at 11:39
and DCA finally arrived on scene 14:06 – two previous DCA’s diverted from it. Only a 2 min difference in ETA, but R1 is an
automatic backup for FRV so DO would need to assign a DCA as well
rd
3 call from K13 incorrectly inputted so did not show as duplicate – different post code and house name incorrectly spelt
Type: Delayed Response To Green1/Gre
Category:
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: Minor
Base: HP EOC
Extension: XX
XX
Area/Divisional:
Patient Outcome:
XX
Summary: Inconsistent Approach With Adisons
Case Details: Delayed reposnse, and inconsisent approach to patient in Addisons Crisis
Patient and partner attend GP surgery where they are told that the Trust had cancelled the appointment.
Caller like warning marker on address outling call handling and treatment for his partner.
• Establish if all calls were correctly handled
• Partner wants to know why Addison’s Disease receives an inconsistent response from the Trust
• Why was there a delay in attending the patient.
• Partner wants to know why the final calls coded as a Cardiac Arrest
• Can a warning marker can be placed on the address to ensure more consistent approach
• Did someone for the Trust call GP’s office cancel patient’s appointment for the afternoon
•
•
CAT
•
•
XX Name, (initial) – Skill level, EE date: IPR date:
State what support staff have been given and by whom (using the job title not names)
Healthcare Decisions Panel (HDP) referral: No. N/A
Timeline of Events
Date and Time
Event
13/9/2013
12:18
999 call received from the patient stating she has Addison’s Disease and feels sick
12:21
Call coded G4 – suitable for further Triage by Clinical Assessment Team (CAT)
12:23
Call is transferred direct to CAT
12:41
Patient is referred to GP. Worsening advice given and call closed
12:49
Call received from neighbouring Trust passing a 999 call to patient coded G2, requiring on
scene attendance within 30 minutes
12:54
CAT contacts patient’s GP and arranges for them to contact patient. G2 call is closed by
CAT
13:18
999 call to patient stating vomiting and not alert from neighbouring Trust
13:20
Note that CAT team spoken to, advised that the Trust are dealing with call
13:21
Call coded G1, requiring a 20 minute response
13:21
Patient’s partner calls 999 on way home. Partner states patient barely conscious and
barely breathing
13:22
CAT speaks with GP surgery. Advice patient is taken into hospital
13:23
Fast Response Vehicle (FRV) assigned with 39 minute ETA to detail ***not closest***
13:24
Call coded Cardiac Arrest – R1 (09E02)
13:25
Neighbouring Trust assigned
13:36
Neighbouring Trust arrives on scene
13:43
Neighbouring Trust stands down FRV – “Not a Cardiac Arrest”
14:38
Patient treated on scene and GP appointment made
On the 13 September 2013, several calls we received to a --- year old female with Addison’s Disease. This is a
chronic adrenal insufficiency which can, in severe crisis, result in a coma.
At 12:18 the patient rang 999 stating she had Addison’s Disease and that she felt sick. This call was coded as G4,
suitable for further Triage by the Clinical Assessment Team (CAT). The Emergency Medical Dispatcher (EMD)
places caller on hold. The speaks directly to the CAT and arranges to transfer the patient directly over to CAT so
the patient does not have to wait for a call back. This call was audited as correctly handled, with the EMD
following the new Trust Policy regards to Addison’s disease, and “hot transferring” the call to a member of the
CAT. This Policy ensures that all Addison Patient’s, whose call is coded lower than an immediate 8 minute
dispatch, are assessed immediately by a qualified clinician.
The CAT assesses the patient over the phone. CAT advises that the patient contact GP and arrange for them to
come and see her. The call is then closed down by the CAT and worsening advice given. The call has been audited
as incorrectly handled. The CAT failed to explain the nature of the assessment, nor did he agree a plan for assisting
the patient. The auditor states that the CAT failed to realise the “dangerous state the patient (was) in.” Due to
this the CAT referral to GP was incorrect as patient stated crisis comes on suddenly, that she will “go off quickly”
and that it was happening at the time. The auditor advises that the CAT refreshes knowledge on Addison’s and its
presentation in crisis
At 12:49 a 999 call is passed from Neighbouring Trust. This call is coded as G2, requiring a Trust response of 30
minutes. CAT, who spoke with patient in original call, contacts patients GP and requests that Doctor call the
patient.
At 13:18 the Neighbouring Trust calls with another 999 call to pass for this patient. This call is coded as a G1 call,
requiring a 20 minute on scene response from the Trust. The CAT phones patient’s GP who requests that the
patient be taken into hospital. As CAT does this, the partner of the patient calls 999 as well. The partner states
that the patient is “barely conscious” and “barely breathing”. When a patient is described in this way the EMD is
required to make an automatic ECHO code showing ineffective breathing. This means that the patient has been
described as breathing not being sufficient to sustain life. An ECHO code (R1) is the highest Trust response
requiring an 8 minute response from the nearest vehicle. Neighbouring Trust attend and state patient not in
cardiac arrest. Patient treated on scene and referred to GP for appointment.
Patient and partner attend GP surgery where they are told that the Trust had cancelled the appointment.
Conclusion
Date Resolved:
Grade: Minor
Status: Unresolved
Root Cause (SI Only)
XXX
Contributing Factors (SI Only)
•
XXX
Letter Date:
•
•
XXXX
XXX
Recommendation
CAT assessor to
refresh knowledge
on Addison’s disease
and crisis
presentation.
Action
CAT Team Leader to
work 1 to 1 with --on reflective practice
regards this call.
Concentrating on the
issues raised within
the audit and
ensuring a better
understanding of
Addison’s Disease,
Crisis Presentation
and the new Trust
Policy regards to
Addison calls Hot
Transferred to CAT
Lead
Due Date
31/11/13
Evidence
Copy of 1 to 1
report, signed by --to show
understanding of
condition and issues
raised
XX can be more than one and/or both for staff and the organisation X
Evidence Gathered
XXX
XXX
identified.
Type: Injury To Patient
Category: Assault
Source: Email
Written or Verbal: W/V (Delete)
Acknowledgement Date:
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: 0
Base:
R2
Area/Divisional: Lincolnshire
Patient Outcome: Treated at hospital then taken
into police custody
Extension: XX
Summary: Allegation Of Assault Against Crew
Case Details: Patient’s brother states two ambulance crew abused & assaulted the patient on video while also
being very rude at the scene suggesting 'it was all a fake'.
• What did the crew do on scene?
• What does the video footage show?
• Were the crews actions on scene amount to assault?
• Was crews treatment of the patient correct?
• Where did the patient’s medications go?
• What action is the Police taking against the crew?
Staff involved
1. Technician
2. Paramedic
3. EMD
4. EMD
Timeline of Events
Date and Time
Event
2/9/13
22:57
999 call received to --- year old male unconscious
22:58
Crew assigned with 21 minute ETA. Caller states Police have “knocked patient
unconscious”
22:59
No Community First Responders on duty in area
23:02
Call coded 31D02 – R2 requiring response within 8 minutes
23:04
Police state that male is “faking unconsciousness” with strong pulse and breathing
nd
23:00
2 call received to patient. Patient collapsed – unconscious
23:02
Unable to ascertain if patient breathing sufficiently so call coded ECHO – R1
23:15
Crew note attempted to insert an “OP” airway. Patient sat/jumped up and removed it.
01:16
Crew state police travelled in with crew – member of family filmed crew with camera
phone. Police with patient in hospital
On 2 September 2013, 22:57, a 999 call was received to a --- year old male on floor and unconscious. This call was
coded given an R2 code. This requires that an ambulance arrives on scene within 8 minutes. Audit of the call
shows that the Emergency Medical Dispatcher (EMD) used the wrong protocol for this call. The EMD used the
“unconscious” card, but should have used the “assault” card as allegation was that patient had been pushed to the
floor by Police.
At 23:00 a second call is received from the patient’s brother who is on way to the address. This call is coded as R1,
requiring an on scene response of 8 minutes. An audit of this call shows the EMD also used the “unconscious”
incorrectly. The EMD should have used the “Unknown” protocol as caller was not with the patient.
Crew were assigned to call at 22:58, and arrived on scene at 23:15 and is outside the 8 minute response time
required. The location of the incident is classed as a remote area, and so is classed as not achievable from any
standby point in the Division.
Patient’s brother has placed 4 video’s on Youtube, but only one includes Trust staff. The video in question has the
Brother videoing from behind a paramedic (P2). There is a male (patient) on the floor. The brother is asking what
the crew have just done to the patient and tells the other paramedic (P1) that he “is responsible as well.” P1
states he is responsible, and calmly asks the brother not to record them. Brother says “if you are doing the right
thing you don’t have a problem.” P1 asks the Brother to listen to him. Brother re-iterates last statement. P1
refuses to speak to Brother any more. P1 requests that Police stand in front of the brother to stop the videoing, he
points out they do not know who the brother is or if he has the right to take video footage of the patient. Brother
describes what is happening, and that paramedics have done something that has had a “radical reaction.”
Paramedic explains they have put in an OP airway as brother was concerned about patient’s airway. Crew try to
wake up patient, and inform patient he is fully conscious. They attempt to get patient off of the floor – brother
accuses crew of assaulting patient as they, and police move patient onto a chair.
Examination of the Patient Report Form (ePRF) states that, on arrival, patient was lying on the floor, not
responding to verbal commands, patient “appears to have become unconscious”. Crew state, in the ePRF, that an
attempt was made to insert an “op” airway. This is a tube that is used to prevent an unconscious patient’s airway
from being blocked by the tongue covering the back of the throat. When a person becomes unconscious, the
muscles in the jaw relax and so allowing the tongue to block the airway. P1 states, in record of conversation, that
it is a standard procedure “this or another adjunct (airway device) would be used – we treat for the worst”. Notes
in the ePRF state that “on insertion of the “op” airway patient sat/jumped up and removed it.” Crew noted no
obvious signs of injury other than a small amount of blood from his mouth. The crew were unable to assess the
cause and noted “??? When patient ripped out op airway. ??bitten tongue”. Clinical assessment of the ePRF raises
no concerns about patient treatment, other than an elevated pulse on the initial examination which then settles.
Crew transported patient to hospital, with Police travelling in the ambulance. Crew followed Resus handover
protocol whereby patient is noted to regain full consciousness on arrival. Crew handed over a holdall and
medication to nursing staff.
Police have received a complaint that the attending Trust crew assaulted the patient. Due to this Trust enquiries
were suspended until it was established with the Police that such an investigation would not impede their
enquiries. Confirmation has been received from the Investigating Inspector that there are no police actions
against the Trust crew. The findings of the investigation was that the crew acted within their professional role and
the ‘balance of probabilities a notifiable offence had not been committed and paramedics were carrying out a
medical procedure with the implied permission of the patient’.
The crew’s actions in this matter were correct, and they were well within their rights to ask patient’s brother not
to record them or the patient. The Trust has a responsibility to ensure patient confidentiality at all times. The
Paramedic acted promptly in protecting the patient, and the crew’s, right not to be filmed without consent by
requesting the Police officer blocked the brother’s view.
Conclusion
On arrival on scene the crew assessed the patient that was laid on the floor, and appeared to be unconscious. Due
to this, the crew attempted to insert an ‘op’ airway to protect the patient’s airway. This is a tube that stops the
patient’s tongue dropping into the back of his throat and blocking his airway. This actions are were within
standard protocols for the management of an unconscious patient’s airway. Upon insertion, the patient is
reported to “sit/jump up” and removed the tube. Clinical assessment of the Patient Report Forms raises no
concern regards to the treatment of the patient.
Patient’s brother has placed 4 video’s on YouTube, but only one includes Trust staff. The video in question has the
Brother videoing from behind a paramedic (P1). There is a male (patient) on the floor. The brother is asking what
the crew have just done to the patient and tells P1 that he “is responsible as well.” P1 states he is responsible, and
calmly asks the brother not to record them. Brother says “if you are doing the right thing you don’t have a
problem.” P1 asks the Brother to listen to him. Brother re-iterates last statement. P1 refuses to speak to Brother
any more. P1 requests that Police stand in front of the brother to stop the videoing, he points out they do not
know who the brother is or if he has the right to take video footage of the patient. Brother describes what is
happening, and that paramedics have done something that has had a “radical reaction.” Paramedic explains they
have put in an OP airway as brother was concerned about patient’s airway. Crew try to wake up patient, and
inform patient he is fully conscious. They attempt to get patient off of the floor – brother accuses crew of
assaulting patient as they, and police move patient onto a chair.
The Police have closed the allegation of assault against the crew. Their investigation shows the crew were carrying
out a medical procedure as per their professional role. Due to this the actions of the crew do not constitute an
offence of assault. On arrival at hospital, the crew handed over a holdall and medications to the nursing staff in
the Resus room.
Date Resolved:
Grade: Moderate
Status: Unresolved
Letter Date: 19/09/2013
Recommendations
Any call audit less
that 90% to receive
special case review
Action
Training Team to
give feedback to
EMDs who scored
below 90% to ensure
understanding of
correct protocol that
should have been
used in these
circumstances
Lead
Due date
31/10/13
Evidence
Copy of review
Evidence Gathered
You tube footage
Consent form
Record conversation
Call audits
999 calls
PRF
PRF audit
CAD SOE x 2
Police contacted to establish if they are currently investigating assault allegation against crew when complaint was received.
Police confirm that complaint has be closed down as NFA. Contacted investigating office who confirmed investigation
established that crew were acting for medical treatment and nothing untoward noted. Police have an ongoing internal
investigation into officers attendance, meeting with investigating officer to establish TOR and to ensure that our investigation
does not impede theirs.
All calls listened to and video footage viewed. No concerns raised about crew behaviour. Advice requested from solicitors re
Youtube footage being removed. Will then speak to crews when have confirmed that police investigation will not be affected.
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: HP EOC
Extension: XX
G2
Area/Divisional: HP
Patient Outcome: deceased
Summary: Delayed Response. Elderly pt died later that day.
Case Details: Elderly stroke patient seen to be collapsed on the floor and barely conscious in her home. No-one
had a key to get into the property. Friend called 999 for ambulance & police. Ambulance took 90 minutes to arrive
and break in. Pt taken to Chesterfield Royal Hospital where she died later that same day. There is no complaint
against the attending crew.
•
•
•
•
Establish what the Ambulance Service were told about the patient condition
Ascertain if the call was correctly handled
Ascertain if vehicles were correctly assigned to the call
Establish the length of delay and the cause
Involvement of Staff
•
•
•
Staff involvement:
EMD
EMD
Timeline of Events
Date and Time
Event
13 September 2013
11:59
12:00
999 call received to patient laying on the floor – cannot gain access to her
Dispatcher checks Res/Alloc – Fast Response Vehicle assigned and stood down as per Meal
Break Policy
Call coded G2 (32B02) requiring a 30 minute response. Note requesting police to force
entry
Dispatch Officer (DO) notes no vehicles available
nd
2 999 call received to patient --- year old female Stroke (CVA). Call coded G2 as
timescale onset symptoms not known
DO checks res allocate and assigns a crew (3426) and stood down diverted to another call
Crew assigned with 13 min ETA (8815) and diverted to another G2
rd
3 999 call received to --- year old female unconscious. Coded R2 requiring 8 minute
response
Res/alloc checked
Clinical Assessment Team puts note in CAD requesting they be passed the call.
FRV assigned
FRV arrived scene
rd
3 call stopped as duplicate of 5835984
Crew assigned
Crew arrived scene
Left scene
Arrived hospital
12:01
12:10
12:34
12:35
12:39
12:47
12:48
12:50
12:51
12:54
12:55
13:16
13:23
13:41
13:48
Call Handling: On 13 September 2013, at 11:59 a 999 call is received to a female laying on the floor, caller cannot
gain entry to her. The call is coded as G2 – requiring a 30 minute response. The call has been audited and
assessed as correctly handled.
At 12:34 a second 999 call is received to a patient the caller, who was not with the patient, may be having another
stroke as she has previous history of it. This call is coded as a G2 call. Audit of this call shows that the Emergency
Medical Dispatcher (EMD) did not handle the call correctly. The EMD used the incorrect protocol by going on the
Stroke card. The caller was not with the patient and was assuming another stroke based on the fact they could not
get into the property. As the EMD had chosen the Stroke protocol the correct coding, based on the information
given by the caller, should have generated a G1 code. This would have required the Trust to be on scene within 20
minutes. As this code still falls within the Meal Break Window policy, this error did not delay attendance as the
Dispatcher would have acted same for G1 as G2 calls.
At 12:47, a third 999 call is received from caller not with the patient. Audit shows this call was again processed on
the incorrect card. The call is coded on the unconscious card, and call is coded as a R2 call and passed to the
Clinical Assessment Team for further triage. Clinical assessment of the triage shows the call was correctly handled.
Dispatch Handling: During the call, the Dispatcher assigned 6 vehicles to the call. The first vehicle was stood down
as its crew member was in their meal break window. This action complies with the Dispatch Deployment
Framework, 2013 Section 18.3. This requires any vehicle in its meal break window be stood down from G1/G2
calls and be returned to station for a break.
The second crew was diverted to a higher priority. The third crew were diverted to another G2 call, a road traffic
collision (RTC) that came in after this call was received. There is no note from the Dispatcher explaining why the
crew was diverted. The Dispatcher immediately assigned a Fast Response Vehicle to the call, which arrived on
scene two minutes after the estimated time of arrival for the third crew. Dispatch protocol requires that a Fast
Response Vehicle be backed up if attending an incident in a public place, such as an RTC. By switching the FRV
with crew three, the dispatcher removed the need to back up at the RTC, and allowed the FRV to attend and assess
the unknown situation relating to this call. The actions of the Dispatcher was correct under the Dispatch
Deployment Framework, 2013.
First Trust vehicle arrived on scene at 12:54. This was 55 minutes after the receipt of the first G2 coded call.
Conclusion
On the 13th September 2013 three 999 calls were received to a patient collapsed behind locked doors. Due to this
the caller had no information regards to the patient’s condition. The initial call in the series was correctly coded,
nd
rd
but the 2 and 3 were not as both were handled on the wrong protocol.
Call 2 was incorrectly coded on the Stroke card and given the wrong code on that code. Based on the call audit the
code generated should have been G1, which requires a 20 minute response. This error in coding did not affect the
arrived scene time for the Trust. The Dispatch Deployment Framework policy prevents the Dispatcher assigning
any vehicles in their meal break window to calls coded as G1/G2. At 12:47, Call 3 was incorrectly coded as a R2 call,
requiring an 8 minute attendance.
The Dispatcher assigned to this call on 6 occasions, and their actions complied with the Dispatch Deployment
Framework throughout. This R2 timescale was achieved, but the 30 minute original response was exceeded by 25
minutes. Due to this the Trust failed in its duty of care to this patient.
Date Resolved:
Grade: Moderate
Status: Unresolved
Recommendations
Special case reviews
for calls resulting in
less than 90% audit
EMD’s to be advised
re Hot Transfer to
clinician
Actions
All EMD’s whose call
audits fall below the
90% required under
AMPDS are to be
given 1 to 1
feedback during
special case review
Training Team to
message all EMD’s
and advise them
that when call
Lead
Due Date
31/10/13
Evidence
Copy of call review
31/12/13
Copy of message –
action completed
11/10/13
received for a
collapse behind
locked doors G2
they should consider
Hot Transfer of call
to CAT. This will
allow a clinician to
establish any
previous medical
history which
indicates the need
to upgrade the call
immediately
Evidence Gathered
CAD SOE x 2
999 calls
Audit of calls
STEIS form
DCA resource log
PRF
identified.
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: no harm
Initial Call Coding: URGENT
Patient Outcome:
Treated
in
hospital
Extension: XX
Summary: 6 Hour Delayed Response-Dr Urg
Case Details: Doctor visited elderly pt with Cellulitis at home and arranged an Urgent ambulance admission to
hospital at approx. 8.30pm. The ambulance took over 6 hours to arrive at 02.35am the following morning.
• Why was there a delay of over six hours in sending an ambulance
TOR agreed by:
Patient’s daughter
Crew Stood Down:
3.
N/A EOC delay
Yes/No. If No state rationale
N/A EOC delay due to demand
Healthcare Decisions Panel (HDP) referral: No – EOC delay
Date: 27 September 2013
Being Open
Initial Contact Date: 2 October 2013 on 01623 844354 voicemail left.
Timeline of Events
Date and Time
Event
22 Sep 2013
Incident Number 5859238/5859714
20:49
new call received from a GP, call ref. 5859238, on behalf of an --- year old female suffering
from cellulitis in both legs. No specific medical requirements, stretcher required, urgent
booking requested within four hours.
Call received from patient’s daughter asking why ambulance had not yet arrived as the GP
advised it would be there within one to two hours. Caller advised that the ambulance was
requested within four hours.
Call made by a member of the Clinical assessment team (CAT) to check on patient’s
condition as an ambulance was not yet allocated. Patient is very tired, but there is no
change in her medical condition. Advised that an ambulance would be dispatched as soon
as possible. Call marked to upgrade in one hour if a response has not been allocated.
Call upgraded to emergency under call ref. 5859714.
Resource 2912, double crewed ambulance (DCA) allocated to incident.
Resource 2912 mobile to incident.
Resource 2415 allocated to incident as nearer resource and mobile. Resource 2912 stood
down.
Resource 2415 leaves scene with patient.
Resource 2415 arrives at the hospital with the patient.
patient handed over to hospital staff.
23:27
00:51
01:49
02:06
02:07
02:17
02:30
03:00
03:22
03:54
Handling of emergency call: the original booking was made for within four hours. An ambulance arrived on scene
five hours and 41 minutes after receipt of the call. This is considerably in excess of the target timeframe.
Entries from Performance Delivery Manager (PDM) resource log:
19:31 Notts holding 1 green 1 call and 7 green 2 calls.
20:12 Notts holding a large proportion of green 2 calls. Delays at Bassetlaw hospital with four crews waiting.
22:52 Delays at Kingsmill hospital, two crews waiting.
23:08 Notts holding 1 green 1 call, 5 green 2 calls and 5 urgent calls.
23 Sept 00:02 Notts holding 2 green 1 calls, 12 green 2 call and 5 urgent calls.
Entries from Nottinghamshire dispatch desk (NOTTS) resource log:
19:58 holding 2 back-up requests and 2 green 2 calls.
20:11 holding 1 red back up, delays at Bassetlaw with crews still waiting to handover, longest delay is one hour 45
mins.
20:46 holding 3 green 2 calls and 1 red 2 call.
21:34 holding 2 green 2 calls and 2 urgent calls.
21:57 handover delays at Kingsmill hospital.
22:56 holding 5 green 2 calls and 5 urgent calls.
23:57 Notts north holding 19 calls.
23 Sept 00:22 holding 5 green 2 calls, longest since 20:50.
02:08 holding 1 green 1 call and 2 urgent calls.
Conclusion
The delay in responding to this urgent call was caused by high demand for emergency responses, and was
exacerbated by handover delays at Bassetlaw and Kingsmill hospitals.
Date Resolved: 25 Oct 2013
Status: Unresolved
Grade: Moderate
Letter Date: 25 Oct 2013
No recommendations to be made on this occasion, delay caused by high demand and handover delays.
Evidence Gathered
CAD report
Performance data from resource logs.
identified.
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
XX
Patient Outcome:
Referred to out of hours
Summary: Alledged Inappropriate Behaviour
Case Details: ---------------------- alleges that our staff member threatened to punch him. --------------- asked him to
leave, this is due to his mother suffering Mental Health problems, and it was her that called 999 as she was unable
to sleep.
From Security Management Specialist:
Following receipt of the IR1 reported below we issued -------------------------------------- with an Acknowledgement of
Responsibilities Agreement (ARA) re his alleged behaviour towards our staff member.
LSMS received IR1 12/09/13 states “ whilst attending a --- year old female, job 5691701 (unable to sleep & head
pains) the patient’s son who was a very large man suddenly entered the room we were in and became very loud
and abusive to myself. He had his fists clenched and appeared to be very close to using them. I pressed my
emergency button and got out of the house ASAP. The man was mad because we had kept him awake he was very
scary and I am sure he would have hit me if i had not left”.
• What were the circumstances surrounding the incident.
TOR agreed by:
Complainant
Date: 2 October 2013
Crew Stood Down:
No. If No state rationale – incident originated from the member of staff raising an
untoward incident report.
Being Open
Telephone contact made with ---------------- on 2 October 2013. He advised that his mother witnessed our member
of staff threaten to hit him. I advised that a full investigation would be undertaken and a formal response would
then be sent.
Timeline of Events
Date and Time
Event
16 Jul
01:59
01:59
02:05
02:06
02:14
03:24
03:52
03:55
03:59
new call received on behalf of a female patient who has a headache and cannot sleep.
call assessed as a Green 2 requiring a 30 minute response.
resource 3535, solo responder, allocated to the incident.
resource 3535 mobile to incident.
CAD message: Community Paramedic (CP) awaiting a call from the GP.
CP activates emergency button on his radio.
Police informed.
CAD message: CP is fine. Son of patient got agitated but all ok now. Police stood down. CP
to call the out of hours service (OOH) again. Patient’s observations are ok, query whether
she is depressed and she is not able to sleep.
CAD message: resource 3535 contacted Control – was treating patient when her son came
in very aggressive towards the Paramedic, shouting and clenching his fists at him as the
Paramedic was preventing him from going to sleep. Paramedic had to leave the scene.
Prior to this he had referred the patient to OOH, and he has let OOH know that he has had
to leave the scene. The patient is happy to wait for the GP – ongoing problem with
headaches. Paramedic advised to complete an untoward incident report (IR1) and a
safeguarding referral.
resource 3535 calls clear from the scene.
CAD message: decision made to contact the GP for background information on social
circumstances. On contacting the GP it was ascertained that the GP healthcare visit is due
today. Explained the problems through the night, and the electronic patient report form
(EPRF) was accessed and faxed to the GP for information.
04:17
04:27
09:16
Handling of emergency call: the call was correctly assessed as requiring a 30 minute response, and the responding
resource arrived 15 minutes after receipt of the call.
Care and treatment of the patient: prior to having to leave the scene, the Paramedic took a full set of
observations which were all within normal parameters. The Paramedic had contacted the out of hours service, and
once he had left the property he made further contact to ensure the patient’s GP would be in touch with her. It
was later established that a healthcare visit had been arranged for that day.
Detail of the incident with patient’s son: the patient’s son did repeat the allegation that the Paramedic had
threatened to hit him, although he did acknowledge that it was his word against that of the member of staff. The
Paramedic has reported that the patient had already become agitated as he was unable to get to sleep with the
Paramedic present, and he approached the Paramedic in a threatening and aggressive manner. The altercation
was recorded in part when the Paramedic activated the emergency button his radio, and he can be heard asking
the patient’s son to go to bed and leave him alone. The gentleman shouted something in response to this but it
could not be established what was said. In a further transmission after he had left the property the Paramedic
advised that the patient’s son had his fist close to the Paramedic’s face, and he stated that the patient’s son had
stated it was he (the Paramedic) who had become aggressive.
Conclusion
There are two differing descriptions of the incident, but the partial radio transmission supports the Paramedic
asking the patient’s son to go back to bed and leave him alone. A letter is to be sent to the complainant advising
him that the issuing of the ARA remains appropriate.
Date Resolved:
Status: resolved.
Grade: Moderate
Letter Date: 6 November 2013
Evidence Gathered
CAD report
EPRF
IR1
identified.
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
XX
Patient Outcome:
Patient deceased
Summary: Alleged Poor Care Management
Case Details: Pt had ovarian cancer and had difficulty breathing. The pt's daughter states that when the ambulance
crew examined her they did not give her any oxygen and didn't pay her enough care and attention. Eventually they
agreed to take her to hospital and gave her Oxygen through a nasal cannula even though she stated that she
couldn't breathe through her nose. Pt arrested en route to hospital and died.
• Why was the patient not given oxygen?
• Why did the member of staff not notice when the patient went into cardiac arrest?
TOR agreed by:
Complainant
Date: XX
Crew Stood Down:
No. If No state rationale
4.
XXX delete if not needed or nothing actioned; otherwise list XX
Staff support and involvement: EMT attending member of staff. ECA secondary member of staff. Ongoing
support via line management.
Healthcare Decisions Panel (HDP) referral: No. If No state rationale – clinician not registered.
•
Being Open
Telephone contact was attempted on 2/10/2013, and a voicemail message was left.
Timeline of Events
Date and Time
Event
30 Aug 2013
07:28
07:28
07:29
new call received on behalf of a --- year old female who is unable to breathe.
Despatch code 06D01, Breathing problems, not alert, allocated to incident with a
response time of eight minutes.
CAD message: patient had a similar attack on Monday (26 Aug).
CAD message: --- year old female, cardiac arrest, CPR in progress. ETA at hospital five to
ten minutes.
CAD message: hospital informed.
resource 0811 arrives at hospital with the patient.
crew of resource 0811 call clear from the hospital.
07:30
07:32
07:48
08:11
08:12
08:16
08:37
Handling of emergency call: call was coded as a Red 2 eight minute response, and the responding resource arrived
on scene two minutes after receipt of the call.
Care and treatment of the patient: the attending member of staff advised that on arrival at the address he and his
crewmate were presented with a --- year old female who was in distress and clearly hyperventilating. He and his
crewmate began to take observations, which caused no concern apart from the raised respiration rate. This slowed
as the patient became calmer, and after about ten minutes she advised that she felt much calmer. The patient had
suffered a similar attack four days previously and seen her GP, and it was established that the patient had been
diagnosed with cancer five weeks ago and she had just completed a course of chemotherapy. The patient’s
daughter expressed concern about the crew not giving the patient oxygen, but as oxygen saturation level was 95%
this was not considered necessary. Oxygen saturation levels of 95% and above are considered normal and do not
require the administration of additional oxygen.
The attending member of staff discussed the options available, which included contacting the hospital where the
patient had undergone chemotherapy, referring to her GP or travelling to hospital for further assessment. In view
of the early hour the GP referral was discounted as the patient would have had to wait for the surgery to open,
and it was decided to take the patient to hospital for further observation. The patient was moved to the
ambulance and monitoring equipment was put back in place, and the ambulance crew began their journey to
hospital. The member of staff fitted a nasal mask to the patient to administer oxygen, and he cannot recall being
advised that she was having difficulty breathing through her nose. A finger probe was also fitted to measure the
patient’s oxygen saturation level, which was again recorded as 95%.
Approximately 15 minutes into the journey the patient went into respiratory arrest and then cardiac arrest, and
the member of staff fitted a bag and mask. He did have to briefly move some equipment to gain better access to
the patient and he asked his colleague to pull over. Defibrilator pads were placed on the patient and then CPR was
commenced. The patient was given a couple of shocks and the decision was taken to continue the journey to the
hospital with CPR continuing. The hospital was alerted of the patient’s imminent arrival and she was moved
straight through to resuscitation. Unfortunately the patient passed away shortly after arrival at the hospital.
The member of staff has reviewed this incident and is unable to identify anything he would have done differently
to bring about a different outcome. He acted promptly when the patient went into cardiac arrest, commencing
basic life support techniques and maintaining these until arrival at the hospital .He would like to pass on his sincere
condolences to the family.
Clinical opinion and review of PRF: the divisional Locality Quality Manager (LQM) has reviewed the incident and
advised that the decision not to administer oxygen is reasonable based on the patient’s observations and the
national guidelines published by the British Thoracic Society. The recorded oxygen saturation levels were 95% in
each case. Once on board the ambulance the patient was given low level oxygen to maintain in target range of 9497% and this was monitored with the pulse oximeter on the vehicle.
The following issues were highlighted in respect of the PRF, and will be addressed with the member of staff in a file
noted discussion:
No time of arrest recorded.
No evidence that ant treatment was given in terms of the arrest
Initial rhythm recorded as Asystole and two shocks given… I am assuming the initial rhythm was VF/VT
as two shocks were delivered and asystole is non-shockable.
No documented evidence of assisted ventilations
No documented drugs administered to treat an arrest.
Conclusion
It has been concluded that the attending member of staff took all possible action when the patient went into
cardiac arrest, and the decision not to administer oxygen when the patient was first examined appears to be
appropriate.
Date Resolved: 29 October 2013 Status: Resolved
Grade: Moderate
Letter Date: 29 October 2013
Action: A file noted discussion to take place with the attending member of staff to highlight improvements which
need to be made in respect of PRF completion.
Improvement: Improvement in PRF completion as monitored by a random audit of ten PRF’s.
Outcome Detail: Results of the PRF audit.
For:
Deadline: 31 December 2013
Evidence: File noted discussion confirmation and results of PRF audit.
Evidence Gathered
PRF
CAD report
Statement from attending member of staff
identified.
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: 0
Extension: XX
Green 2
Patient Outcome:
Transported to hospital
Summary: 2 Hour Delayed Response
Case Details: ---year old patient fell at home and was unconscious. She has previously had a brain injury called
arterial venous malformation (some sort of bleed) and this was explained to the call taker.
It took 2 hours for the ambulance to arrive and during this time the call taker gave no first aid advice at all.
Would like the call transcripts from this incident and from her previous complaint.
Previous complaint for the same patient having a delayed response to brain haemorrhage- FC/016/11 and SI 20117619
• Why was there a delay of two hours in sending the ambulance?
• Why was the previous medical history not taken into account?
• Why was no first aid advice given?
TOR agreed by:
Complainant
Date: 2 October 2013
Crew Stood Down:
No. If No state rationale EOC delay
Healthcare Decisions Panel (HDP) referral: No EOC delay
Being Open
Telephone contact attempted 2/10/2013. Voicemail message left.
Timeline of Events
Date and Time
Event
29 Sept 2013
01:00
new call received, call ref. 5874608 on behalf of a female patient who has fallen down and
hit her head.
patient is a --- year old female who has fallen from standing and hit her head. The patient
is conscious and breathing.
Despatch code 17B01, fall, possibly dangerous body area, assessed as a Green 2 30 minute
ambulance response.
resource 3424, double crewed ambulance, allocated to incident but then stood down and
diverted to a higher priority call with a Red 2 eight minute response as patient is not alert.
further call received, call ref. 5874760. Call stopped as a duplicate of call ref. 5874608.
resource 3012, double crewed ambulance, allocated to incident.
resource 3012 hand patient over to hospital staff.
01:02
01:03
01:28
02:09
02:30
02:31
02:54
03:10
03:29
03:43
Handling of emergency call: the call was correctly assessed as requiring a 30 minute ambulance response. The
responding resource arrived on scene one hour and 54 minutes after receipt of the emergency call, missing the
target on this occasion.
Entries from PDM resource log:
00:03 Derbys holding 3 Green 2 calls and 4 Urgent calls.
00:47 Capacity Management Plan actions 1 and 2 implemented.
01:33 Derbyshire holding 3 Green 2 calls, 1 Green 4 call and 3 Urgent calls.
02:38 Derbyshire holding 1 Red 2 call and 1 Green 1 call.
03:53 Derbyshire holding 1 Green 2 call and 1 Urgent call.
Entries from DERBYS resource log:
01:11 Derby south holding 1 auto back up, 2 Green 2 calls and 3 Doctors urgents.
Review of audio files for both calls: the review of the audio files confirms that the patient’s previous medical
history in 2011 was not passed on to the call taker, and appropriate medical advice was given on both calls to
advise the caller how to stop the bleeding. Appropriate instructions were also given in respect of deterioration in
the patient’s condition and the actions the caller should take pending arrival of an ambulance.
Conclusion
Due to the demand for emergency responses on the day of the incident the response was delayed until one hour
and 54 minutes after receipt of the emergency call.
Previous medical history was not relayed to the call taker, and appropriate first aid advice was given on both calls.
Date Resolved: 29 Oct 2013
Status: Resolved
Grade: Minor
Letter Date: 29 Oct 2013
Evidence Gathered
Cad report and call audit
Audio files of emergency calls
Resource log information for Performance Delivery Manager (PDM) and Derbyshire dispatch desk (DERBYS)
resource logs.
identified.
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base:
G2
Patient Outcome:
Released with bumps and
bruises
Extension: XX
Summary: Delayed Response
Case Details: Complainants wife was getting into her car but fell backwards and badly bumped her head on the
pavement. 999 was called and very quickly a fire responder crew appeared at the scene (they came across the
incident rather than being dispatched to it). The ambulance took around 2 hours to arrive. Why was the response
time so long?
• Why was the ambulance so long?
•
•
•
•
EMD – CAD 5872785
EMD – Fire call 2 and 6
EMD – Fire call 3
EMD – Fire call 5
Timeline of Events
Date and Time
Event
28 Sept 2013
11:20
999 call received to a female who had fallen in road, banged head. Call coded G2
requiring 30 minute response
Community First Response (CFR) desk checks Resource Allocation (Res/Alloc) – complaint
noted as not suitable. Dispatcher checks Res/Alloc – notes “K0 at present”
Dispatcher checks Res/alloc – no vehicles available
2nd 999 call received to patient. Call coded G2
Emergency Medical Dispatcher (EMD) notes Fire have found patient fallen and want to
confirm Trust aware
Dispatcher checks Res/Alloc – 7130 (OSM) at station eta 26 minutes; vehicles from
Grimsby 64 minute ETA
Fire call for ETA
Fire call to state patient now has head pains
Police requesting update
Dispatcher checks res/alloc
Fire stat patient is losing consciousness
Dispatcher checks res/alloc
New call created based on info from Fire that patient has deteriorated. Coded R2
requiring 8 minute response
Crew assigned (7113) with 54 minutes ETA (not correct ETA from KL)
Dispatcher checks Res/Alloc
Police update Fire have run out of oxygen, patient fell out of vehicle, not in a good way
Dispatcher checks Res/alloc
East Division Resource Log (RL) states 2 crews from Gr helping in call area (62 minute
running time)
2nd Crew assigned (6323) with 62 minute eta
Crew stood down (7113)
Local responder assigned
3rd crew assigned (6710) with 26 min eta
2nd crew stood down (6323)
East Division RL states local crew clear but have puncture
Officers report – G2 – K0 – 7113 heading back from QEKL – 6323 running from Grimsby
area – 6710 clear BPH closer than 6323
Fire state patient pulse now dropping
Local responder arrives on scene
Crew leave scene
Crew arrive hospital
11:22
11:26
11:29
11:36
11:52
11:59
12:01
12:03
12:14
12:18
12:19
12:21
12:22
12:25
12:27
12:30
12:34
12:37
12:38
12:39
12:40
12:43
12:45
12:48
12:49
13:01
13:07
13:08
13:24
14:01
Service Issues:
East Division (East Dispatch) shortfall 1 crew and 3 Fast Response Vehicle (FRV)
At time of call East holding: R2 x 1 in area of call; G1 x 2 (1 in area of call); 3 x G2 (1 in area of call)
Call Handling: On 28 September 2013 at 11:20 a 999 call was received to patient fallen over. Call was coded as G2
requiring a response within 30 minutes. This call has been audited and found to be correctly handled. At 11:29 a
second call was received to this patient. The call was audited as correctly coded a G2 response, but compliance
issues were raised as call only scored 70%. The required minimum score is 90%.
At 11:36 local Fire, driving by the location, come across the patient and call 999 to confirm we are aware of the
call. Between this time and 13:01 six calls are placed by Fire, and Police to this patient. All call recording have
been submitted to the Auditing Team to ascertain if the Emergency Medical Dispatchers (EMDs) handled the calls
as per Trust policy. Call 1 and Call 4 were audited as correctly handled with new calls being created as patient
condition had changed. During calls 2, 3, and 6 the EMDs ascertained that the patient condition had changed but
did not create a new call. Call 5, the EMD did not ask if the patient condition had changed. These omissions were
a breach of Trust Protocol. Due to the EMDs failures to input new calls and utilise the Advanced Medical Priority
Dispatch System it is not possible to say if the call should have received a higher response or not.
th
Dispatch Handling: At 12:21 EMD creates a new call in response to Fire’s 4 call. The call is coded R2 and requires
an on scene attendance of 8 minutes to the patient. This timescale is not achieved, as nearest Double Crewed
Ambulance (DCA) is shown as having a minimum estimated time of arrival of 54 minutes. Dispatcher notes in the
East Division Resource Log (RL) that there is a shortfall of 1 DCA and 3 Fast Response Vehicles (FRV). The
Dispatcher notes they are currently holding 5 unassigned 999 calls, three of them being in the area of this call. The
RL states that Dispatcher currently running two crews from Grimsby on blue light to assist with other calls, an
estimate traveling time in excess of 1 and a quarter hours. This indicates high demand for Trust resources in this
section of the Division.
Based on the original call coding of G2, the Trust should have been on scene with this patient by 11:50 hours. This
target was not met, and was exceeded by 78 minutes.
Conclusion
The original two calls were correctly coded as G2, requiring a 30 minute response. This timescale was exceeded by
78 minutes. Due to this the Trust failed in its duty of care to this patient.
The Dispatcher acted correctly based on the coding that were received, and whilst experiencing high demand in
the area. On four occasions Emergency Medical Dispatchers failed to generate new calls to the patient, based on
information given by Fire. It is not possible to ascertain what coding these calls would have generated, or whether
this would have resulted in a Trust vehicle arriving sooner. These omissions were a breach of Trust Protocols for
handling calls from another Emergency Service.
Date Resolved:
Grade: Moderate
Status: Unresolved
Recommendations
EMDs to be given
feedback and advice
where appropriate
Action
Training Team to
arrange one to one
feedback with EMDs
who processed calls,
either scoring less
Lead
Due Date
16/11/2013
Evidence
Email confirmation
of “Record of
conversation”
than the
prerequisite 90%, or
who failed to create
a new call for the
patient when
required to do so
Evidence Gathered
WAV file of all calls
Audit of calls
CAD SOEs
identified.
Unique Reference: 2013 095
Type: Patient Safety
Category:
Incident Date:
Division: East
Source: Email
Date Agreed:
Final Contact Date:
Harm Rate: Major
Base: BBEOC
R2
Area/Divisional: East
Patient Outcome:
Baby Deceased
Delays Incurred
Reason for Delay: Email was sent to 2 recipients, one on long term leave other covering both roles.
Email sent to secondary email account
Extended/Agreed Completion Date: 29/10/13
Summary: Request was made for an emergency ambulance to The Practice to transfer a patient to Hospital, a
phone call made at 1823 by the General Practitioner (GP). A solo Paramedic was sent. Once on site, the
Paramedic made calls to the emergency services at 1840 and 1900 to expedite a blue light transfer. The
ambulance arrived on site at 1915 (52 minutes after initial call). The Practice advised that the provision of a lone
Paramedic to site provided very limited value to the provision of patient care/safety and in fact delayed the patient
pathway to secondary care.
• Establish if the call was correctly handled
• Did the Dispatcher act correctly in sending a Fast Response Vehicle (FRV)
• Ascertain if the attendance of the FRV delayed patient transport to hospital
• Establish what communications occurred between FRV and Control
• Ascertain what was the delay in Ambulance attending
Emergency Medical Dispatcher
Dispatch Officer
Dispatch Officer
Paramedic 1
Paramedic 2
Technician
Being Open
Initial Contact Date: 18 October 2013
Complaint originally raised by Doctor’s Practice. Being Open letter sent to patient to advise her of the Trust
investigation. Details for patient obtained from the Patient Report Form.
Timeline of Events
Date and Time
Event
16 April 13
18:25
999 call from GP surgery received. --- year old female – 32 weeks pregnant bleeding. Call
coded R2 – 8 minute response required
Resource Allocation (Res/alloc) checked.
Fast Response Vehicle (FRV) assigned with 11 minute ETA and informed K0 DCA
FRV dispatcher puts out K0 (no unit available) to cover R2 call
Dispatcher retrieves call and exits
FRV dispatcher sends out 2nd K0 message to all crews in area for outstanding R2 call in
area
FRV calls control to confirm DCA from St on way
Crew assigned with 15 minute ETA
Crew held up at Level crossing
Crew arrived
FRV calls control to say clear call
Crew leave scene
Crew arrive hospital
Crew clear hospital
18:26
18:27
18:30
18:36
18:36
18:43
18:45
18:51
18:52
19:03
19:09
19:15
19:17
19:37
20:43
Service Issues: 18:48 notes in the RL regards to 3 vehicle entrapment Road Traffic Collision (RTC) requiring 3 DCA
in Boston area. Daily Performance shows the time this call was received was second highest for calls that day.
Hospital handover delays at three main hospitals in this area from 20 to 36 minutes – target is 15 minutes
Call Handling: On 16 April, 2013 at 18:25, a 999 call was received from a Doctor’s Surgery (The Practice). This call
is to a female, --- weeks pregnant and having a PV (vaginal) bleed. The call was coded R2 requiring a Trust
response within 8 minutes. This call has been audited correctly coded an R2 response.
Dispatch Handling: The Dispatcher checked the Resource Allocation (Res/Alloc) to ascertain what vehicles were
available to attend this call. As it was a call from a Doctor’s surgery Best Practice would require a Double Crewed
Ambulance (DCA) be assigned. Under standard Dispatch Protocols, the Dispatcher is required to assign the nearest
available resource to a R2 call. The Dispatcher complied with Trust Protocols by assigning the Fast Response
Vehicle (FRV) to give support and assistance until a DCA was available. The implementation of the Trust Operating
Instruction FRV A19 Response protocol is for when DCA resources are limited or delayed. The aim is to ensure
that the appropriate level of support is given to Health Care Professionals (HCP) at all times. The FRV is advised to
liaise with the health care practitioner, offer clinical support and update the Dispatch desk of any change in the
patient’s condition. The Service Delivery Manager (SDM) states that this is not to replace the attendance of the
DCA but is in recognition of the clinical experience of the FRV in attending immediate incidents daily. The Trust
requirement, in these situations, is that a DCA attend to transport within 19 minutes.
FRV arrived on scene 11 minutes after the call was received. This is outside the required timescale. The FRV was
informed upon allocation to this call, that no DCA were available to back up, but that a crew was due on in the Stm
area at 18:45. The Res/Alloc list showed the nearest available DCA was 56 minutes away, the remaining vehicles
were indicated as on scene attending other calls. Only four FRV were shown available in the Res/Alloc check.
At 18:29 the Divisional Resource Log registers that an entrapment Road Traffic Collision (RTC) was in progress in
the Bstn area and three DCA were required as Red backup. At 18:36 and 18:45 the Dispatcher placed open
broadcasts to all crews in the Division. The messages were to alert all DCA that the Dispatcher was unable to
allocate to this R2 call, and requested any free resources call into control. The Hospital Handover report for this
date shows all three hospitals in the area exceeding the 15 minute requirement to handover patients. These
issues contributed to the inability of the Trust to ensure a DCA arrived on scene within 19 minutes.
Conclusion
The call was correctly handled by the Emergency Medical Dispatcher and assigned a Red 2 (8 minute response).
The Dispatcher then acted correctly by assigning a Fast Response Vehicle (FRV) to this patient. There were no
double crewed ambulances (DCA) available in the area, and so the Dispatcher was required to assign the nearest
vehicle to offer support and assistance till a DCA resource could be sent.
The attendance of the FRV was a correct assignment under the Dispatch deployment policies. The FRV did not
achieve the 8 minute response. The DCA then took 44 minutes to arrive on scene. Due to these delays, the Trust
failed in its duty of care to this patient.
Radio transmission between the FRV and control have been located for the initial allocation, and for the radio
message at 18:51. On allocation the FRV was aware that there were no DCA available to provide a backup. On the
18:51 message the FRV called to check that a Double Crewed Ambulance (DCA) was on way. The Dispatcher
confirmed that the DCA was on way. No trace has been found of the radio transmission at 19:00. A search of all
records, 10 minutes either side of this time scale have not been able to locate it.
At the time of this call the nearest available DCA was showing 56 minutes away. At the same time as this call there
was an entrapment Road Traffic Collision in progress within the Division. This required multiple units to attend,
and affected the Trusts ability to attend the GP surgery with a Double Crewed.
Date Resolved:
Grade:
Status: Unresolved
Letter Date:
None
Evidence Gathered
WAV radio transmissions
Daily performance data
EOC operation Instruction A19
Dispatch Deployment Framework
RTC CAD
WAV file 999 call
PRF
PRF clinical assessment
East Resource Log
identified.
PALS Form
JC/PALS/0370/13
FC/2013/096
JC/PALS/0370/13
Enquirer Name:
Correspondence
Address:
Response required:
Enquirer phone no:
Enquirer category:
Type of concern:
Date of incident:
Description:
Incident Location:
Patient Name:
Patient Address:
Patient phone no:
Patient Deceased:
Date Received:
Date due back:
PALS Coordinator:
Initial grading:
Area:
Service Delivery:
Purchaser:
Investigator:
How Received:
Acknowledge date:
Logged by:
Not stated
Letter
Email
Phone
Call Management (Timeliness, Activation/Response)
23 July 2013
Unhappy with call code and no ambulance sent.
No
26 July 2013
20 August 2013
Minor
Nottinghamshire
A&E Control Nottingham (A/E Control)
*A&E Nottinghamshire
Pals.office
26 July 2013
Chronology of On 23rd July, 2013
Events: At 17:08 hours CAD 5711883 coded Green 4 (triage within 60 minutes)
At 17:38 hours the CAT team rang the caller back (30 minutes)
At 17:46 hours the call was stopped as nurse triage referred to other provider
Investigation At 17:08 hours 999 call CAD 5711883 was received and correctly coded
Report: 26A08 (sick person) Green 4 (triage within 60 minutes)
The EMD noted on the CAD ‘leg gone white, in pain, thrombosis query’
At 17:09 hours a DCA was mobile to the scene. ETA 8 minutes
At 17:11 hours the call was correctly passed to nurse triage
At 17:12 hours the DCA was stood down. Reason CAT C
At 17:46 hours the CAT team noted on the CAD ‘patient had recent heart
surgery, leg wound healed where veins have been stripped, but circulation to
left foot appears to be reduced, looks white and feels cold, patient has been
able to mobilise on it but foot is numb. Able to make own way to A&E’ and the
call was stopped as nurse triage referred to other provider.
This call was covered by the Notts North dispatch desk and there is nothing of
note in the Nottinghamshire resource log.
Below is taken from the PDM’s resource log:23 Jul 2013 16:39 hours Call from ------------------:- With immediate affect G4 calls will now
be triaged within 240 mins and not 60 mins.
R1 and R2 assessment will now cease. CAT will now focus on G calls.
23 Jul 2013 17:32 hours Standing water reported in several locations across Notts from heavy
rainfall
23 Jul 2013 17:37 hours Resources reporting can only travel 20 miles due to heavy rain and
standing water in Notts
Daily performance figures for Nottinghamshire on 23/07/2013
A8 = 63%
G1 = 75%
G2 = 68%
scope of the
concern
The control training and quality assurance team have evaluated this call and
their report is attached. In summary:- Total compliance score 100%
The call was handled and coded correctly.
The EMD did advise a specialist clinician would be calling back to arrange the
best form of treatment for him.
The CAT team ring back has been audited and their report is attached. In
summary:- Total compliance score 100%
I have clinically audited this call and can confirm it was an exemplary call.
The caller had stated she was unhappy at having to wait 30 minutes for a call back.
The call back parameter for a G4 call is 60 minutes so the nurse was correct in
explaining this.
After the triage questions were completed an ambulance was offered but was turned
down as the patient had managed to arrange his own transport. This arrangement
was accepted by the nurse.
Regards
--------------------------IO update to report 4/11/2013: The call was correctly coded, and the caller was
advised that a clinician would be calling back to undertake a further assessment.
When the clinician did call back 30 minutes later the timeframe was questioned and
the clinician did advise that the target timeframe for a call back was 60 minutes. The
clinician spoke to the patient and undertook a further assessment. On conclusion of
this assessment the clinician advised that an ambulance would be sent, at which point
the patient volunteered the information that he had transport available to take him to
Bassetlaw hospital. On this basis the call was closed with the patient making their
own way to the hospital.
If yes what?
Action:
Deadline:
Concluded:
Action:
Deadline:
Concluded:
Learning Identified
Coordinator:
Coordinator:
Type: Driving
Category: Innapropriate Driving Actions
Final Contact Date:
Source: PALS Office
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: Nil
Base: Public Place
Extension: XX
R1 – Cardiac arrest
Patient Outcome:
N/A
Summary: Dangerous Driving
Case Details: At approximately 15:07 some on the A46 east vehicles travelling north were forced to take evasive
action as an emergency ambulance, came over the brow of the hill on the wrong side of the road directly into the
path of oncoming traffic. Complainant believes ambulance driver’s actions constitute dangerous driving.
LINCOLNSHIRE POLICE INCIDENT REF: 295 06/10/2013
• Discover what ambulance was being driven down the road at this time?
• What reason was the vehicle being driven on blue lights for?
• Was the vehicle being driven as per Trust policy for Blue Light condition?
• Establish what actions, if any, police are taking in the matter?
Timeline of Events
Date and Time
Event
6 Oct 2013
13:58
13:59
14:06
14:08
14:15
14:44
14:48
15:07
15:09
15:12
15:53
16:24
16:25
999 call received to patient in Cardiac Arrest
DCA1 assigned
DCA2 assigned
DCA1 arrived
DCA2 arrived
DCA1 leaves scene with patient
DCA2 leaves scene
Complainant takes evasive action to avoid South Bound blue light DCA1 on A15
Complainant passes DCA2 traveling normal road speed same raod
DCA1 arrives hospital
DCA2 arrives hospital
DCA1 clears call
DCA2 clears call
On the 6 October 2013 at 13:58 a 999 call is received to a cardiac arrest. Two Trust Double Crewed Ambulances
(DCA) attend the address and started Advanced Life Support (ALS). After working on the patient for 46 minutes
DCA1 leaves scene with patient on board. DCA1 is then driven down the A15 under blue light conditions. DCA1 is
driven by a newly qualified Emergency Care Assistant whilst ALS is continued in the rear of the ambulance. This
complies with the Trust Driving Policy V2.1
At approximately 15:06, DCA1 is southbound along the A14, approaching the A46 roundabout. The section of the
road is a single carriage way road and is long straight with a 50 miles an hour speed limit. The reason for the speed
restriction is because the road has multiple “blind” dips, marked by solid white lines. These dips create blind spots
on the road ahead. The Complainant was driving Northbound with his family on board. Two cars were ahead of
the Complainants car. The Complainant noticed blue emergency lights in the distance. There was traffic both on
the northbound carriageway, and travelling south towards the junction with the A46. The Complainant states he
was therefore aware at some point that he “might be expected to be as considerate as possible for an emergency
vehicle.”
At approximately 15:07 some 750m north of the A46/A15 junction the Complainant states he, and the cars ahead
of him, were forced to take evasive action. The Complainant reports that the ambulance, came over the brow of
the hill on the wrong side of the road directly into the path of the oncoming traffic. The Northbound cars were able
to pull into a layby and come to abrupt stop. The Complainants car came to a stop in the last section of the layby,
striking a pothole as he did so. At the time of investigation the Complainant did not believe any damage was
caused to his vehicle by this. The Complainant believes had the traffic travelling north not taken drastic and
immediate action, the position of the ambulance “would unquestionably have caused a head on traffic accident
with closing speeds of 100mph or more.” The ambulance then continued to the hospital on blue lights.
Following the incident the Complainant contacted Police and reported the driver of DCA1 for Dangerous Driving 295 06/10/2013. Police have been spoken to regards to the incident. Police report that the Complainant has
decided not to pursue the allegation further at this time. The Complainant has the right to apply for a summons
up to 6 months after the date of the incident, so cannot be classed as closed at this stage.
The Emergency Operations Centre (EOC) was notified by Police of the allegation and action was taken to identify
the ambulance involved. The Duty Manager (DM) identified the vehicle involved as the Complainant passed
another, non-blue light DCA was on the road north of the incident location. Enquiries established that the only
ambulance of the two, that was running on blue lights was DCA1. Team Leader spoke with the ECA regards the
matter. The ECA stated he was not aware of the near miss incident, but has confirmed he did overtake vehicles on
the approach to the roundabout. The ECA gave his speed at approximately 25 miles per hour. Request for tracking
data on the vehicle has been made, but no data has been received to confirm the ECA statement regards to speed.
The Team Leader has confirmed that the ECA has been re-advised of the dangers of hidden dips and other road
markings to consider when responding. The Complainant appreciates that DCA1 was working on a seriously ill
patient, but states that the dangerous manner in which DCA1 came over the brow cannot be negated on this basis.
The Complainant is concerned that all blue light drivers should be of a sufficient standard that their response does
not endanger others. Due to the nature of the incident, and the danger the Complainant feels he and his family
were placed in, the Complainant requests that the ECP’s driving be re-evaluated to ensure he is competent to
respond. The Incidents Involving Ambulance Service Vehicles V5.0 states that Driver’s involved in Road Traffic
Collisions will be subject to re-assessment. This incident does not fall under the remit of this policy, but the nature
of the incident has caused the member of public concern for the safety of his family. Due to this the Complainant
has notified the police that the ECP’s actions amounted to Dangerous driving. The Complainant will not take the
matter further if he can be assured the ECP’s blue light driving skills are to be reviewed by the Trust.
Conclusion
The Double Crewed Ambulance (DCA1) was being driven down this road transporting a patient in active Cardiac
Arrest. DCA1 was travelling on blue lights and sirens, with DCA2 some way behind and travelling at normal road
speed. This response complied with the Trust Policy for Blue Light Driving under the Driving Policy V12.
The Complainant has notified Police that he feels that the ECP’s actions equated to Dangerous Driving. The
incident with Police is currently registered as no action. The Complainant is happy for proceedings to be closed
with the Trust, and Police, if he receives assurance that the ECP’s blue light training is re-assessed. The ECP is new
to the Trust and only recently trained to respond on blue lights.
Date Resolved:
Grade: Moderate
Status: Unresolved
Letter Date:
Recommendation
ECA training and
support to be
reviewed
Action
Team Leader to
liaise with Driver
Trainer regards to
any additional
Lead
Due Date
4/02/2013
Evidence
Copy of assessment
review
training and
supportive action
required regards to
blue light driving
Evidence Gathered
Driving Policy V2.1
CAD 5892893
Email copies
identified.
Source: E-mail
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Doctors Urgent 2 hr
Patient Outcome:
Patient travelled next day
Summary: Delayed response
Case Details: Thursday 3rd October at around 3.00pm, ------------ Surgery in Leicestershire, contacted East Midlands
Ambulance Service to book an ambulance for that afternoon to Leicester Royal Infirmary for my --- year old father.
He has a cancerous tumour and the --------- Doctor believed he had an infection. He was told to go home and the
ambulance would be with him within two hours. He did later receive a call - presumably from the ambulance
service - saying it would be delayed.
My father sat in home awaiting the ambulance until 9.45pm when he rang me to say he had had enough and was
retiring to bed.
I have today checked with the ambulance service who claim it arrived at 9.41pm. My father is adamant - and there
is nothing wrong with his hearing that no ambulance arrived at his home.
• Why was there such a delay for an ambulance?
• Why did the ambulance service say an ambulance turned up at 21:41?
TOR agreed by:
Complainant
Date: 9/10/2013
Call audio records and CAD reports
Being Open
E-mail contact made 14 Oct 2013
Timeline of Events
Date and Time
Event
3 Oct 2013
15:07
new call received on behalf of a --- year old who is thought to have an infection. The call is
received from a Doctors surgery and the request is for an ambulance within two hours.
Call from the Emergency Operations Centre (EOC) to the doctor’s surgery to request an
extension as no resource available. Two hour extension agreed by the doctor.
Call received from the Leicester Royal Infirmary (LRI) asking when patient would arrive.
Advised LRI of the delay and that we would make a welfare call to the patient. (No record
of the welfare call.)
Call upgraded to a Green 1 20 minute response due to the length of time waiting and
condition of the patient.
New call created, call ref. 5885948.
Resource 4615, double crewed ambulance, allocated and mobile to patient.
Call made to patient advising that ambulance was outside and was unable to gain access.
The patient advised that he had just got into bed and he was not turning out now. Patient
was advised that EMAS would arrange for another vehicle for the next morning, but he
advised that he had arranged for a friend to take him in around nine am.
CAD message: called patient as crew struggling to gain access. Patient has just got into bed
and does not want to go to hospital now. Patient advised a friend is taking him into
hospital the next morning. Ambulance cancelled.
16:49
19:05
20:17
20:25
21:22
21:41
21:52
21:56
Handling of emergency call: the original call was a doctor’s urgent request for a two hour response. As the two
hour deadline approached an extension of two hours was requested and granted by the doctor. The call was
upgraded to a Green 1 20 minute response at 20:17 and the resource arrived on scene at 21:41, which was a
response time of six hours and 34 minutes. This was considerably outside the original request and the upgraded
timeframe. A welfare call should have been made to the patient but was not received.
Notes from PDM resource log:
15:45 Leics holding two Red 2 calls, one Green 2 call and 14 urgent calls.
20:06 Leics holding six Green 2 calls and six urgent calls.
Notes from LEICS resource log:
13:53 Leics rural holding two green 1 calls.
15:42 Leics holding one red 2 call.
19:33 holding four green 2 calls.
20:48 holding one green 1 call and five green 2 calls.
Conclusion
The delay in providing a response was due to the high demand for emergency responses on the day of the
incident. The correct procedure was followed to request an extension to the timeframe from the doctor, and the
call was upgraded by a clinician in view of the length of time the patient had waited. There is no record of a
welfare call being made to the patient.
Date Resolved: 4 November 2013
Grade: Moderate
Status: Resolved
Letter Date: 4 November 2013
Action: A reminder should be cascaded to the EOC staff responsible for making welfare calls to patients where a
request falls out of time that the welfare call should take place on each occasion.
Improvement: Welfare calls to all patients
Outcome Detail: All uncovered calls receive a welfare check when they fall out of time.
For: Performance Delivery Manager EOC
Evidence: Copy of communication to staff.
Evidence Gathered
Audio records of calls
CAD report
Notes from the Performance Delivery Manager (PDM) and Leicestershire dispatch desk (LEICS) resource logs
identified.
Type: EOC Issue
Category: AMPDS/CAT Assessment
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: Nil
Base: East Division HQ
Extension: XX
G3
Patient Outcome: Treated at AE and discharged
Summary: Call Handling -Was PALS/13/00210
Case Details: Wife would like to know why their call was sent to Clinical Assessment Team instead of having an
ambulance immediately sent out.
• Was the call correctly handled?
• Was sending call to Clinical Assessment Team (CAT) correct action?
• Was the call correctly handled by the CAT?
• Why does the Trust not send out ambulances when people call?
Timeline of Events
Date and Time
Event
15 Sept 2013
01:41
01:42
01:43
999 call received to male with upper abdominal pain
DCA assigned with 22 minute ETA
Call is coded G3 and sent to Clinical Assessment Team
01:45
02:06
02:10
02:13
02:21
02:29
02:41
02:54
02:56
03:00
03:45
DCA stood down
CAT rang back
CAT create new call and upgrade to G1 – 20 minute response required
Fast Response Vehicle (FRV) allocated with 6 minute ETA
FRV requests Red Backup. DCA assigned with 19 minute ETA
DCA arrives on scene
DCA leaves for PBH
CAD notes: ‘crew running red to Pilgrim, patient has ST elevation and an LBBB, need to go
to Pilgrim for stabilization first, has pre-alerted’
DCA arrives PBH
CAD notes: ‘crew taking patient to Lincoln County Hospital.’
On the 15 September 2013, a 999 call was received to a male with abdominal pains. The call was taken through the
Advanced Medical Priority System (AMPDS) and given a coding of G3. This requires that the call be passed to the
Clinical Assessment Team (CAT) for further assessment within 20 minutes. The call has been audited as correctly
handled.
At 2:06 the Clinical Assessment Team (CAT) called the patient back. Four minutes after connecting to the address,
the CAT upgraded the call to a G1, requiring a 20 minute response. The clinical audit of the call shows that the call
was audited as correctly handled.
A Fast Response Vehicle (FRV) was assigned at 02:13, and arrived on scene within 11 minutes. The FRV then
requested Red (immediate) blue light back up from a Double Crewed Ambulance (DCA). The patient was then
taken to PBH for stabilisation for a heart attack, before being taken to LCH.
The Advanced Medical Priority System (AMPDS) is a telephone triage system. This allows our Emergency Medical
Dispatchers (EMD) to follow a highly developed set of questions to categorise emergency calls, and identify
immediate life threatening cases. The system then creates a code based on the responses given by the caller. The
Department of Health review all the codes, allocate a response and creates a national database for the UK
ambulance service Trusts. The Trust follows these codes as per the Department of Health guidelines. When a call
is coded G3 or G4 a member of the Clinical Assessment Team calls back to ensure a thorough assessment is carried
out so con
Conclusion
The call received for this patient was correctly handled based on the information provided by the caller. The call
was then passed to the Clinical Assessment Team (CAT) for further triage. This action was correct, and complied
with the Department of Health guidelines.
The patient’s wife was concerned as to why an ambulance is not sent to everyone that calls 999. The Trust’s
resources are finite, and so it is essential that we identify those in most need of our assistance, whilst sign posting
other patient’s to more suitable treatment options. There is always a concern that this system may fail to identify
patient in need, so an additional layer of triage was set up. By utilising the CAT assessors the Trust can identify
patients with potentially life threatening conditions that the original questions failed to identify. In the case of this
patient, the CAT assessor immediately identified the patient’s condition was time critical and upgraded the call to
an 20 minute response.
Date Resolved:
Grade: Minor
Status: Unresolved
Evidence Gathered
rd
3 party share consent form
CAD SOE 5810016
CAD SOE 2840086
PALS 210 call audit PRF
CAT audit
WAV cat call audit
identified.
Source: PALS Office
Final Contact Date: «RESOLVE_DT»
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: Minor
Base: Public Place
Extension: XX
G2
Area/Divisional: HP EOC
Patient Outcome: Treated at AE
Summary: Non Deployment To ---yo In RTC
Case Details: The Trust received a 999 call from Police for a Road Traffic Collision (RTC) involving a --- year old with
head injury. The police rang for an ambulance 3 times to be told non were available. Due to delay patient was
taken to hospital by family. On arrival at the LRI family saw 6 ambulances parked up.
• How many calls were made by Police to this call?
• Were all calls correctly handled?
• Why were Police told there was no ambulances?
• Was there a delay?
• What was the cause of the delay?
• Why were 6 ambulances at LRI when the family arrived?
Timeline of Events
Date and Time
Event
8 Oct 2013
18:30
999 call received from Police. Road Traffic Collision (RTC); two vehicle; small child
bleeding from the nose
Call coded G2 (29B01) – requiring a 30 minute response
Community First Responder (CFR) checked Resource Allocation (Res/Alloc) – Complaint
not suitable for responder
Divisional Resource Log (RL) incoming Dispatch Officer (DO) notes minimal cover on shift
change; holding 1 x Red Backup; 2 x G2 (oldest 17:55); 5 x Doctors Urgent – awaiting
available resources
Divisional RL: holding 5 x G2 calls
Police call for ETA; Dispatcher checks Res/Alloc
Divisional RL: running distances to R2 x 3 calls North West Division
Divisional RL: two FRV off line due to vehicle failure
Divisional RL: Holding multiple calls, Dispatch Manager (DM) aware
Police call for ETA
Divisional RL: Capacity Management Plan (CMP) 1&2 implemented
Call viewed by PTL
Dispatcher checks Res/Alloc; Notes that no vehicle available and holding emergency calls.
Out of Performance reason set: High Demand in Area
Duty Manager Log notes Division placed in local Capacity Management Plan (CMP) 1&2,
holding 13 uncovered calls
Police call to state that relatives will transport to hospital. Dispatcher checks Res/Alloc
Call stopped
Call to Police advising that Division in CMP
18:33
18:34
18:36
18:38
18:52
18:53
18:56
19:07
19:09
19:10
19:12
19:13
19:15
19:23
19:24
19:27
th
On the 8 Oct 2013, at 18:30, a 999 call was received to a Road Traffic Collision (RTC) where a small child was
reported to be bleeding from the nose. This call was made by the police and coded as a G2 response. This
requires that a 30 minute on scene response by the Trust. This call has been audited as correctly coded.
The Community First Responder (CFR) desk checked to see if a local volunteer responder was available to attend.
No responders in the area are cleared to attend Road Traffic Collisions, or to attend Paediatric patients, so the CFR
desk were unable to assign anyone to this detail. The CFR desk acted correctly in this matter.
At 18:38, the Dispatch Officer(DO) checks the Resource Allocation (Res/Alloc) function to establish which vehicles
are in the area to attend the call. Four vehicles are shown as available but they are not assigned to this call. One
vehicle is a Fast Response Vehicle (FRV) that is reserved for R1 calls only, and two are for dealing with Doctor’s
Urgents only. The Doctor’s Urgents vehicles can only be assigned to calls if the Urgent Desk authorises their
deployment in times when there are no outstanding Urgent details. The final vehicle was manned by a single
Emergency Care Assistant (ECA). The Dispatch Deployment Framework (DDF), Oct 13, states that “a single ECA will
not be permitted to respond under any circumstances”. The DO’s decision not to assign any of these four vehicles
was correct.
At 18:52, the Police state they made an additional call for an ETA. A search of the Telephony and Radio system has
resulted in no trace of the recording. The complainant has stated Police called the Trust on three occasions, and
this corresponds with the number of calls located on the Trust systems. The Police did call at this time for another
call, unrelated to this detail. This call has been listened to, and there is no mention of this patient at any point.
The DO checks the Res/Alloc at this time, but is unable to assign to the call. The only vehicles available was the
ones noted above, and one Double Crewed Ambulance (DCA) that was in its meal break window. Under the DDF,
no vehicle within its meal break window can be assigned to a call that is coded G1 and G2. The decision of the DO
not to assign any of these vehicles was correct.
At 19:10, the DO notes that there is High Demand in the area, and that the Division is holding multiple calls. The
Divisional RL notes that Capacity Management Plan (CMP) 1&2 is locally activated, with resources running
distances to cover R2 (8 minutes response) calls. This means that the number of calls coming into the Division is
currently outstripping the resources available to respond. At this time, the Police call for an update on the Trust’s
attendance to this call. The Emergency Medical Dispatcher (EMD) acted correctly in informing the Police there was
no ETA at that time. The EMD then established that there was no change in the patient’s condition and so was not
required to enter a new call for this incident. The Police were not given the CMP speech by the EMD, telling them
that there is no ambulance available and advising patient to make own way to hospital, as it was received at the
same time as the Plan was instigated.
The patient’s family state that when they transported the patient to hospital themselves there were 6 ambulances
parked up. Interrogation of the Hospital handover data has established the 6 vehicles that the family appear to be
referring to, details of which are in the table below.
Arrived Hospital
to Handover
time
(00:15:00)
00:51:00
Time outside
of required
Handover time
Total time
at hospital
(00:30:00)
Reason for delay
00:36:00
Handover time
to resource
clear
(00:15:00)
00:00:27
00:51:27
No beds
Fall
00:30:00
00:15:00
00:11:33
00:41:33
No Clinical Staff
G2 (17:25hrs)
Fall
00:15:00
00:00:00
00:13:09
00:28:09
R2
Chest pain
00:10:00
00:05:00
00:07:00
00:17:00
R2
Stroke
00:15:16
00:00:16
00:10:33
00:25:49
R2
Agonal
Breathing
00:15:00
00:00:00
00:10:41
00:25:41
Call Coding
Problem
R2
Emergency
Transfer
G1
Complex Clinical
Handover
All ambulances identified were in the process of handing over patients, with 3 vehicles being subject to
unavoidable delays resulting in required timescales being breached. All breaches related to hospital delays, with all
Trust resources becoming available for additional calls within the required times. All calls that these vehicles
attended have also been assessed, and all were correctly assigned by the Dispatcher. They were either higher
priority calls, or calls with same coding but were received before this 999 call was made.
Conclusion
How many calls were made by Police to this call?
Police records note that four calls were made to the Trust - 18:30; 18:52; 19:10; and 19:23. Searches have been
made of the Telephony and Radio systems to locate all calls . The call time given as 18:52 has not been located.
The Police did contact the Trust at this time, but this was in relation to another patient on a different call. The
Trust records show only three calls were received from Police for this patient. This corresponds with the number
of calls specified by the complainant.
Were all calls correctly handled?
Yes. All calls received were correctly handled. The initial call was coded as a G2 call, requiring a 30 minute
response. The second call the Police stated that there was no change in the patient’s condition, so the Emergency
Medical Dispatcher (EMD) acted correctly by not starting a new call. The third call the Police stated that family
were making their own way to hospital.
Why were Police told there was no ambulances?
The Police were not told that there were no ambulances. The Police were informed that the EMD was unable to
give an estimated time of arrival as no vehicle had yet been assigned to the call. When the 19:10 call came in from
Police, the Division went into Capacity Management Plan (CMP) 1 & 2. This is where the number of calls are
outstripping the Trust’s available resources. Within this plan is the requirement for the EMD to give a specific
speech to Police. This speech notifies Police that there is no available ambulances to attend the patient, and ask
that they advise people to make their own way to hospital where possible. As this call coincided with the
implementation of CMP, the Police were not given this speech for this call and so were not told that there were no
ambulances to send.
Was there a delay?
Yes, there was a delay. The call was coded as requiring a 30 minute response, but by 19:00 a resource had not
been assigned. When Police called to state family were taking the patient to hospital it was 53 minutes after the
original call. The 30 minute timescale was not met, and due to this the Trust failed in its duty of care to this
patient.
What was the cause of the delay?
When this call was received the Division was holding 8 calls that were awaiting resources for assignment, three of
which had to be dealt with before this call. The Dispatch Officer made notes in the Divisional Resource Log
throughout, showing that the Division was subject to a high demand of calls, and that vehicles were now running
distances to attend to R2 (8 minute calls). At 18:56, the Divisional issues were further compounded by two Fast
Response Vehicles becoming unavailable due to mechanical failures. The Dispatcher acted correctly in dealing
with this call, as per the Dispatch Deployment Framework, Oct 13. The Community First Responder (CFR) desk
attempted to allocate a volunteer responder to this call, but none in the area were qualified to attend trauma
events, such as Road Traffic Accidents, or to deal with child patients. The CFR Desks actions also complied with the
Dispatch Deployment Framework, Oct 13.
Why were 6 ambulances at LRI when the family arrived?
Six ambulances have been identified as being at the hospital for the timescale that the family arrived. The hospital
handover data shows that 3 were subject to delays outside of their control - unable to hand over due to: lack of
beds; no clinical staff and due to a complex handover. All 6 crews, when handover of their patient was completed,
made themselves available for additional calls promptly and within required timescales. Each of the calls that the
6 ambulances attended have been assessed as well. All were correctly allocated by the Dispatcher ahead of this
999 call. They were either a higher priority call, or a call with the same coding received before the 999 call for this
patient was made.
Date Resolved:
Grade: Moderate
Status: Unresolved
Letter Date:
None
Evidence Gathered
WAV file 999 call
Dispatch Deployment Framework Oct 13
WAV files Police calls x 3
WAV file for unrelated call at 18:52
Handover data
CAD SOE
identified.
members must agree on the
recommendations arising from this investigation to prevent and/or minimise recurrence and associated action plan to ensure
that the recommendations are implemented and embedded into practice.
Appendix
Arrived
Hospital to
Handover time
(00:15:00)
00:51:00
Time outside
of required
Handover
time
00:36:00
Handover
time to
resource clear
(00:15:00)
00:00:27
Total time
at hospital
(00:30:00)
Reason for
delay
00:51:27
No beds
Fall
00:30:00
00:15:00
00:11:33
00:41:33
No Clinical
Staff
G2 (Received
17:25)
Fall
00:15:00
00:00:00
00:13:09
00:28:09
R2
Chest pain
00:10:00
00:05:00
00:07:00
00:17:00
R2
Stroke
00:15:16
00:00:16
00:10:33
00:25:49
R2
Agonal
Breathing
00:15:00
00:00:00
00:10:41
00:25:41
Call Coding
Problem
R2
Emergency
Transfer
G1
Table of hand over data
Complex
Clinical
Handover
Category: Transport
Source: Email
Reason for Delay: Handed over to new IO. Once handed over the IO carried out a desk top study and provided
verbal feedback to the complainant on the day. The 20 day KPI of feedback within timescale was met.
Final Contact Date:
Harm Rate: Unknown
Base: Leicseter
G1
Area/Divisional: HP EOC
Patient Outcome: N/K
Attending a --- year old lady - Relatives arrived 9.45 a.m. on Sunday 6 October to find her slumped in a chair,
unable to support or move her left side limbs and her speech was affected. Family dialled 999 immediately giving
details of symptoms.
30 minutes later a further call was made to chase up ambulance to be told by dispatcher they had other
emergencies and an ambulance would be on its way. 10.45 am Paramedic Fast Response Vehicle (FRV) arrived and
after a very quick assessment radioed through to control; at which point a vehicle was dispatched. The ambulance
arrived at 11.10 a.m.
• Were the calls correctly handled, and coded?
• What was the reason for the delay in attending the patient?
Timeline of Events
Date and Time
Event
6 Oct 2013
Incident Number 1
09:52
09:53
999 call received to --- year old female with a stroke
Dispatch Officer (DO) checks Resource Allocate (Res/Alloc) – FRV showing available
Call coded G1 – response within 20 minutes required
Community First Responder (CFR) Desk checks Res/Alloc – none in area
DO checks Res/Alloc – FRV showing available
Out of Performance Report: No vehicles; Holding 1 x Amber Backup; 1 X G1 and 1 X G2
09:57
10:03
10:10
10:11
10:17
10:30
10:33
10:34
DO checks Res/Alloc
Incident Number 2
nd
2 999 call received to this patient – now worse, in and out of consciousness
DO checks Res/Alloc
Call coded G1
Divisional Resource Log (RL) – Holding 1 x Amber Backup; 1 x R2; 1 x G1; 1 x G2.
DO checks Res/Alloc – FRV showing available
Divisional RL – Holding 2 x G1; 3 x G2
DO checks Res/Alloc
Double Crewed Ambulance (DCA) assigned and stood down immediately, diverted R2
10:41
10:43
10:49
10:52
11:00
11:02
11:16
11:22
11:34
11:50
12:20
Incident Number 3
rd
3 call received to patient from Lifeline centre – call is coded G2
Fast Response Vehicle (FRV) assigned
FRV requests Amber Backup
DCA assigned
DCA stood down – diverted to R2 outstanding
DCA1 assigned – closest DCA
DCA1 arrives on scene
DCA1 leave scene
DCA1 arrives at hospital
DCA1 clears hospital
Service Issues
07:09
11:03
11:18
11:21
CMP revoked
Divisional DCA placed unavailable after a call for decontamination
Divisional DCA placed unavailable due to brakes issue
Divisional RL notes: holding 1 x G1; 7 x G2 and running distance to calls
Trust Performance
A8 (8 minute response ) – 63.7% against required 75%
A19 (conveying response on scene within 19 minutes) – 90.93% against required 95%
Green 1 calls – 65.56% against required 95%
Green 2 calls – 73.36% against required 95%
Trust call level at this time was relatively high in comparison to the rest of the day, but it was not the case in the
Divisional area itself. The call demand in the Division does not appear to impact on the Divisions ability to
respond.
The Trust Operational emergency activity notes that there was a substantial (72.71%) increase in G1 calls across
the Trust.
Hospital Handover times in the area are not excessive. Both hospitals in the Divisional area are achieving the 15
minute handover target. Only one has breached this target by 7 minutes (22.44) over all the 24 hour period (94
vehicles attended).
On the 6 October 2013, at 09:52, a 999 call was received to a --- year old female with a stroke. The call was coded
as G1, requiring an on-scene attendance of 20 minutes. The call has been audited and found to be correctly
coded.
At 09:53, the Dispatch Officer (DO) checks the Resource Allocation (Res/Alloc) function to identify any vehicles in
the area that could be assigned to this call. The DO then notes that the Division currently had no available vehicles
in the area, with 4 emergency calls currently awaiting assignment. Emergency calls require a higher priority
response and allocation of resources above that of any other existing pre coded call waiting.
At 10:10, a second call is received to the patient, now described as condition worsened. The call was also coded as
G1. The call has been audited as correctly handled.
The DO checks Res/Alloc at 10:11, but is unable to assign a vehicle to the detail. The Divisional Resource Log (RL)
at 10:17 shows that the Division is still holding 3 calls ahead of this detail, as per the Dispatch Deployment
Framework, October 2013. The DO checks Res/Alloc at 10:30, and notes now holding only 1 call ahead of this
detail (an earlier G1 call).
At 10:41, a third call is received to the patient from a lifeline centre. The call receives a G2 (within 30 minute
coding. This call has been audited as incorrectly handled. The Emergency Medical Dispatcher (EMD) failed to ask
any Key Questions and instead input unknown for all questions. Due to this it is not possible to know if the final
coding achieved was correct. The EMD is to receive a record of conversation relating to the handling of this call.
At 10:43, the DO assigns a Fast Response Vehicle (FRV) to the patient. Four minutes after arriving on scene, the
FRV requests amber backup from the next available Double Crewed Ambulance (DCA) on lights and sirens. This
level of backup indicates that the patient is in a serious, but not immediately live threatening condition and can be
diverted if necessary. At 11:02, a DCA is assigned, but then has to be diverted to a higher priority call. This is a
correct action by the DO. The DO then assigns another DCA at 11:34, who attend scene and transport the patient.
Consistently throughout all the Res/Alloc checks a single call sign was shown as available as a local hospital, but not
assigned. Enquiries have confirmed that this vehicle was not manned, or logged on. Due to a technical
malfunction this vehicle was showing at the last location recorded before the vehicles on board computer was
switched off. This meant that the vehicle was not physically there, so could not be assigned to this detail.
A review of Trust performance shows that there was underperformance across all levels of 999 calls. Though the
Division does not experience a spike in calls at the time of the call, the Trust as a whole does. Notes within the
Trust Operational Accident and Emergency (AE) activity shows that there is a 71% increase in the number of G1
(response within 20 minutes) calls received. A review of the hospital handover times shows no issue with regards
to vehicles clearing for additional calls. The Divisional Resource Log (RL) does note that eight 999 calls are being
held, with vehicles running a distance. All the Res/Alloc calls for this detail show that vehicles are already on scene
of calls, at hospital or on way to appropriately assigned calls.
Conclusion
Were the calls correctly handled, and coded?
The first two calls have been audited as correctly handled, and coded as G1. This requires that the Trust respond
to the patient within 20 minutes.
The third call, at 10:10, was incorrectly handled as the Emergency Medical Dispatcher (EMD) failed to ask the
correct questions. Due to this it cannot be ascertained if the code assigned of G1 was correct. The EMD, in
question, has been referred to the training team. An FRV was assigned, and arrived on scene, within 8 minutes of
the third call being received so this coding issue did not affect the overall response time.
Was there a delay in attending this patient?
Yes. The Trust should have been on scene within 20 minutes, but did not arrive until 51 minutes after the first call.
What was the reason for the delay in attending the patient?
At the time of this call the Trust was under performing on all levels of 999 calls, including a substantial spike in G1
calls across the Trust (72.71%). The Resource Log sates that the Division was holding this call, along with a backup
request from a paramedic on scene and a lower priority G2 call. Due to this delay the Trust failed in its duty of
care to this patient.
Date Resolved:
Grade: Moderate
Status: Unresolved
Recommendation
EMD scoring less
than 90% for
compliance to
receive record of
conversation
Action
Any EMD whose call
was assessed as less
the 90% required
compliance level is
to receive a record
of conversation in a
one to one setting
(JB)
Evidence Gathered
WAV files 999 calls x 3
CAD SOE x 3
Call audits x 3
PRF x 2
Divisional RL
Daily performance review
Handover data
Lead
Due Date
12/12/13
Evidence
Record of
conversation
identified.
Source: Email
Final Contact Date:
Reported as Patient Safety Incident: No
Harm Rate: xx
N/A
Base: Primary Care Setting
Extension: N/A
Area/Divisional: Primary Care Setting
Patient Outcome:
N/A
Summary: Alleged Inappropriate Behaviour
Case Details: The ECA is alleged to have smacked a female on the bottom with his toughbook, and previously
made remarks that have made her feel uncomfortable
• Did the EMAS staff member inappropriately touch the hospital staff member?
• Is there any previous history of incidents between these staff recorded?
Crew Stood Down:
No. None clinical accusation.
Statements taken from all witnesses, crew and victim by ME.
•
Emergency Care Assistant, EE date: 19 April 2012. IPR date: 29 March 2013.
Paramedic, EE date: 9 October 2012. IPR date: July 2013.
Team Leader (TL)
Emergency Department QMC
colleague at QMC
colleague checked mark from allegation
provided support by TL and given appropriate referral information. HS supported by staff at QMC.
Healthcare Decisions Panel (HDP) referral: No – Non clinical incident
Being Open
Timeline of Events
Unknown date
Following her return from University and commencing work at , the Emergency Department (ED) HS recalls a
remark made to her by the Emergency Care Assistant --- using words to the effect of “I’m glad you’re back”. --recalls saying “why’s that?” and the response was “something decent to look at” or words to that effect. This
incident was not reported by ---, but --- and --- confirms that they are known to each other in a work capacity only.
15 October 2013
The crew (Paramedic and Emergency Care Assistant) attend the Hospital with a patient. They were recorded at
20.58 on Close Circuit Television (CCTV) walking through the Hospital corridor from 20:58hrs.
At 20:59hrs, the CCTV footage shows --- with a colleague (---) towards the end of the corridor cleaning a Hospital
trolley.
The crew go towards and past HS at 20:59hrs. MH is seen walking along the corridor with the Toughbook in his
right hand and trolley with the Patient on his left. The Paramedic is walking in front pulling the trolley with her
back to ---.
As he walks down the corridor, --- can be seen swinging his right arm and hand which is carrying the Toughbook.
This is consistent with his gait all the way along the corridor.
--- is not alone at the end of the corridor and comments made at the time by --- and the observations raised by the
are reported to have been witnessed by the colleague ---.
By 22:00hrs a Team Leader from East Midlands Ambulance Service (EMAS) is made aware of the accusations.
Statements are taken from the staff and witnesses involved between 22:30hrs and 02:06hrs of the 16 October
2013.
30 October 2013
10:30 IO obtains copy of CCTV when incident occurs from security office at Hospital.
Prior to the incident occurring on 15 October 2013, --- states she has received at least one inappropriate comment
from ---. This was not reported or escalated at the time as --- states she did not think anything further would occur.
On the evening of 15 October 2013 the crew (Paramedic and ECA) were attending Hospital taking in a Patient on a
trolley after attending a job for East Midlands Ambulance Service.
CCTV footage obtained from the Hospital Security Office show the crew walking past --- and ---. The Paramedic is at
the head of the stretcher pulling with her back to --- and the alleged incident. --- is guiding the trolley with his left
hand carrying an open Toughbook in his right.
As --- approaches --- the Toughbook appears to swing out towards ---, whilst the --- continues to walk. Due to the
angle of the footage, it is not possible to see when or confirm impact occurred.
After the crew had passed ---, the footage shows she reacts by walking away from the trolley she was cleaning.
--- speaks with another East Midlands Ambulance Service (EMAS) colleague and asks advice what to do about the
incident. At this point she is advised to report the incident and speaks with the Sister in charge who reported the
incident to EMAS.
--- asks a further colleague --- to check her bottom which was the area reportedly hit, as this was causing her some
discomfort. --- checks this and notices a small red mark which was fading. There was no bruising.
The EMAS Team Leader is made aware of the allegations at 22:00hrs and begins to take statements from all
involved.
--- remembers walking past HS and catching her accidently with the Toughbook. He states he said sorry and that
she made a comment that his actions were inappropriate. --- did not think anything further of the incident; as far
as he was concerned it was an accident and continued along the corridor with the Patient.
--- is reported to have been was upset that he has been reported for the accident and stated he had only ever
previously seen --- in passing and no other inappropriate comments had been made.
Conclusion
The CCTV footage does show movement to the hand of --- however, it is not conclusive whether the contact was
made intentionally or accidentally to ---.
Contact was made by --- to ---.
Previous comments made to --- by --- are not recorded.
Date Resolved:
Grade: Moderate
Status: Unresolved
Recommendation
Paramedic to be
reminded to remain
professional at all
times.
Invite parties to
become an EMAS
dignity champion.
Further incidents to
be logged.
--- to be
regarding
awareness.
trained
spatial
Action
Bulletin/communication
to be processed by
Medical Director to
remind staff to remain
professional at all times
despite their opinions or
feelings.
Forward any relevant
contact information to
allow this.
HS to log any other
incidents which occur
with EMAS.
Team
Leader
to
document conversation
around
spatial
awareness.
Report forwarded to
Divisional HR for
review.
Report forwarded.
Crew
to
attend
current EE course.
To be booked onto EE
course
via
Organisational
Learning.
Lead
Evidence Gathered
Copy of statements from crew, victim and witnesses.
CCTV footage Of incident
Due Date
Evidence
01/01/2014
Clinical Bulletin.
01/01/2014
Copy of email showing
information forwarded.
On going
Copies of statements if
further occurrences.
01/01/2014
Copy
of
record
of
conversation between TL
and ---.
10/11/2013
Email or notification to
Division on file.
01/12/2013
Email confirmation of
booking
made
and
completion
from
Organisational Learning.
Formal Complaint Proforma Ref: FC/219/12 and FC 103/13
Date Received: 17 October 2013
Complainant Name:
Telephone Contact:
Correspondence
Address:
Patient Name:
Deceased? No
Their reference:
Logged by:
Incident Location:
FC 219/12 - Road traffic collision patient had hurt her chest & it hurt to
breathe. Ambulance crew wouldn't take her to hospital & told her to ring a
friend for a lift is she wanted to go in. The patient was in hospital for five
days with broken sternum, broken nose & collar bone.
complaint:
FC 103/13 – this complaint has been opened as the complainant was
unhappy with the original response, and the re-opened case was not
passed across as an active case when the Investigation Officer went
absent from work.
Pat. Assessment/Diagnosis (Quality of Care, Clinical Issue)
Type of Complaint:
Use of refusal to travel
(15 working days)
Date for Investigation conclusion: 9 November 2013
14
November
2013
(20 working days)
Staff involved
& Station:
Initial grading
& Rationale:
Scope of
Investigation
(must include all
complainant
concerns) :
Moderate
Why wouldn’t the ambulance crew take the patient to hospital?
Contacted by telephone, very tearful and upset. 11
March 2013
Expectations of Complainant: Investigation and apology
Date OSM/PTL/Manager informed: 11 March 2013
Staff involved informed: 11 March 2013
Immediate actions taken: Staff supported by PTL’s
FC/219/12
Date of incident: 28 Feb 2013
Chronology developed from Computer aided Dispatch (CAD) sequence of events (SOE) for call
reference 5362523
Time
1400hrs
1406hrs
1415hrs
1444hrs
1447hrs
Events
Call started on CAD. This was a ‘running call’ initiated as the crew came across a
four car Road Traffic Collision (RTC) on -------------------------- as they were transiting
back to Ripley from ---------------------------. They were traveling West, saw the RTC
and turned round and parked safely behind the vehicles.
CAD Note; Police informed
CAD Note; 4 vehicle collision low impact - no major injury no entrapment - no
further vehicles required
2313 Time Clear: 28 Feb 2013 14:44:36
CAD Note; 2 pts rtt (2 patients, refused to travel)
Evidence Gathered:
CAD SOE
Electronic Patient Report Forms (ePRF) x 2
Clinical opinion on ePRF’s
Complaint letter
Handling of emergency call: the call was received from the attending crew after they had
discovered a road traffic collision as they were travelling back to base. The crew made an initial
assessment and advised that no other resources were required.
Review of PRF’s:
The divisional CQM was asked for a clinical opinion on the ePRF’s and supplied the following.
I have reviewed the PRF and these are my comments
From the comments section
The PRF reports a four car RTC with this patient’s car being the third in the line. It
reports that the speed was low 15mph and slowing. There is frontal and minimal rear
impact.
It is reported that the airbags had deployed but it is not specific which ones had
activated. It is reported that the driver was wearing their seatbelt and they were not
trapped.
From the assessment it is reported that the patient was not knocked out and had a full
recollection of events. The comments section continues to report the patient has a
minor facial abrasion to the bridge of the nose (from airbags) and seatbelt trauma to the
sternum which was tender on palpation. The chest is then examined and it is reported
that there is equal chest expansion and clear chest sounds.
A further comment is made that the drivers of the other three cars refused
treatment/transport - I would ask were PRFs also completed for these patients?
The past medical history reports that the patient has a history of asthma , thyroid
problems and rheumatoid arthritis
There are two full sets of observations recorded with all the observations recorded being
within the normal range - there are even two pain scores
The physical examination records an assessment of the relevant systems with no
significant findings reported.
In the Incident details section it is reported that the patient refused transport - the patient
has also signed the refused treatment, refused transport section.
The crew were on scene for 44 minutes
From solely reviewing the PRF I feel that the appropriate assessments were carried out
and that a thorough examination of the patient was conducted and documented.
However there is no documentation around what advice was given to the patient and
whether the patient was advised to attend hospital or not.
It is clear that the patient had sustained some injuries as part of the RTC as they are
documented but it is not clear what advice was given – if it was not explained to the
patient that she had potentially sustained a sternal fracture she would not have sufficient
information to make an informed decision around whether to refuse to travel or not.
From the PRF I cannot really comment on the allegation that the patient felt bullied into
not travelling.
Statements of attending crew:
Both members of staff were interviewed separately at their base station during a period of duty.
--- requested union representation which was provided by the Unison Lead for Derbyshire. --declined to have any 3rd party present.
Both members of staff were shown their ePRFs and also had access to the CAD as needed.
Both had a good memory of the job and were very surprised that a complaint had been received
as they felt that the call had generally gone well.
Both members of staff gave an account which was consistent with the other but was not similar
enough to make the investigator believe they had colluded beforehand. These members of staff
are not regular crewmates.
From their interview accounts / ePRF and CAD the following is proposed as the probable course
of events.
The crew had come clear at Kingsmill Hospital and were sent back to Ripley Ambulance Station
to have their mid shift rest period as they were just inside of their meal break window.
As they were driving west they saw that a four car road traffic collision (RTC) had occurred on
the eastbound carriage way, just as the road changes from duel carriageway to single
carriageway. They felt that this was a fast piece of road and the vehicles were in a dangerous
position and so the made a U turn and parked at the rear of the RTC with their warning lights
activated.
The crew informed control that they had found an RTC and then started to move along the
vehicles, checking each of the drivers / passengers. --- took the first vehicle they came to and --the second which was the vehicle with the complainant in. IA took a while assessing the two
ladies in his vehicle, checking their c-spine and generally assessing their condition. They
reported that they were traveling at about 15 mph however IA noted that their air bags had
activated.
From Internet research.
Air bags are typically designed to deploy in frontal and near-frontal collisions, which are
comparable to hitting a solid barrier at approximately 8 to 14 miles per hour (mph).
Roughly speaking, a 14 mph barrier collision is equivalent to striking a parked car of
similar size across the full front of each vehicle at about 28 mph. This is because the
parked car absorbs some of the energy of the crash, and is pushed by the striking
vehicle. Unlike crash tests into barriers, real-world crashes typically occur at angles, and
the crash forces usually are not evenly distributed across the front of the vehicle.
Consequently, the relative speed between a striking and struck vehicle required to
deploy the air bag in a real-world crash can be much higher than an equivalent barrier
crash.
http://www.crashforum.info/viewtopic.php?f=22&t=151
--- continued down the line of cars and spoke to each of the drivers and ascertained none were
injured or required ambulance assistance. Unfortunately no details of these drivers were
obtained or PRFs completed (--- realised that this was an error on his part and stated that he
will strive to complete PRFs, either paper or electronic, for all concerned should he be
confronted with a similar situation again).
The two ladies being attended by --- were judged fit enough to get out of their vehicle and were
taken into the ambulance for further assessment and treatment as necessary.
During the course of their examination the crew felt that they had developed a good relationship
with the patients and they were chatting freely back and forth. The crew report that the
complainant in this case was preoccupied with getting to Kingsmill Hospital for an outpatient
appointment and asked that the crew take her to her appointment. The crew remember telling
her that they couldn’t do that but would be more than happy to take her to Kingsmill ED where
arrangements could be made reference her appointment.
The complainant has only heard however that the crew wouldn’t take her to hospital. It would
appear likely that the complainant was much more upset than the crew realised from her
outward demeanour and wasn’t really taking on board what was being said and therefore
couldn’t really make an informed decision as to what to do.
This situation is further compounded by their being no record of the advice given within the
ePRF and no care plan.
Conclusion:
The ambulance crew have come across a four car RTC and stopped to care for all the persons
involved.
The crew correctly identified the two persons with the worst injuries and treated them but failed
to record their conversations / treatment of the other three persons involved.
The crew have recorded on the ePRF two out of the three injuries sustained by the patient.
During the course of the ensuing conversation the crew have tried to tell the complainant that
they would take her to the ED but couldn’t take her to her out patient’s appointment. The
complainant has only heard that they crew would not take her to hospital.
In view of the injuries sustained by the complainant, in hindsight it would have been prudent for
the ambulance crew to have conveyed her to hospital for further observations and assessment.
Recommendations:
Recommendation 1: PTL to discuss PRF completion with the crew.
Action: PTL to discuss PRF completion with the crew. Conversation to include the importance
of completing a PRF for every patient and also that a care plan and any advice given must be
recorded.
For:
By: Completed 30 April 2013
Evidence: Record of conversation.
Expected outcome: Improved PRF completion.
Recommendation 1: PTL to discuss this incident with the crew.
Action: PTL to discuss this incident with the crew. Conversation to include the importance of
safety netting for every patient and the need to convey the patient to hospital if there is any
uncertainty regarding the potential injuries sustained.
For:
By: 31 December 2013
Evidence: Record of conversation.
Expected outcome: Improved safety netting of patients.
say?
Category: Non transport
Harm Rate: Negligible
Initial Call Coding: Multiple
Base:
Source: Letter
Written or Verbal: W (Delete)
Final Contact Date:
Patient Outcome: No harm
Summary: Paramedics Refused To Transport Patient
Case Details: Complaint notes that from June to October 2013, ambulance staff attended and refused to treat or
transport patient to hospital.
• Why did the paramedics refuse to take patient to hospital to be checked out?
• Why are the paramedics not treating the patient when they arrive?
• Why is the Trust refusing to come out to the patient?
Timeline of Events
No
Date
Problem
Closing reason
Call 1
6 June 2013
Breathing problems
Transported
Call 2
10 June 2013
Assault
Passed to CAT
Call 3
10 June 2013
Clinical Assessment Triage (CAT) upgrade to Green1. 20
Transported
minute response
Call 4
17 June 2013
Passing out
Transported
Call 5
22 June 2013
Breathing problems
Transported
Call 6
30 June 2013
Collapsed
Transported
Call 7
6 July 2013
Tingling fingers
Transported
Call 8
12 July 2013
Chest pain
Transported
Call 9
14 July 2013
Collapsed
Transported
Call 10
19 July 2013
Breathing problems
Treated scene
Call 11
19 July 2013
Duplicate call (call 10)
Duplicate
Call 12
20 July 2013
Loss of conscious
Transported
Call 13
20 Sept 2013
Query stroke
Transported
Call 14
22 Sept 2013
Off of scooter
Transported
Call 15
24 Sept 2013
Chest Pain (CP)
Treated scene
Call 16
24 Sept 2013
Shaking
Treated scene
Call 17
29 Sept 2013
Duplicate call
Duplicate
Call 18
29 Sept 2013
Fit
Treated scene
Call 19
2 Oct 2013
Collapsed twice
Transported
Between the date lines, 6 June to 2 October 2013, the Trust records 18 calls to the Complainant’s home address.
One additional call has been located to the patient at the GP surgery. Due to the number of calls received in this
time scale a request has not been made to have a 999 calls to the Trust audited.
Out of the 19 calls received, 1 relates to a call that was passed to the Clinical Assessment Team (CAT). This call was
promptly upgraded to a G1, requiring on scene attendance within 20 minutes. Two calls were closed down as
duplicates of calls already in progress (Calls 11 and 17). The remaining 16 calls the patient was transported 12
times, with 4 calls noted as treated on scene. Due to the quantity of calls this investigation will review the calls
where patient was not transported, only.
Call 10
On the 19 July 2013 at 17:32, a 111 call was received for the patient having an asthma attack. The call was coded
DX012, due to difficulties in breathing, and required an on scene attendance of 30 minutes. Clinical audit was not
completed as the call was taken by 111, not by the Trust. A Fast Response Vehicle (FRV) was assigned and arrived
on scene within 6 minutes. The electronic Patient Report Form (ePRF) states that the patient was complaining of
breathlessness. The Patient was concerned after taking two prednisolone tablets prescribed by his General
Practitioner (GP), due to his diabetes. On arrival the patient was reported by the crew to be chatty and a good
colour. All observations were noted as within normal parameters with a normal peak flow of 550 litres per minute.
The FRV notes that this was a marked improvement on peak flow from the morning. The patient’s chest was
reported to be clear with no chest or abdominal pains. The FRV advised the patient of the correct regime for the
medications and explained potential side effects regards to his asthma, blood sugars and gastric irritation. The
Patient was then given worsening advice and what to do should their condition deteriorate. The Patient signed the
ePRF agreeing to this care plan.
Call no. 15
On 24 September 2013, at 07:07, a 111 call was received to the patient complaining of Chest Pain. The call was
given a coding requiring on scene attendance within 8 minutes. Clinical audit was not completed as the call was
taken by 111, not by the Trust. A Double Crewed Ambulance (DCA) arrived on scene within that timescale. The
attending DCA completed two full sets of observations. A clinical review by the Clinical Team Mentor (MM) of the
ePRF states that basic observations were within normal parameters and appropriate treatment given for the
patient’s presenting complaint. The review states that the patient was adequately safety netted with the patient
being advised to keep his GP appointment. The patient was left in the care of his partner and the patient signed
agreeing with this treatment plan.
Call no 16
On the 24 September 2013, at 22:24 the Trust received a 111 call to attend the patient. The call outlined the
problem as: diagnosed with a stroke, 13 weeks, ago, waiting for a MRI scan, GP said paralysed on both side and
brain damage, about 15mins ago, was shaking. GP told him that he will get shaking with the brain damage, it was
seizure. Has angina, diabetes, asthma, enlarged prostate. The call was coded as requiring an 8 minute on scene
response. Clinical audit was not completed as the call was taken by 111, not by the Trust. A Fast Response Vehicle
was assigned and arrived within 5 minutes of the call being received. Notes in the Computer Aided Dispatch (CAD)
stated that the patient had had episodes where his arm was shaking. The patient had been to Hospital during the
week, and his GP that morning. The patient was advised to contact his GP in the morning, if still concerned, and it
was arranged for his partner to monitor the patient. The patient, and partner, were giving advise if the patient
should deteriorate. The patient signed the PRF agreeing to this treatment option.
Call no 18
On the 29 September 2013, at 01:27 a 999 call was received to the patient for who had had a fit. This is a duplicate
of a 111 request at 00:58 for collection of the patient within 1 hour. The call was coded R2, requiring on scene
attendance within 8 minutes. The DCA arrived within 4 minutes of the call being received. Both timescales for the
111 call and the 999 call were achieved. The 999 call has been audited as correctly handled. The ePRF notes that
on arrival, the patient was alert and looked well. The patient was FAST (stroke test) negative, had no dysphasia (a
disturbance in comprehension) and orientated. The patient stated he was not nauseous and did not have a
headache. Treatment options were discussed with the patient and his partner. Patient was advised to make a
diary record of episodes to assist with future GP appointments. Patient signed ePRF agreeing to this treatment
plan and for his records to be shared with the GP.
Clinical Review of Patient Report Forms (PRF/ePRF): The Clinical Team Mentor (CTM) was asked to do assessment
review of the 12 times the patient was transported. The CTM states that the patient “appears to have had a
thorough assessment with the appropriate treatment for presenting complaint. On each occasion the patient’s
basic observations were within normal parameters which again appear consistent upon each attendance. We
stress among staff the importance of concise documentation and the recording of a minimum of two sets of
observations, on each occasion the patient appears to have had a good level of care with the appropriate service
outcome.”
Clinical assessment of the PRF/ePRFs relating to when the patient was not transported raised no concerns. The
CTM states that the “treatment and outcomes have been within expected norms, similar to the other occasions of
non-conveyance. He has had two sets of recorded observations and been advised accordingly.” The CTM also
confirmed that the patient signed the forms himself to state that he was satisfied with the treatment plan at the
time.
The letter of complaint references that he wants to know why ambulances are refusing to come out to him. The
patient has been spoken to and states that, during a conversation with 111, he was told that the ambulance
service will not come out to him. All records have been checked, and there is no case where 111 contacted the
Trust between the dates stated where an ambulance did not attend. Enquiries have been made with the Local
Security Management Specialists. This is the only department in the Trust that can inform a patient that the
ambulance service is placing restrictions on attending the patient. This can only be done after certain processes
are complied with. The Security department has no knowledge of the patient and no notification has been has
been issued to this patient limiting his interaction with the Trust.
Conclusion
Why did the paramedics refuse to take patient to hospital to be checked out?
The Paramedics did not refuse to take the patient to hospital. Out of 16 calls, the patient was transported 12
times. On the four occasions the patient was not transported, was done with the agreement of the patient after
ensuring he was giving informed consent.
Why are the paramedics not treating the patient when they arrive?
A Clinical assessment states the Patient Report Forms show that the attending crews actions were correct, and
were supported by the observations taken at the time. A comparison of observations on all four occasions show
that they were all similar, and all were within normal ranges. On all four calls the patient was adequately safety
netted, and given advice should his condition worsen.
Why is the Trust refusing to come out to the patient?
The Trust has not issued any form of restriction on attending this patient. The Local Security Management
Specialists, who are be responsible for issuing any restrictions, state they have not been approached by the Trust,
or any other external organisations, to do so. Of the 16 calls received where we attended to this patient, the
patient was either correctly triaged on scene and left at home on 4 occasions, and conveyed on 12 occasions.
Date Resolved:
Grade: Negligible
Status: Unresolved
Letter Date:
Evidence Gathered
CAD SOE x 19
PRF x 16
Letter of complaint
ePRF audits
999 call
Security Department email
Located all calls to patient in timescale specified
Placed all in table for easier reference
Sent PRF for comparative assessment by CTM
Spoke with patient
Emailed security department
identified.
Incident Date: 06/10/13 + 23/10/2013
Source: Email
Written or Verbal:
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base:
Extension: XX
xx
Red 2
Patient's House
Patient Outcome: Treated and discharged
Summary: Complainant Was Sent An Abusive Letter/Not happy with the service received
Case Details: Complainant received a handwritten letter telling them its costs £250 every time they ring 999 and to
stop doing it.
The complainant and her son are very upset and have called the Police who will visit them and confirm what can
be done.
A complaint has also been received in relation to the treatment received by the complainint’s son on 6 October
2013. The crew are said to have been unhelpful and and treated the patient in a nasty manner pressing on his
head where there was a wound inflicting pain.
•
Why did the crew member press on the patient’s head?
•
What is he reason the ambulance crew did not assist the patient to gather
belongings and get to the ambulance?
Crew Stood Down:
No. If No state rationale
Emergency Care Practitioner, EE date: 12 June 2012. IPR date: 25 January 2013
Paramedic, EE date: 20 August 2012. IPR date: 19 April 2012
Paramedic, EE date: 15 October 2013. IPR date: June 2013
Support and referral process for self-support given to staff by Team Leader.
Being Open
Timeline of Events
Date and Time
Event
6 October 2013 Incident Number 5893567
19:01
19:02
19:03
19:03
19:04
19:04
19:07
19:34
19:43
20:01
20:22
21:03
9 October 2013
23 October 2013
24 October 2013
Call received into Emergency Operations Centre and processed through Advanced Medical
Priority Dispatch System (AMPDS).
Dispatcher (D1) accesses Resource Allocation (RES/ALL) function, no resource allocated.
Dispatcher (D1) accesses Resource Allocation (RES/ALL) function, no resource allocated.
Dispatcher (D2) accesses Resource Allocation (RES/ALL) function and allocates First
Response Vehicle (FRV) to attend.
Call coded correctly as 30D02 by Emergency Medical Dispatcher (EMD). A Red2 (R2) 8
minute response. EMD establishes call is from Doctor (GP) who is on scene with the
patient.
FRV arrives on scene with patient and GP.
Amber response back-up requested from FRV on scene.
Double Crewed Ambulance (DCA) 9313 allocated to attend as Amber response.
DCA arrives on scene with FRV and patient.
DCA leaves address towards hospital with patient.
DCA arrives at hospital with patient.
DCA calls clear from this job.
Letter received to PALS regarding treatment given to patient by ambulance personnel
whilst on scene.
Anonymous letter received by family.
Escalated to Formal Complaint due to content of letter.
All investigations with regards to the letter received by the family are being dealt with by East Midlands
Ambulance Service (EMAS) Human Resources (HR) department. An internal investigation is taking place. The Police
confirm having attended the address they are unable to proceed any further with the letter complaint. As this is an
isolated incident it is not classed as a hate crime. Any further incidents are to be logged with the Police.
A call was received into the Emergency Operations Centre (EOC) on 6 October 2013. This call was made by an Out
of Hours (OOH) Doctor (GP) who attended the property due to concerns raised by the patient’s Mother. The
patient was reported to have had a fall the previous evening and hurt his head. The GP was querying a concussion
with vomiting present and superficial bruising to the forehead. It was known that the patient had epilepsy and was
an insulin dependent diabetic.
The Emergency Medical Dispatcher (EMD) processed the call through the Advanced Medical Priority Dispatch
System (AMPDS) and a disposition code of 30D02 Red2 8 minute response was correctly gained. AMPDS is a set of
questions used to determine the most appropriate response based upon answers given by the caller. The more
immediate life threatening the patient’s condition is, the higher the priority that is given.
Whilst the call was being coded, the Dispatcher correctly accessed the Resource Allocation (RES/ALL) function and
allocated a First Response Vehicle (FRV) to attend. The FRV arrived on scene with the patient within 3 minutes of
the call being received.
3 minutes after being on scene, the FRV establishes from the GP that a Double Crewed Ambulance (DCA) will be
required to convey the patient to hospital. This DCA resource is allocated correctly at 19:34 and arrives on scene at
19:43. The DCA leaves for hospital with the patient at 20:01 arriving with them at 20:22. After handing over the
patient at hospital, the DCA calls clear from this job at 21:03.
Whilst the FRV is on scene, it is established that the patient has an abrasion to the front of his forehead with fresh
blood present. There is also a small indentation to a plywood door. The patient had taken part in an argument with
his mother 24 hours prior to the ambulance being called and had been told by the Police he would be arrested if
did not behave. The patient’s mother called for the GP as the patient had been in bed all day and she did not want
her son to misbehave again.
The GP explained to the FRV concerns relating to the head injury and requested immediate hospital admission.
When asked his date of birth and regarding the incident the previous day, the patient became absent minded.
The FRV confirms they did touch the head wound on the patient’s head with a wet gauze to clean off the blood
and see the extent of the injury; as the patient was claiming memory loss with concussion from the head injury.
The DCA personnel did not enter the patient’s property and waited for the patient at the ambulance as it was their
understanding that the patient was making his way to them as communicated with the FRV. No request for
assistance from the patient or patient’s mother was made.
On route to the hospital, the patient refused to talk to the crew.
A review of the electronic Patient Report Form (ePRF) by the Locality Quality Manager shows two full sets of
observations were taken. The patient’s blood pressure is shown as marginally low with a BM being slightly
elevated. Neither of these readings would have required intervention by East Midlands Ambulance Service (EMAS).
It is shown that the Emergency Care Practitioner (ECP) cleaned the wound on the patient’s forehead.
The ePRF shows that minimal intervention was required by EMAS.
Conclusion
The Emergency Care Practitioner (ECP) from the First Response Vehicle (FRV) pressed on the patient’s head with a
gauze to clear away blood; this also enabled the ECP to check the extent of any injuries sustained. This was the
correct process as confirmed by the Locality Quality Manager (LQM).
It is not common practice for the ambulance crew to assist in the gathering of clothes and personal belongings.
The ECP felt the patient was able to walk to the ambulance and as such he was walked to the ambulance unaided.
There was not a need for all ambulance personnel to be present whilst the patient was going to the ambulance.
Recommendation
Investigation
by
Human Resources to
take
place
and
confirm if member of
staff has sent letter
EE and IPR to be
completed
by
operational staff
Action
Lead
Due Date
Evidence
All
actions
and
information to be
passed.
Completed
Information already passed.
Staff to complete EE
and IPR for current
year
01/01/2014
Email
of
books/evidence
completion
Evidence Gathered
Sequence of events from call
Copy of voice recording from call
Call audit
Copy of electronic Patient Report Form (ePRF)
ePRF review
Copy of letter sent to patient
Patient report forms and Incident Reporting forms of crews attending the address
of
dates
IPR
Source: Letter
Final Contact Date: 03/12/2013 Local Resolution Meeting (LRM)
Delays Incurred
Reason for Delay: Complex Formal Complaint
Harm Rate: Major
R2
Patient Outcome:
Deceased
Summary: Care Management Of Cardiac Pt. Pt Died
Case Details: Crew called to attend pt with history of heart problems. Wife feels that the crew had no sense of
urgency or care towards the pt. Crew made pt walk down the stairs and he then arrested on the ambulance.
Wife believes that the Paramedic was flustered and struggling, and the ambulance was rocking and bumping
enroute to hospital.
•
•
•
•
•
•
•
•
•
•
•
•
Why did the ambulance not have the right medications on board?
Why did the crew not show any “urgency” on scene with the patient?
Why did the crew member use the toilet at the house?
Why was the patient asked to walk downstairs and to the ambulance?
Why was the patient not kept warm?
Why was patient initially going to LCH?
Why was the patient’s wife not belted in?
Why was the patient’s wife handed ampules of morphine to open?
Why was the patient taken to BPH instead?
Why did the ambulance not stop when patient went into cardiac arrest on the second occasion?
Why did the paramedic “wedge” patient’s arm into the trolley?
Why didn’t the driver avoid the road works, and did this delay hospital treatment?
Timeline of Events
Date and Time
Event
15 Sept 2013
Incident Number
20:19
999 call assigned to --- year old male with Chest Pain with history of heart problems.
Patient takes GTN x 4 and 75mg aspirin prior to Double Crewed Ambulance (DCA) arrives.
DCA assigned with 4 min eta
Community First Response Desk notes no CFR in area
Echocardiogram (ECG) shows patient having ST elevations MI (heart attack) inferior
Paramedic (P1) inserts cannula size 18, 3 x 75mg aspirin and give patient oxygen via mask
– 10 litres per minute.
DCA leaves scene for LCH after pre alerting for Percutaneous Coronary Intervention (PCI)
ECG shows ST elevation spread to V4, V5, V6. Patient then goes into ventricular fibulation
(VF).
T1 calls control – patient in cardiac arrest diverting to PBH – CPR in progress
Dispatch Officer (DO) calls PBH and pre-alerts ETA 15 minutes
T1 calls DO – patient now out of cardiac arrest; breathing on own
T1 calls back 30 seconds later to DO – patient back in cardiac arrest; shocking patient
DO calls Paramedic Team Leader (PTL) called and asked to meet DCA to assist at hospital –
ETA 10 minutes
Patient shocked 200 joules Biphasic
T1 calls DO – patient has rhythm and pulse of 88; advised PTL will meet at hospital
DO calls BPH – updates Resus team, ETA 5 minutes and that only two crew on board doing
CPR
DO updates PTL of patient condition
Patient VF - 1 adrenaline given and i-gel inserted CPR continued
DO updates PTL of crew details
DCA arrives PBH
Patient re-assessed – Unresponsive
Patient re-assessed 2 breathes per minute; irregular; slow distress and shallow. Patient
shocked 200 joules Biphasic
Patient handed over to hospital Resus team
T1 calls DO – patient re-arrested just outside the Emergency department. Patient
declared deceased
T1 states DCA been assisting with CPR and resuscitation at hospital
20:20
20:24
20:26
20:35
20:50
21:06
21:08
21:10
21:12
21:13
21:14
21:15
21:17
21:18
21:24
21:22
21:26
21:28
21:29
22:18
22:59
On the 15 September 2013, at 20:19, a 999 call was received to a --- year old male with Chest Pain. The call was
coded R2, requiring an on scene response of 8 minutes. The call has been audited, and established as correctly
handled. The caller informs the Emergency Medical Dispatcher (EMD) that the patient has a history of heart
problems, and has taken Glyceryl Trinitrate (GTN – heart medication) and 75mg of aspirin.
A Double Crewed Ambulance (DCA) is assigned with a 4 minute ETA , and arrived on scene at 20:24. This achieves
the 8 minute timescale required. On arrival, the Paramedic (P1) and the Technician (T1) stated during interview,
that the patient was upstairs in bed. The patient was complaining of chest pain, was pale and was anxious. P1
completed an Electrocardiogram (ECG – measuring the electrical activity in the heart) which showed that the
patient was having a heart attack (MI).
P1 asked the patient’s wife to get the patient’s aspirin, as this was in 75mg tablet form and the dose to be given
needed to be 300mg. P1 confirmed that there was aspirin on the ambulance, but only in 300mg doses. P1 wanted
to ensure that the patient was not given more than the maximum 300mg, so applied best practice by giving the
patient 3 more doses of his own medications. A Clinical assessment of the Patient Report Form (PRF) confirms the
actions of P1 as being correct.
Both P1 and T1, independently during interview, stated that the patient was anxious and this was noted on the
PRF. Due to this P1 became concerned about the impact of the patient’s emotional state on the heart attack
progress. P1 and T1 purposefully acted in a calm and relaxed manner whilst interacting with the patient with the
intention of calming the patient down. P1 stated he had experience of the effect of stress levels patient’s with
time critical conditions, and that it was essential to reduce the patient’s anxiety levels as quickly as possible. The
Clinical review of the PRF states that the Trust aims to leave the scene, with a time critical patient, within 15
minutes of arriving. The DCA was on scene for 25 minutes. The review considers this delay acceptable considering
the patient was in an upstairs room.
The patient’s wife recounts that whilst P1 was completing the observations on the patient, T1 asked to use her
bathroom. T1 does not recall this, but also has no recollection of the wife objecting to him doing so if he did. Trust
protocol for a patient having a heart attack is that he should be taken direct to a specialist centre for Percutaneous
Cardiac Intervention (PCI – an emergency procedure to widen blocked arteries). The nearest centre to the
patient’s address was an hour drive on blue lights and sirens. Clinical review confirms, though this is not
something that the Trust would feel is ideal, when there is a long and demanding drive ahead the request from T1
was understandable. T1 was asked if he had not gone to the toilet at the house, did he foresee this having an
impact on his ability to assist the patient on way to hospital. T1 could not say for definite, but stated he did feel it
may have caused a distraction whilst driving, or treating the patient, that he would have wanted to avoid. P1
confirmed that when T1 was not in the room, P1 was caring for the patient and completing his observations at all
times.
Once P1 had completed the observations, he contacted the PCI unit and made arrangements to take the patient
there. This complied with the Trust’s policy for heart attack patients as per the Non Conveyance Guide. The
patient’s wife has asked why the crew were taking the patient to PCI, when he was awaiting triple by-pass surgery
at another hospital. According to the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), any patient
presenting with these symptoms should be transferred to a PCI centre under emergency conditions, and as per
local arrangements. The crew acted correctly and complied with the Trust policy by arranging to go direct to LCH
PCI as the patient needed immediate lifesaving treatment.
T1 recounted, during interview, that the patient did not initially want to go to hospital, but that P1 and T1
managed to persuade the patient it was the best option. Both members of the crew, independently stated, that
the patient was still very anxious. The patient’s level of anxiety the increased when he was asked to get in a chair
to be carried down the stairs. P1 was also concerned about the width of the stairs itself. As the patient was
getting more anxious, both crew members felt that insisting on using the chair would be more damaging to the
patient’s condition. Due to this the crew members felt it was better to abide with the patient’s wish to walk down
instead. P1 stressed, during interview, the importance of calming the patient down because of the danger to his
health if he maintained this level of anxiety. Once the patient was downstairs he was again asked to use the chair,
but again refused. T1 states that the carry chair was at the bottom of the stairs at this point. When the patient
refused to use the chair, T1 said he would bring the stretcher to the front door, but the patient refused to do that
as well. There were no concerns about the patient’s mental capacity, so the crew acted correctly in abiding by the
patient’s informed decision in this matter. Both crew members were asked where the wife was during these
conversations with the patient. Both stated the wife had been “in and out” during their time on scene.
Once on the ambulance stretcher, P1 had to bare the patient’s chest to re-connect him to the monitors and
complete a couple of observations. These observations, and any medications given, were then noted in the
Patient Report Form, as per JRCALC guidelines, and is essential for the treatment of time-critical patients. This took
a couple of minutes, but then P1 got the patient covered up and ready to travel. T1 and P1 then explained, during
interview, that the carry chair was then stowed away into the open ambulance door, the lift raised and the door
shut. Both crew members stated that the doors were shut within a couple of minutes to ensure patient privacy.
Clinical review has confirmed that, though it is important to keep the patient warm, the priority must be regards to
Intravenous Access (a needle in the hand or arm for fluids to go through) and ECGs. P1 continued with the
paperwork, and monitoring the patient, as T1 started the drive to the PCI unit.
The patient’s wife has raised the concern that she was not belted into the ambulance seat before they left, or told
to put the belt on at any point. Both crew members stated it is their standard practice to belt in the family
members on way to the hospital, and have no recollection of not doing this. Both crew members state that the
wife did not mention that they had forgotten to do this. Though it is best practice for the crew to strap the wife in
themselves, the legal onus lays with the wife to ensure this is done. Due to this, the requirement is that the wife
brings this to the attention of the crew, or she secures the belt herself. The only time when the driver is legally
responsible for a passenger’s belt is when they are under the age of 16.
At 20:50, the DCA leaves the scene and starts on route to PCI unit. Sixteen minutes later T1 calls the Dispatch
Officer (DO) to inform them that the patient has gone into cardiac arrest, and active Cardiopulmonary
Resuscitation is in progress. T1 states that they will now be diverting to PBH. The crew is correct in doing this as
the patient now needs to go to the nearest Emergency Department. P1 explained, during interview, that the aim
would be to stabilise the patient at PBH, with a view to taking him to PCI once it was safe to do so. This action
complies with Trust Policies.
During the transport to PBH, the patient went into cardiac arrest on three occasions. On the first occasion, the
DCA pulled over, and T1 went to the back of the ambulance to assist P1. By this time the DCA was on a main “A”
road approximately 8 miles from BPH, with an ETA of 15 minutes. Once the patient was stabilised, the crew
members made a clinical decision to carry on to BPH so that the patient could get additional help quickly. Both
crew members were asked, during interview, what the ideal number of Trust personnel would be when dealing
with a cardiac arrest. Both stated three is preferred so that two persons could work on the patient, whilst the
third drove to hospital. During interview, both crew members were asked why they did not remain at this location
and request backup join them. Both crew members explained, independently, that P1 was able to do advanced
life support on his own as everything was now set up from the first cardiac arrest. Due to this the priority was to
get the patient to an Emergency Department to be stabilised where the Control Room had organised for a Team
Leader had been organised to assist the crew.
The patient’s wife has asked why she was asked to open a clear package containing four ampules. The patient’s
wife confirmed that the vehicle was “rocking about a great deal” at this time. P1 explained, during interview, that
at that time he was doing multiple processes to give the patient his best chance of survival. Most of this would be
done stood up in the rocking ambulance. P1 described the new packaging for the ampules as similar to food
packaging and quite difficult to open, especially in a moving ambulance. P1 stated he politely asked the patient’s
wife to open the cover, and that she did not object. P1 clarified that had she not wanted to assist he would have
done it, but by her doing that job it freed him up to do some other treatment on her husband.
The patient’s wife was also concerned that the patient’s arm kept falling out of the trolley, and that P1 “roughly
jammed” it back in. P1 stated that it was necessary to have the arm secured as it presented a danger whilst
administering the shocks to the patient. P1 was concerned that it could transfer the shock to him, or the patient’s
wife, if it touched them at the wrong time. Clinical assessment confirms that the priority lays with saving the
patient’s life, the moving arm could hinder the paramedics treatment and would need to be placed out of the way.
At 21:26, the DCA arrived at the hospital and the patient went into cardiac arrest for a third time. The patient’s
wife has asked why the DCA took a route to hospital that involved road works, and wanted to know why they had
not avoided them. The patient’s wife was also concerned as to why T1 had spoken to the man at the road works,
as she felt this had delayed in the transport of her husband. T1, who had been driving, stated he had no
recollection of the road works, and would not have been able to avoid them as he did he did not know they were
there before hand. An estimated traveling time from patient’s address, to BPH, is 30 minutes. For at least 10
minutes of this journey, the DCA was heading along the A17 and A52, in the wrong direction for BPH as the original
destination was PCI in LCH. The DCA then had to pull over, stabilise the patient, and then turn round to go in the
opposite direction on the A52 to BPH. Total time taken to travel from the patient’s address to BPH was 32
minutes. With consideration to all factors involved, the DCA made good time to BPH, and there is no indication
that T1 delayed transport at any time.
On arrival handing over the patient to the hospital staff, both crew members remained with the patient to assist
staff with the active resuscitation of the patient to give him his best possible chance.
In the initial stages of this investigation, based on patient outcome only, a request was made for the complaint to
escalated. This consideration was reviewed by Board members, and involved the facts relating to the patient
walking down the stairs. The finding of the Board was that “it appears clinical judgement was made and that slow
mobilisation of the patient was acceptable in the circumstances” and that there was “no care management
failure”.
Conclusion
Why did the ambulance not have the right medications on board?
The ambulance did have the right medications on board, but the Paramedic was aware that the patient had
already been given 75mg of aspirin. The patient needed a total dose of 300mg. As ambulances carry aspirin in
300mg, it is best practice, for the patient to be given three more of his own medication to ensure the right amount
is take. Clinical review of the Patient Report Form (PRF) states the paramedic acted correctly in this matter.
Why did the crew not show any “urgency” on scene with the patient?
The attending crew are experienced staff who understand the importance of a calm manner when dealing with a
time-critical patient. Both the Paramedic and Technician expressed concern about how anxious the patient was,
and the possible impact that could have on the progress of the patient’s heart attack. Due to this, both crew
member purposefully kept their manner relaxed. The clinical review confirmed the importance of the crews
manner in such circumstances. The clinical review states that time taken before leaving scene is the amount he
would expect for a patient that needs to be taken out of an upstairs room. Both crew members acted correctly in
their actions.
Why did the crew member use the toilet in the house?
Though such a request is not ideal as the Technician was aware there was a long drive ahead his actions are
understandable. At no point was the patient left alone whilst the Technician used the facilities, and this did not
delay the patient leaving for hospital. Had the Technician not used the facilities beforehand it is not to rule out the
possibility that it would have affected his concentration when driving on blue light, or his assistance of the patient.
Due to this the Technician acted correctly in dealing with the issue on scene.
Why was the patient asked to walk downstairs and to the ambulance?
The Crew members did not want the patient to walk downstairs, but to use the carry chair they had provided. The
patient was very anxious on their arrival, and discussions about being carried downstairs just increased the
patient’s stress levels. Both crew members were experienced, and understood the implications on the patient’s
condition if they were not able to reduce his stress levels. Due to this, and consideration for the narrow staircase,
the Paramedic used his clinical decision to slowly mobilise the patient. The carry chair was placed at the bottom of
the stairs, and the patient was asked to use the chair when he reached it. The patient refused again, to use the
chair and also the offer to bring the trolley to the front door. An assessment supported the paramedic’s clinical
judgment to slowly mobilise the patient in these circumstances, and that there was no care management failure.
The paramedic’s actions were correct.
Why was the patient not kept warm?
Whist it is important that the patient is kept warm, there are certain procedures that must be completed first. On
arriving at the trolley, the paramedic had to bare the patient’s chest to reconnect him to the monitors. Then the
Paramedic needs to check other observations and note them down in the Patient Report Form.
Good
documentation in time-critical is patients is essential, as per Joint Royal Colleges Ambulance Liaison Committee
(JRCALC) guidelines. As soon as this was complete, the paramedic ensured that the patient was covered with a
blanket. The clinical assessment of the PRF confirms that these procedures would need to take priority over
placing the patient over the patient. Both crew members explained, during interview, that the doors cannot be
immediately closed as the carry chair and ramp need to be stowed first. This took a couple of minutes, but the
doors were closed as quickly as possible to ensure patient privacy.
Why was patient initially going to LCH?
The patient was initially going to be taken to LCH as this is the local hospital with a Percutaneous Coronary
Intervention unit. The is a specialist department that is used, in an emergency situation, to stabilise patient’s
suffering a heart attack and is to reduce any blockage of the arteries. This was not a procedure to replace the
patient’s need for a triple bypass at a later date, but one intended to give the patient the best possible chance in
emergency conditions. The actions of the crew in taking the patient there was correct, and complied with the
Trust’s and JRCALC guidelines for such situations.
Why was the patient’s wife not belted in?
Though it is best policy for the crew to belt in any passengers in the ambulance, this can sometimes be overlooked.
The legal onus regards the belt lays with the patient’s wife, as she is an adult, not with the Technician. The crew
were actively dealing with a patient having a heart attack, and were not informed by the wife that she did not have
her belt on at any time. Due to this the crew cannot be held responsible for the wife’s seatbelt as she did not bring
this to their attention.
Why was the patient’s wife handed ampules of morphine to open?
The paramedic was actively dealing with a patient who was in active cardiac arrest on the back of a fast moving
ambulance. The patient’s wife described the ambulance as rocking substantially. The paramedic politely asked the
wife to open the packaging around the morphine ampules. This is difficult to do when the ambulance is stationary,
and even more so in this situation. The wife did not abject to assisting in this matter, and this allowed the
paramedic to do other treatments in the meantime. The paramedic was grateful for the wife’s help, but stated
had she not assisted he would have opened the packaging himself.
Why was the patient taken to BPH instead?
When the patient went into cardiac arrest, the crew had to alter their treatment plan. The patient’s condition now
required stabilisation at the nearest Emergency Department. Due to this the crew correctly diverted to BPH and
alerted the Resuscitation team that they were coming in with an active cardiac arrest. This action was supported
by the clinical review and by Trust procedure in such circumstances.
Why did the ambulance not stop when patient went into cardiac arrest on the second occasion?
This was because the paramedic now had everything he needed to give Advanced Life Support from the first
arrest. As the ambulance was mobile and had an estimated time of arrival to hospital of 10 minutes. The crew
acted correctly by continuing to hospital to ensure patient could receive additional assistance as soon as possible.
Why did the paramedic “wedge” patient’s arm into the trolley?
The patient was subject to active cardiopulmonary resuscitation, this involved him being shocked during the
journey. The paramedic has stated he was concerned what would happen if the arm touched him or the wife
when a shock was delivered. Due to this the paramedic had to put the arm back. Clinical assessment of this
matter supports the paramedic’s actions as the over-riding priority was saving the patient’s life. If the arm was
hindering this treatment, then the paramedic was correct in moving it out of the way.
Why didn’t the driver avoid the road works, and did this delay hospital treatment?
The Technician could not avoid the road works as he did not know they were there. The Technician took the best
route to the hospital as he could to ensure the patient received prompt treatment. The estimated traveling time
from the patient’s home to the hospital is 30 minutes. For 10 minutes of the journey the ambulance was heading
along the A17 and the A15. This is the route to LCH and not for BPH. The ambulance then had to pull over to deal
with the first cardiac arrest, before turning around to divert to BPH. Total time taken for the ambulance to arrive
to the hospital was 32 minutes. With due consideration for all the facts there is no indication that the Technician
delayed transport at all. The time achieved indicates that the Technician made good time to hospital in the
circumstances.
Date Resolved:
Grade: Major
Status: Unresolved
Letter Date:
None
Evidence Gathered
WAV file 999 call
WAV file radio transmissions x 13
PRF
PRF audit
CAD SOE
Complaint letter
Record Verbal Interview T1
Record Verbal Interview P1
STEIS escalation form
STEIS board response
Non Conveyance Guide
Seatbelt law
identified.
Source: Email
Final Contact Date:
Harm Rate: Negligible
G3
Area/Divisional: North Notts
Patient Outcome:
Surgery required
Summary: G2 Delayed Response-Ruptured Aneurysm
Case Details: Three 999 calls were received to patient complaining of leg pain. Initial call was coded G3 and sent to
the Clinical Assessment Team for further triage. The following two calls were coded G2. Family state that an
ambulance was not with patient until 70 minutes. Patient had history of ruptured aneurysm
• Were the calls coded, and handled, correctly?
• Was there a delay in attending the patient?
• If there was a delay what was the cause?
Timeline of Events
Date and Time
Event
4 Sept 2013
Incident Number 1
18:51
18:53
999 call received to ---year old female with pain in right leg
Call coded G3 (26A01) and sent to Clinical Assessment Team (CAT) for triage within 20
minutes
Incident Number 2
nd
2 999 call received – leg turning blue/black swelling
Community First Response (CFR) desk checks Resource Allocation (Res/Alloc) –
No CFR in area
CAT triage starts
19:12
19:14
19:15
19:16
Call coded G2 (on scene response within 30 minutes) – altered level of consciousness
19:18
19:37
19:42
Dispatch Officer (DO) upgrades call 1 to G2 call and checks Res/Alloc
DO checks Res/Alloc and nearest available Fast Response Vehicle (FRV) assigned
FRV stood down and diverted to R1 (highest priority) call
Incident Number 3
rd
3 call received to the patient stuck upstairs – cannot move
Call coded G2
DO checks Res/Alloc and FRV re-assigned back to this detail (no patient found on R1 call)
FRV arrived on scene
FRV requests Amber back up
Double crewed ambulance (DCA) assigned
DCA arrived on scene
DCA left scene
DCA arrives at hospital
FRV clears scene
19:44
19:52
19:55
20:06
20:08
20:14
20:31
20:46
20:59
20:53
Service issues
Divisional Resource Log (RL) shows DCA x 6 shortages across the division; no Team Leader South of division; and 3
x FRV shortfall.
At 19:57, Duty manager Resource Log (RL) shows Division holding: 7 x G2; 9 x Doctor’s Urgents.
Divisional Fleet database shows 7 DCA off line on this date
Weather review show temperatures averaging 20 degrees; no impact on service delivery
On the 4 September 2013, at 18:51, a 999 call was received to a patient with pains in her leg. The call was coded
G3, and passed to the Clinical Assessment Team (CAT) as suitable for further triage within 20 minutes. An audit of
this call has shown that it was correctly handled and coded G3.
At 19:15, the call is picked up by a member of CAT for triage. This was 4 minutes outside the required ring back
timescale, and by this point the family was calling back with a second 999 call for the patient. The second call, at
19:12, was then coded as G2, with an on scene response of 30 minutes being required. This call has been audited
as correctly coded, but that the Emergency Medical Dispatcher (EMD) failed to stay on line with the patient. Due
to this the compliance score for this call was 74%, with the target score being 90%.
At 19:44, a third call was received to the patient. This call was again coded as G2. This call has been audited as
correctly coded, but only scored 76% for compliance. This was because to EMD gave no instructions on the care of
the patient, and failed to stay on line with the patient. Both EMD’s are being referred to the Training Team
regards following the relevant calls.
At 20:06, a Fast Response Vehicle (FRV) arrives on scene with the patient. This is was outside the 30 minute
required response time by 24 minutes. At 20:06, the FRV then requests Amber backup. The Solo Responders SOP
V1.0 states this level of backup is for patients that an not in an immediate life threatening, but where the patient
requires prompt treatment to prevent deterioration.
At 20:31, a Double Crewed Ambulance arrives on scene. A clinical assessment of the Patient Report Form (PRF)
indicates that the patient received appropriate treatment on scene for a possible ischaemic (not enough blood
supply to) foot.
Assessment of resources available to the Division on the 4 September 2013 shows a shortfall of multiple vehicles.
The Division was down 6 x DCA; 3 x FRV and one Team Leader. The Divisional Fleet Database records that an
additional 7 DCA were off line on this date. These factors would have impacted on the Divisions ability to respond
in a timely manner to calls received. At 19:57, the Duty Manager noted that the Division was holding 7 x G2 calls,
and 9 Doctors Urgents (non-blue light collection of patients).
Conclusion
Were the calls coded, and handled, correctly?
Call 1 was correctly coded, and handled, when the patient condition was assessed as suitable for further triage by
the Clinical Assessment Team (CAT). Calls 2 and 3 were both coded correctly, G2 (on scene response within 30
minutes), but neither Emergency Medical Dispatcher (EMD) scored the required 90% compliance for these calls.
On both occasions the EMD failed to stay on line with the patient, who was reported to not be alert. Due to this
both EMDs, handling call 2 and 3, have been referred to the Training Team.
Was there a delay in attending the patient?
Yes. When call 2 was coded G2 the response to the patient’s condition was upgraded to a lights and sirens
emergency. This required that the Trust be on scene with 30 minutes of the receipt of call 2. This timescale was
not achieved as the first Trust resource was in scene 24 minutes after this time had expired. Due to this delay the
Trust failed in its duty of care to this patient.
If there was a delay, what was the cause?
On the date of this incident, the Division had a shortfall of 6 Double Crewed Ambulances; 3 Fast Response Vehicles
and 1 Team Leader. In addition to this, was that 7 Double Crewed Ambulances were off line for maintenance.
These shortfalls had an impact on the ability of the Division to respond to incoming emergencies. At 19:57, the
Duty Manager noted that the Division was holding 7 G2 calls, and 9 non-emergency Doctor Urgents.
Recommendation
EMDs (LF & PB)
achieving less that
90% to have record
of conversation
regards call
Action
Any calls that result
in a compliance
score of less the 90%
are to receive 1 to 1
feedback during a
record of
conversation to
ensure reflective
practice
Lead
Training Team (HY)
Due Date
09/02/14
Evidence
Record of
conversation
Evidence Gathered
Fleet data, Call audits, Dispatch Deployment Framework May 13, CAD SOE x 3, PRF, PRF audit, Duty Manager RL,
999 call handling info sheet, WAV files of 999 calls
Type: EOC Issue
Category: EOC/CAT Callback Issue
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Reported as Patient Safety Incident: N – EOC delay
Harm Rate: Patient outcome not known
Green 4
Base: Private house
Extension: XX
Area/Divisional: South - Leicestershire
Patient Outcome:
Taken to hospital
Summary: Call Handling&NonProvision - Kidney Pain
Case Details: Pt had acute right kidney pain. He'd called 999 at around 22:15 and was told that someone would
ring him back. Mother rang 999 at 22:45 and was told someone would ring her back. No one rang them back.
Parents took pt to LRI in their car.
• Why was an ambulance not sent straight away to the patient?
• Why did the patient not receive a call back?
TOR agreed by:
Complainant
Crew Stood Down:
Date: 28/10/2013
Timeline of Events
Date and Time
Event
Date
Incident Number
19 Oct 2013
22:27
5925171/5925201/5925305
new call received; call ref. 5925171, on behalf of a --- year old male with severe kidney
pain.
resource 4017, double crewed ambulance (DCA), allocated to incident.
call assessed as a Green 4 requiring a call back from a clinician within 60 minutes.
Resource 4017 stood down from the incident.
further call received call ref. 5925201. Call assessed as a Green 4 and stopped as a
duplicate of call ref. 5925171.
Clinician attempts to make a call back to the patient. No reply and call marked to attempt
again shortly.
Clinician makes a further attempt to call the patient, with no reply. Call upgraded to a
Green 1 20 minute response in line with no contact policy. New call created under call ref.
5925305.
resource 4933, solo responder, allocated and mobile to incident. CAD message: no reply to
several phone calls, Contacted Nuneaton Accident and Emergency but patient has not selfpresented there. Upgraded as per no contact policy.
resource 4933 stood down from incident as not required.
22:28
22:29
22:40
23:13
23:40
23:47
23:53
00:02
Handling of emergency call: the call was assessed as requiring a call back from a clinician within 60 minutes. A
return call was attempted 46 minutes after receipt of the original call with no reply. When a further call was
attempted at 23:40 with no reply, the call was correctly upgraded to a Green 1 20 minute response under the
Category C Emergency Call Procedure. A resource was allocated at 23:47 and this arrived on scene at 23:53.
Although this was one hour and 26 minutes after receipt of the original emergency call procedures in line with the
call coding had been followed.
Conclusion
The call was correctly coded as a Green 4 requiring a call back within 60 minutes. When no contact could be
established with the patient the incident was marked as ambulance required under the Category C Emergency Call
Procedure.
Date Resolved:
Grade: Minor
Status: Resolved.
Evidence Gathered
CAD report
Category C Emergency Call Procedure V4
identified.
Source: PALS Office
Final Contact Date:
Harm Rate: Nil
Base: Public Place
G2
Patient Outcome: Treated AE for broken leg
Summary: RTC-Inappropriate Comments To Police
Case Details: Patient had a motorcycle accident where he was side swiped by a car causing a broken femur.
Police breathalysed the patient in the back of the ambulance. The ambulance woman followed the policeman off
the ambulance asking for a quick word with him, then stated to him that the patient had been speeding. The
Patient claims that this is untrue and shouldn't have been said or anything to do with her, as she wasn't there to
witness any of the accident. Patient believes this is slander towards him and his personal character as her opinions
and thoughts on this incident should have been kept to her self
• What did the female crew member say to the police?
• Was it appropriate for her to do speak to the police on this matter?
• Did the Paramedic’s actions amount to Slander?
Timeline of Events
Date and Time
Event
29 Sept 2013
Incident Number 1
13:40
13:44
999 call received to Rod Traffic Collision (RTC) car v. motorcycle
Double Crewed Ambulance (DCA) assigned with 9 minute eta
13:46
Incident Number 2
Police call control with details of the RTC – confirm they are mobile
13:48
Police notified Log 234
13:52
14:48
15:26
16:22
DCA leaves scene
DCA arrives LCH
DCA clears hospital
On 29 September 2013, 13:40, a 999 call was received to a Road Traffic Collision (RTC) – car versus motorcycle.
The call is coded as a G2 response requiring a 30 minute on scene attendance by the Trust. At 13:52 a Double
Crewed Ambulance (DCA) arrives on scene, achieving the required timescale.
On arrival the Paramedic (P1) spoke with members of the public who had witnessed the accident to ascertain the
speed at which the RTC had occurred. During these enquiries, the Patient Report Form (ePRF) notes, witnesses
stated that the patient had been traveling at 40 to 50mph, which contradicted the patient who stated he had been
traveling at 30mph.
The patient was then taken into the ambulance, and the investigating Police Officer spoke to P1 to ascertain
whether any injuries were potentially life threatening. P1 recounted what she had been told by all parties, and
stated she could not tell if the injuries were life threatening until she had completed a full assessment. Clinical
Team Mentor (CTM) confirms “that it is very important that the attending clinician makes enquiries as to the speed
of any person or vehicle involved in an RTC as this information and the mechanism of injury in vital in the patient
treatment…. The police will ask the condition of the patient and information of their likely outcome as this can
determine if they are required to close the road etc.” P1 did not divulge any patient sensitive information, and
complied with her legal requirement to assist the Police in the course of their duties. P1 did not breach any Trust
Information Governance policies and complied with Health Care Professional Council (HCPC)regards to lawful
disclosure as within the patient’s best interests.
The Complainant states that the actions of P1 amounted to slander. This term relates is where a person knowingly
speaks an untruth about another, with the purpose of intentionally damaging the reputation of the other. In this
case P1 recounted, honestly, the information she had been given by members of the public. This does not fall
within the remit of Slander. It is a HCPC requirement that she assist in any lawful investigation when required to
do so. P1’s actions in this matter were correct.
Conclusion
It is essential in all RTC’s that the speed at impact is established to assist in ascertaining if the patient has life
threatening injuries; if the patient needs to go to a specialist Trauma Centre; or if the Police need to close the road
down. This action is covered within the best interest for the patient, as per Health Care Professional Council
(HCPC) Guidelines. The Paramedic did not discuss anything relating to Patient Sensitive information, but worked
with Police to try to establish what happened in the Road Traffic Collision (RTC).
The Paramedic’s actions do not amount to slander. The Paramedic honestly recounted information she had been
given to assist in a legal investigation. The Paramedic attending the patient complied with her HCPC Paramedic
Registration, Trust Information Governance Policies and legal duty, by assisting the Police Officer in the course of
his duties.
Date Resolved:
Status: Unresolved
Grade: Minor
Letter Date:
Evidence Gathered
WAV file 999 call 1
WAV file 999 call 2
CAD SOE 5875867
CAD SOE 5875880
PRF
CTM response
identified.
Type: Patient Not Taken To Hospital
Source: Letter
Delays Incurred
Reason for Delay: Unable to obtain case information from LQM
New Agreed Date: XX
Harm Rate: Patient admitted to ITU
Green 3
Extension: XX
Patient Outcome:
Admitted to ITU
Summary: Diabetic Ketosis Left At Home
Case Details: Diabetic vomiting, generally unwell for 2 days.
In the early hours of the morning patient had trouble breathing and his heart was beating fast so he rang 999.
Ambulance arrived and paramedic did blood sugar, ECG, BP.
Paramedic rang patient parents to go and sit with him then left.
A few hours later, patient was worse so parents rang 999 again.
This time patient was blue lighted to hospital, taken to resus, transfered to intensive care and put on a kidney
machine due to ketosis.
• Establish what observations and diagnosis were undertaken by the attending clinician
TOR agreed by:
Complainant
Date: 5 November 2013
Crew Stood Down:
No. If No state rationale: Following telephone interview the decision was made within
division not to stand down the member of staff.
•
•
•
•
•
•
•
•
•
•
•
Name:
Skill: Paramedic
EE date: 17 April 2013
IPR/PDR date: to follow
Name:
Skill: ECA
EE date: to follow
IPR/PDR date: to follow
•
Timeline of Events
Date and Time
Event
Date
Incident Number
1 Oct 2013
02:19
5879548/5879584
new call received on behalf of a --- year old male who is struggling to breathe and
dehydrated. Patient is also a diabetic.
call assessed as 06C01, breathing problems, abnormal breathing, allocated a Green 3
code, return call from clinician within 20 minutes.
resource 5011 stood down from incident. Reason for stand down: category C call.
Return call to patient for further assessment. Patient advises his blood sugar reading is 26.
call stopped and response upgraded to a Green 1 20 minute response under new call
reference 5879584.
resource 4210 calls clear from scene, patient treated on scene.
02:20
02:20
02:21
02:21
02:41
02:49
02:50
02:51
03:07
04:48
Handling of emergency call: the call was originally coded as a green 3 call, requiring a telephone assessment
within 20 minutes. The telephone assessment commenced 22 minutes after receipt of the call. This was two
minutes outside the target timeframe. At 02:49 the call was upgraded to a Green 1 response within 20 minutes,
and the attending crew arrived 18 minutes later.
Care and treatment of the patient: the attending clinician advised that on arrival he and his crewmate were met
by the patient who was breathing very fast and was very anxious. The patient had been vomiting since 15:00 the
previous day and he was an insulin dependent diabetic. The patient also explained he got very nervous and
anxious when in a medical environment or situation. The Paramedic assessed the patient’s breathing and this
eased with reassurance and coaching. The patient’s oxygen saturation level was 100% and his chest was clear. The
patient was tachycardic, hypertensive and his blood sugar reading was high. The patient was fully alert with a GCS
of 15, and he was able to give full details of his medical history with no signs of confusion. The Paramedic
questioned the patient about his diabetes, and the patient advised that he had not taken any of his novo rapids
due to concerns about his continued vomiting. The patient stated he was previously well and had not had any
issues with his diabetes before.
The Paramedic explained that the most appropriate course of action would be for the patient to be taken to
hospital, but the patient did not wish to travel. The Paramedic referred to the out of hours GP service for further
advice, and the GP advised that the patient should take six units of his novo rapid as this should stabilise his blood
sugar levels in the next hour or so. The patient was also advised to drink little and often and monitor his blood
sugars over the next few hours.
The Paramedic was concerned about leaving the patient on his own and he rang the parents and spoke to the
patient’s mum. The Paramedic relayed the information and advice given by the doctor, and asked if the parents
could come and sit with their son. The patient’s mother advised that they would be there in about 20 minutes.
The patient was also advised of the doctor’s comments, and told to monitor his blood sugar levels. He should call
999 again if these did not lower, and he was given advice on warning signs to look out for such as a deterioration in
his breathing or dizziness. The patient was also advised again about the need to rehydrate himself. The patient
signed the form confirming he did not wish to travel to hospital and he was advised to contact his own GP to
discuss the ECG results, as recommended by the out of hours GP. The Paramedic then left the patient to await the
imminent arrival of his parents.
The Paramedic has confirmed that he placed a telephone call to the parents’ house the following day to ask how
the patient was doing. This was not in any way because he had concerns about his treatment of the patient, but
purely because he had the number on his phone and therefore he had the opportunity to make a welfare call.
The Paramedic has stated that if he were faced with the same circumstances again he would have enlisted the help
of the GP and the parents in trying to persuade the patient to attend hospital. Although the patient did not wish to
travel due to the anxiety this would cause him, admission was appropriate. The Paramedic feels that if he had
made the decision to wait for the parents’ arrival he could have asked them to influence the patient’s decision.
Clinical opinion on PRF and care and treatment given: the divisional Consultant Paramedic has reviewed the
report and the PRF, and has highlighted a number of deficiencies in the PRF documentation. Given the information
available it was not considered appropriate to leave the patient at home.
Conclusion
The decision to leave the patient at home was not appropriate given his presenting condition. This has also been
acknowledged by the Paramedic. Safety netting was put in place by contacting the out of hours GP and the
patient’s parents.
Date Resolved:
Status: Resolved
Grade: Moderate
Action: File note discussion with the Paramedic. This should include a review of the PRF and the decision to leave
the patient at home. It should also be pointed out that telephoning the patient’s parents to check on his condition
was not appropriate.
Improvement: Improvement in PRF completion and decision making processes.
Outcome Detail: Consider a random PRF audit for a period of time.
For:
Evidence: File note of discussion and decision re PRF audit.
Evidence Gathered
Statement of attending member of staff
CAD report
Clinical opinion from CP
PRF
identified.
Type:
Category:
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: Nil
Base: EOC
Area/Divisional: Derby
Patient Outcome: Settled with painkillers
Extension: XX
Summary: Abdo Pain - Triage Self Care Advised
Case Details: Patient with abdo pains was coded for CAT assessment. Mother was advised that patient's condition
did not require an ambulance and adviced to contact 111 or look up symptoms on "Google". Patient's condition
settled down afterwards, and was taken to see the GP. Mother feels being told to Google something is not
acceptable as this may have been a life threatening emergency.
CAD 5963768 refers
• Was the call correctly handled?
• What was the patient’s mum told, and was this correct?
Timeline of Events
Date and Time
Event
4 Nov 2013
18:48
18:48
18:49
19:01
999 call received to --- year old male with recent onset abdominal pain
Call coded G4 (01A01) and passed to the Clinical Assessment Team (CAT)
CAT coordinator requests Capacity Management Plan (CMP3) speech be given
Emergency Medical Dispatcher (EMD) calls back and gives CMP3 speech
Service Issues
A8 performance – 67.10% (required target 75%)
A19 performance – 90.95% (required target 95%)
On the 4 November 2013, a 999 call was received to a --- year old male with abdominal pains. The call was coded
as G4, suitable for further triage by the Clinical Assessment Team (CAT) within 60 minutes. The Emergency
Medical Dispatcher (EMD) then informed the patient’s mother that they would receive a call back. This call was
audited as correctly coded, but highlights that the incorrect speech was initially given. At the time of this call the
Trust had implemented Capacity Management (CMP) 3. This means all calls coded G4, where the patient is aged
between 5 and 69, are told: “We are currently experiencing very high demand for emergency ambulances. From
the information you have given me, we will not be sending you an ambulance. Our advice is to contact a GP, phone
NHS 111, make your own way to a Minor Injury Unit or to an Emergency Department. You could check your
symptoms online at the NHS Direct website. I need to hang up now (to take another call). If anything changes, call
us back immediately on 999 for further instructions” The EMD was contacted by a member of the CAT assessors,
and asked to call patient’s mother back and deliver the correct speech. The EMD did this promptly, apologised for
this error, and delivered the correct speech.
The Capacity Management Plan is designed to “manage demand, and resources, during high call volumes, where
the supply of ambulance service resources is insufficient, or potentially insufficient, to meet the clinical demand of
patients.” The level, CMP 3, is only instigated if 45 or more calls are being held in the region. The aim of the CMP
actions is to maximise responses to the most seriously unwell patients.
Conclusion
Yes. The call was correctly handled by coding it as a G4 call. The Emergency Medical Dispatcher (EMD) did,
initially, give the wrong instruction that a Clinician would call the patient’s mother back. The EMD did rectify this
mistake by calling the patient’s mother straight back, apologising, and then giving the correct speech.
What was the patient’s mum told, and was this correct?
Yes. At the time of the call the Trust had implemented the Capacity Management Plan (CMP). This is used to
manage demand on Trust resources at times of high demand, and is designed to ensure that the Trust maximises
its resources to treat the most seriously unwell patients. On this occasion the CMP level activated was level 3.
This is only activated if the Trust is holding 45 calls, or more. When level 3 is instigated any patient condition,
between the ages 5-69, identified as non-life threatening is given the following speech:
“We are currently experiencing very high demand for emergency ambulances. From the information you have given
me, we will not be sending you an ambulance. Our advice is to contact a GP, phone NHS 111, make your own way
to a Minor Injury Unit or to an Emergency Department. You could check your symptoms online at the NHS Direct
website. I need to hang up now (to take another call). If anything changes, call us back immediately on 999 for
further instructions”
The speech is used to explain the reason why an ambulance is not being provided; signposts the caller to additional
sources of advice more suitable for the patient’s condition; and finishes with giving the caller advice should the
patient’s condition worsen. This complies with Department of Health guidelines.
Date Resolved:
Grade: Negligible
Status: Unresolved
None
None
Evidence Gathered
CMP
Call audit
DM RL
WAV files 999 call and CMP3 speech
identified.
Type: Patient Not Taken To Hospital
Source: PALS Office
Delays Incurred
Reason for Delay: Admin Error/Failure
New Agreed Date: XX
Harm Rate: 0
Green 2
Patient Outcome:
Attended
hospital
Extension: XX
Summary: Dislocated Knee - Not Taken To Hospital
Case Details: CAD 5929074 - Green 2
Pt dislocated her knee. Paramedic attended and gave her gas & air. Popped knee back in and said that pt didn't
need to go to hospital.
Parents later took her to A&E where an X-ray found torn ligaments and her knee was full of blood. Knee in a splint
and pt unable to go to school.
• Establish why patient was not taken to hospital.
TOR agreed by:
Complainant
Crew Stood Down:
No. If No state rationale:
•
Staff support and involvement: DM – Paramedic Skill level, EE date :not completed for 2013/2014 IPR date:
11/09/2013
•
Being Open
Timeline of Events
Date and Time
Event
21 Oct 2013
12:44
12:47
new call received call ref. 5929074 on behalf of a --- year old female who has slipped over.
call assessed as 17B01G, falls, possibly dangerous body area, patient on the ground or
floor. Green 2 30 minute ambulance response.
CAD message: knee cap is out to the side.
CAD message: K0 no available resources.
further call received, call ref. 5929171. Stopped as a duplicate of call ref. 5929074.
Resource 4045, solo responder, allocated to incident.
resource 4045 calls clear, patient treated on scene.
12:47
12:48
13:28
13:34
13:35
13:43
15:02
Handling of emergency calls: the first call was received at 12:44 and was correctly coded as a Green 2 30 minute
response. The second call was received at 13:28 and was identified as a duplicate of the first call with no change in
the patient’s condition. The responding resource arrived at 13:43, which was a response time of 59 minutes and
outside the target timeframe of 30 minutes.
09:59 Leics holding two Red 2 calls and six Green 2 calls.
12:21 Leics holding one Red 2 and one Green 2 call, still in overcapacity plan.
Entries from Leicestershire dispatch desk (LEICS) resource log:
10:32 holding multiple calls in Leics city.
10:54 Leics rural holding two Green 2 calls.
11:53 Leics rural holding one Green 2 call and running 60 minutes to a Red 2 call.
13:35 Leics rural holding two Green 2 calls.
14:48 Leics city holding one hot back up, one Red 2 call, one Green 1 and two Green 2 calls.
Care and treatment of the patient: The patient’s mother has stated that she was advised the patient would not
need to go to hospital. The patient was given gas and air and the Paramedic then popped the knee cap back in
place. Following the incident the injury appeared to get worse with swelling and pain, and the patient was taken to
hospital later that evening where it was diagnosed that her knee ligaments were torn and her knee was full of
blood.
The attending Paramedic has advised that when she arrived on scene she was met by the patient’s mother who
was anxious about the length of time it had taken to get medical help. The Paramedic apologised for the delay and
the mother took her upstairs to the patient, who was sat on the bedroom floor. The patient was understandably
scared and distressed and in a considerable amount of pain. The Paramedic undertook an initial examination and
observations, and she spent a considerable amount of time administering gas and air to the patient to ease the
pain and get her to relax. The patient was then helped to slowly straighten her leg and the knee cap relocated. This
had the effect of immediately relieving much of the patient’s pain although she was still in discomfort.
After a further short period of time the Paramedic encouraged the patient to try and bear weight on her leg, and
the patient was able to walk slowly around her bedroom. She was still suffering discomfort but the pain was
considerably less. The Paramedic recalls discussing the options with the patient and her mother, including
requesting an ambulance to take the patient to hospital, referring the patient to her GP or for the patient to
remain at home and see how her knee felt later. The patient did not want to go to hospital, and it was decided that
she would remain at home. The Paramedic discussed warning signs to look out for such as swelling or numbness,
as there was a possibility that when the knee cap relocated something could have become trapped.
The Paramedic formed the impression that the patient and her mother were happy with the outcome. The patient
was asked if she was going to remain upstairs, and when she advised she was not the Paramedic offered to stay
until the patient had negotiated the stairs. The Paramedic preceded her down the stairs, and after the patient had
completed the descent the Paramedic called clear from the scene. At this point the patient was still in discomfort
but her dislocation had relocated and her pain was considerably less.
Clinical review of care and treatment of patient: the report and PRF have been reviewed by the divisional
Consultant Paramedic and this has concluded that the patient should have been conveyed to hospital so the injury
could be x-rayed. This is particularly the case as this was the first instance of this type of injury.
Conclusion
The response time of 59 minutes was outside of the target timeframe of 30 minutes.
The Paramedic has advised that the patient did not wish to travel to hospital although this was discussed as a
possible option. However the Consultant Paramedic review of the care and treatment has concluded that the
patient should have been conveyed to hospital to exclude any underlying injury by undertaking an x-ray. The first
episode of this type of injury should heighten the awareness of a requirement for x-ray.
Date Resolved: 09/12/2013
Grade: Moderate
Status: Resolved
Action: File note discussion with the Paramedic. This should include the decision to leave the patient at home due
to the nature of the injury and in particular because the first instance of a dislocation should heighten the
awareness of the requirement for an x-ray to be undertaken to exclude any underlying injury.
Improvement: Improvement in the decision making processes.
Outcome Detail: Improved awareness of the need to consider underlying injury.
For:
Evidence: File note of discussion.
Evidence Gathered
CAD report
PRF
Statement from Paramedic
Clinical opinion from Consultant Paramedic
identified.
Type: Delay
Category: Service Failure
Harm Rate: 1
Area/Divisional: Notts
Base: EOC
Source: Social Media
Initial Call Coding: G2 (29D02L)
Summary: Delayed Response To RTC
Case Details: Sent via Twitter: Hi I'd like to talk 2 u re 1.5hr wait for ambulance lying w/multiple inc head injuries
in puddle on A60 after hit by car
•
•
•
•
•
Were the calls correctly handled and coded?
Was the first response on scene late, if so by how long?
What backup request was made for a Double Crewed Ambulance (DCA)?
What was the cause of the delay for the backup?
What is the Trust doing to improve on these delays?
Timeline of Events
Date and Time
Event
01/11/2013
18:18
999 call received to a --- year old female hit by car whilst riding her bike. EMD takes 5
mins to zone address
Call coded G2 (29D02L)
Dispatch Officer (DO) checks Resource Allocation (Res/Alloc)
K13 (Police) administering oxygen to patient; facial injuries
DO checks Res/Alloc
nd
2 call received to RTC from K13 – CAD 5956034 coded G2 (29D02L)
Fast Response Vehicle (FRV) allocated
nd
2 FRV assigned
st
nd
FRV stood down (both at HART base) driver of 1 FRV swapping into 2 FRV car
18:24
18:25
18:28
18:29
18:31
18:43
18:44
18:45
19:03
19:13
19:21
19:26
19:33
19:34
19:48
19:56
19:57
20:15
20:39
nd
2 FRV arrives on scene
FRV requests Red backup
Note in CAD: Desk aware, currently K0 (no resources available)
Automatic message generated: FRV at scene over 20 minutes
Automatic message generated: FRV at scene over 30 minutes
FRV asking for ETA – advised K0
Radio message from FRV – Patient moved out of the rain to pub alcove
DO checks Res/Alloc
Double Crewed Ambulance (DCA) assigned
DCA arrives scene
DCA leaves scene
FRV clears call
DCA arrives hospital
DCA clears hospital
Service Issues
Divisional RL notes, at 18:17 – Holding 1 x Red backup; 5 x G2; 6 urgents
Duty Manager (DM) Resource Log (RL) notes, at 18:31 - Trust in Capacity Management Plan (CMP) 1&2
Divisional RL notes, at 18:41 - all resources committed no cover available, with still majority of
Late/afternoon city resources to start break due to workload, will affect performance
further from days holding x6 uncovered g2 calls, longest 1801 x 6 drs urgents
Divisional RL notes, at 18:59 – 1 x R1 call and 1 x R2 call uncovered
Divisional RL notes, at 19:05 – Holding multiple calls city, all categories, running excessive distance
Divisional RL notes, at 19:27 – Longest G2 call holding 18:01
A 999 call was received to a --- year old cyclist who had been hit by a car. The call was audited as correctly
handled, and coded as a G2 call. This requires that a response from the Trust arrive on scene within 30 minutes.
The audit did establish that there was a 5 minute delay in the Emergency Medical Dispatcher inputting the
location. The location of the Road Traffic Collision (RTC) was in the centre of a built up location, and on a very long
road, covering multiple areas of the city. This difficulty did not contribute to a delayed response as the
approximate co-ordinates for the mobile phone number were received by when the call connected. These coordinates do give the Dispatch Officer (DO) a rough indication of where the call is coming in from. This information
would have been sufficient for the DO to start an available resource running, as per the Dispatch Deployment
Framework (DDF), Oct. 2013, requirements.
At 18:24 the DO checks the Resource Allocation (Res/Alloc) for the first time. This is a computerised function that
allows the DO to see what resources are available to attend this call. This delay is a breach of the DDF Activation
and Mobilisation procedure. Under this policy the DO should have checked the Res/Alloc as soon as the initial call
was received. The DO failed to do this until 6 minutes into the call.
The DO assigns a Fast Response Vehicle (FRV) to the call which arrives with the patient at 18:43, achieving the 30
minute response time required. A Double Crewed Ambulance (DCA) was shown as mobile and available but was
not assigned to this call. The DO acted correctly in not assigning this DCA. The DCA was in the last minutes of its
shift, and under the DDF, cannot be assigned to G2 calls within the last 30 minutes. Shortly after arriving the FRV
requests Red Backup. This requires that any DCA attending a call, coded lower than R2 (8 minute response), be
diverted to this patient. Once assigned to this backup the DCA cannot be diverted to any other call. The DO
places a warning marker on the Computer Aided Dispatch (CAD) record regards to the backup request, and then
notes that the Division is currently “K0”. This is a code that signifies that the Division currently has no available
resources to assign to this backup. The DO does not check Res/Alloc to evidence this is the case, and is a breach of
the DDF which requires that Res/Alloc be checked regularly.
A review of the Duty Manager (DM), and of the Divisional, Resource Log (RL) shows that the Division was holding
12 calls when this RTC was received. At 18:31, the Trust activated the Capacity Management Plan (CMP) 1 and 2.
This is when the number of calls being received outstrips the Trusts abilities to respond. Levels 1 and 2 are
activated when the Trust is holding between 25 and 44 calls of any category. Though the DO did not complete
sufficient Res/Alloc checks to comply with the DDF, the detailed notes in the RL evidences that they would have
had limited time to do them without additional assistance. The Service Delivery Managers (SDM) are currently
looking at what additional support can be given to DO in such times so that Res/Alloc can be checked regularly on
outstanding calls.
Examination of the Divisional RL does evidence that the DO assigned the FRV to this RTC ahead of a G2 call that
was received at 18:01. At 19:27 this other G2 call was still noted as outstanding with no resource on scene at all.
This indicates that the DO used dispatch discretion to ensure that someone was with the patient from the RTC as
soon as possible. This is against the DDF, but was a correct action by the DO as it meant that the patient had
clinical help promptly.
Conclusion
Were the calls correctly handled and coded?
Yes. The calls were correctly handled, and coded for a G2 response. This requires that a Trust resource be on
scene with the patient within 30 minutes.
Was the first response on scene late, if so by how long?
No. This timescale was achieved with a Fast Response Vehicle arrived within 25 minutes.
What backup request was made for a Double Crewed Ambulance (DCA)?
The FRV immediately called the Dispatch Officer (DO) and requested Red Backup. This is the highest priority
request, and requires that the DO assign the nearest available DCA. The DO should also consider diverting any DCA
attending a call lower than R2. The DO acted correctly by placing a warning marked on the Computer Aided
Dispatch (CAD) record to show backup was required, and by informing that FRV that there were DCA available at
this time. This complied with the Dispatch Deployment Framework (DDF), Oct 2013.
What was the cause of the delay for the backup?
It is not possible to fully evidence why there was a delay in assigning backup to this call. The DO is required to
check the Resource Allocation (Res/Alloc) function regularly to show that there are no DCA that can be used. The
DO failed to do this, and so breached the DDF requirement on this matter. A review of the Resource Logs for the
Division show that the Trust activated Capacity Management Plan (CMP) 1 & 2 at 18:31. This means that the
number of calls being received outstrips the Trusts available resources. The level of 1 & 2 is instigated when the
Trust is holding between 25 and 44 calls of any category. The DO made regular updates in the Resource Logs
noting how many calls were being held at the same time of this call. Based on this information it is not believed
that the DO would have had sufficient time to regularly check the Res/Alloc on all calls holding without additional
support. The Service Delivery Managers (SDM) are currently reviewing additional support that can be given to the
DOs in such times of high demand.
What is the Trust doing to improve on these delays?
The Trust has just launched its “Better Patient Care Plan” which is hoped will markedly improve patient care within
a short timeframe. The main emphasis will be on clinical quality and response times. Within this action strategy is
the “Surge Plan” which will allow the Trust to respond more effectively in times of high demand. This includes
working with hospitals to ensure that ambulance crews are promptly able to hand over patients; reduction of lost
hours due to vehicle defects; and the implementation of an ambulance car service to reduce the pressures on
Emergency crews.
Date Resolved:
Grade: Negligible
Status: Unresolved
Recommendation
Refer Res/Alloc
omissions to SMD
(AC)
Action
SDM to review
Res/Alloc failures to
assess whether this
was acceptable due
to CMP 1&2 in
place, and whether
additional support
would have
benefited in this
case
Lead
SDM (AC)
Due Date
21/02/2013
Evidence
Confirmation email
Evidence Gathered
XXX
XXX
identified.
Type: Delayed Response To Red 1
Source: Letter
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
R1 (06E01)
Patient Outcome:
Treated at AE
Summary: Delayed Response- --- Year Old Boy S.O.B.
Case Details: 45 minute delayed response to --- year old boy who was 'gasping fro breath'. Also, the first
ambulance dispatched got lost. He also has general organisation questions about the ambulance service.
•
•
•
•
•
•
•
Why was the car sent from Brn?
Why did the car get lost?
Why did it take so long to get an ambulance to the patient?
Why does the complainant see ambulances resting in laybys?
Where is the extra funding, frontline staff, and changes, and how is this to be implemented?
Timeline of Events
Date and Time
Event
27 Aug 2013
20:41
999 call received to child gasping for breath and being sick
Dispatch Officer (DO) checks Resource Allocation (Res/Alloc)
Nearest Fast Response Vehicle (FRV) assigned with 17 minute eta from Brn
Community First Responder (CFR) Desk checks Res/Alloc – no CFR in area
DO sends out “K0 call” (request any crew available to clear)
DO checks Res/Alloc
Double Crewed Ambulance (DCA) assigned with 50 minute eta from --------FRV arrives on scene
FRV calls for directions
Emergency Medical Dispatcher still on line – offers to assist with directions
DCA leaves scene
FRV arrives clears on scene
DCA clears hospital
Duty Manager (DM) notes: Out of Performance Managers Report... FRV from ---- DCA from
---------- open mike broadcast but no response, responder not of skill to attend. No
abstraction area but experiencing high demand. No r1 assessment, cmp ½
20:42
20:43
20:45
20:58
21:03
21:04
21:11
21:29
21:43
21:54
22:28
23:27
Service Issues
Hospital handover 15 minutes
BPH – 22 minutes
GH – 19 minutes
LCH – 16 minutes
East Division Performance review
A19 response – 91.24% (target 95%)
R1 A8 (within 8 minutes) – 70.27% (target 75%)
R2 A8 (within 8 minutes) – 73.46% (target 75%)
G1 (within 20 minutes) – 81.70% (target 85%)
G2 (within 30 minutes) – 85.37% (target 85%)
G3 (triage within 20 minutes) – 88.21% (100%)
G4 (triage within 60 minutes) – 98.55% (100%)
East Division Resource Log (RL)
Shortfall of 2 x Double Crewed Ambulance (DCA); 3 x Fast Response Vehicles (FRV); and 1 Team Leader
On 27 August 2013 a 999 call was received to a --- year old male with breathing problems. The call was coded R1
and is audited as correctly coded. This is the highest code achievable, and requires an on scene response within 8
minutes. Any available resource should be immediately diverted to it, as a R1 coding takes precedence over any
other call. This action was correct under the Dispatch Deployment Framework (DDF), May 2013.
Upon receipt of the call, the Dispatch Officer (DO) immediately assigned a Fast Response Vehicle (FRV). The
assignment of this FRV was correct, as the only other resource nearer is already on scene at a call. The FRV is
assigned from the Brn area, with a 17 minute estimated time of arrival (ETA). The DO then complies with the DDF
by sending out a “K0” message. This is a required open mike message to all resources in the Division. It informs
them that there is a R1 call in the area, and where the assigned unit is coming from. The aim is for any resource
able to come clear to contact the DO for assignment.
At 20:42, the Community First Responder (CFR) desk checks the Resource Allocation (Res/Alloc) function. This
allows the desk to check for any available volunteers in the area to assist with the call. The desk noted that there
was a CFR on duty in the area, but that the CFR was not qualified to deal with paediatrics (children under 12). Due
to the desk acted correctly by not assigning the CFR to the call.
The DO then assigned, at 20:45, a Double Crewed Ambulance (DCA) to the call with a 50 minute ETA, running from
the Sut Bdg area. This action complies with the DDF requirement to automatically back up any FRVs attending R1
calls. Two other DCA were showing similar ETA, but the DCA selected was mobile towards the Spd area, and had a
better run as it was on a main A road. The ETA generated by the Computer Aided Dispatch (CAD) system works on
a straight line principle (“as the crow flies”). It does not take into consideration whether the resource has to go
over winding country roads, if a river is in the way with no crossing, etc. This means that the DO has to assess the
best route available and not just look at the vehicle showing closest in the Res/Alloc. The DO selected the correct
DCA in this case.
At 20:58, the FRV registers at scene of the call, but is not actually at the patient’s address. Examination of the
Sequence of Events (SOE), a computerised footprint of all actions relating to this call, shows a code *RM next to
the “on scene” message. This *RM indicates that the FRV manually pressed a button on his on-board computer
stating that he was on scene. Usually, if the FRV is close enough to the required address the on-board computer
will automatically book on scene. This generates an *AVL message. The FRV calls the Control Room when he
realises he is not at the address, and expresses concern that the address is not mapping correctly. The FRV gives a
location of -----------, about 1000ft north of the patients address, and on the other side a body of water. The FRV
receives guidance from the DO as to which directions he now needs to take. The DO refers to her mapping and
points out the locations “is a maze” of streets. Enquiries have been made with the Emergency Control Room (EOC)
Back Office Support as to the effect of the “on scene” button being pressed before at the address. EOC Support
states that once the button is pressed the screen blanks out. This is a security feature so that a lit screen of patient
identifiable details are not displaying to passers-by when the vehicle is unattended. Due to this the FRV no longer
had access to computer mapping to locate the address. The Clinical Team Mentor (CTM) for the area is familiar
with this estate. He describes it as a new housing estate that is a maze of houses, all very close together. The CTM
also points out that in the low light an FRV driver has to drive and search for the house number at the same time.
This is less of an issue for DCAs as the passenger can look for the house whilst the driver concentrates on the road.
At 21:11, the DCA arrives on scene - ahead of the FRV still trying to locate the. This is 30 minutes after the 999 call
was made, and 22 minutes outside the required timescale for an R1 call. At 21:14 the Emergency Medical
Dispatcher (EMD) taking the call exits, after establishing that the DCA is now with the patient and his mum.
The complainant has raised questions with regards to Trust services in this area. The Service Delivery Manager
(SDM) was asked with regards to why ambulances were seen “resting” in laybys. The SDM states that the Trust
uses a dynamic deployment framework that identifies the optimum location for resources to respond from.
Essentially, a computer database collates historical data and calculates the most effective place for an unassigned
resource to wait for the next call. In the case of Spd, the ambulance station is based in the hospital grounds which
can cause issues with exiting the car park. Due to this the ambulances wait at laybys for the next emergency call to
ensure a prompter response.
The Locality Manager (LM) states that the ---------- area is currently short of 3 Paramedics and 1 Emergency Care
Assistant (ECA) which is impacting on performance in the area. The Trust is actively recruiting to fill the Paramedic
places, and are currently training an ECA for the short fall in this role. In the meantime, the Trust is utilising Bank
Paramedic staff, where possible, to fill any uncovered shifts. The LM, Emergency Operations Centre (EOC – Control
Room), and Fleet management are also liaising to provide transfer only crews that will help alleviate the pressures
on frontline staff in the area, but this will be dependent on availability of vehicles for this role.
Conclusion
Yes. The call was audited as correctly handled, and given the highest possible coding, R1. This requires an 8
minute response. Any resource available in the area should be immediately diverted to the call as it takes
precedence over all other categories of calls.
Yes. The 8 minute timescale was not achieved. The Double Crewed Ambulance (DCA) arrived on scene 22 minutes
outside of the time required. Due to this the Trust failed in its duty of care to this patient.
Why was the Fast Response Vehicle (FRV) sent from Brn?
At the time of this call this FRV was the nearest one available. There was another FRV on scene of a call dealing
with a patient. The Dispatch Officer was correct in assigning the FRV from Brn, then sending out an Open Mike
message to all crews. The aim of this message was to see if the FRV on scene was able to come clear to deal with
this outstanding R1, and complied with the Dispatch Deployment Framework, May 2013.
Why did the FRV get lost?
When the FRV arrived in the area, close to the address, the driver pressed a button on his on board computer.
This was to show him as arriving on scene. By doing this manually, as opposed to allowing the vehicle to book on
scene automatically, the driver inadvertently knocked out his computerised mapping. This resulted in a blank
screen coming up. This is a security feature to stop patient safety data being displayed when the FRV is
unattended. As the structure of the roads was a network of cul de sacs coming off of long roads, the driver was no
longer able to locate the address. The Dispatch Officer attempted to verbally direct the FRV into the address, but
the Double Crewed Ambulance (DCA) arrived before this could be completed. The CTM describes the estate as a
new build, with houses very close together. The CTM further explains that locating the address would be harder
for a single manned FRV as he would be driving, looking for the number and dealing with low light levels as well.
Why did it take so long to get an ambulance to the patient?
The nearest Double Crewed Ambulance (DCA) was assigned to this call, but was having to run a distance from the
---------- area. This DCA was correctly assigned, and should have been attending as automatic backup for the FRV.
Unfortunately, due to the issue discussed above the DCA arrived on scene before the FRV did. Examination of the
hospital handover data shows that 3 hospitals were breaching the handover time of 15 minutes. These delays
would have impacted on the ability of the Dispatcher to assign a DCA to this call till crews came clear from the
hospital. Additionally, the East Division Resource Log notes a shortfall of 2 DCA; 3 FRV and 1 Team Leader.
Why does the complainant see ambulances resting in laybys?
The Trust utilises as dynamic computerised system to identify the optimum location for vehicles to wait for the
next call. In the Spd area the ambulance station is in the hospital grounds. This can result in difficulties for the
ambulance to leave the grounds when calls are received. Due to this available ambulances in the Spd area wait at
locations, like laybys, to ensure a prompter response to calls.
Where is the extra funding, frontline staff, and changes, and how is this to be implemented?
The issues relating to Spd performance is being impacted by a shortfall in staff of 3 paramedics, and an Emergency
Care Assistant (ECA). The Trust is currently training an ECA for the area, and has advertised the posts of
Paramedic. Until such time as the three permanent positions are filled the Trust is using Bank Paramedics, where
possible, to deal with the shortfall. The Locality Manager for the area states that he is working with the Emergency
Operations Centre (Control room) and Fleet management to set up a crew that will only be used for hospital
transfers and Doctor’s booking. It is hoped that this will take pressure off of frontline 999 services in the area in
due course. There is currently no timescale for this vehicle as Fleet need to identify an available vehicle for the
duty.
Date Resolved:
Grade: Moderate
Status: Unresolved
None
Evidence Gathered
CAD SOE
WAV files radio transmissions
WAV file 999 call
PRF Divisional RL
Call audit
RM code reply
identified.
PALS Form
PALS/13/00504
FC/2013/115
Enquirer Name:
Correspondence
Address:
Response required:
Enquirer phone no:
Enquirer category:
Type of concern:
Date of incident:
Description:
Incident Location:
Patient Name:
Patient Address:
Patient phone no:
Patient Deceased:
Date Received:
Date due back:
PALS Coordinator:
Initial grading:
Area:
Service Delivery:
Purchaser:
Investigator:
How Received:
Acknowledge date:
Logged by:
CONTACTS:
Julie Cowburn
PALS Coordinator
NORTH DIVISION
East Midlands Ambulance
Service NHS Trust
North Division
Education and Training
Centre
Kingsway
Derby
DE22 3XB
Phone
Mobile:
Relative
PALS
25/10/2013
28/10/2013
22/11/2013
Minor
1.
2.
3.
Telephone Call
28/10/2013
Tel:01332 372441 Ext 241
Mob:07971 323730
Email:
[email protected]
or [email protected]
Karen Long
PALS & Service
Improvement Coordinator
– EAST DIVISION
Service
East Division HQ
Cross O’Cliff Court
Bracebridge Heath
Lincoln
LN4 2HL
Tel: 01522 832628
Mob: 07773 793008
Email:
[email protected]
Kathi Tomlinson
PALS Coordinator – SOUTH
DIVISION
East Midlands Ambulance Service
East Division HQ
Bracebridge Heath
Lincoln
LN4 2HL
Tel: 01522 832628
Mob: 07800648563
Email:
[email protected]
Chronology of On 25th October, 2013
Events: At 22:42 hours CAD 5939761 coded Green 3 (triage within 20 minutes)
At 22:48 hours CAD 5939781 coded Green 3 (triage within 20 minutes)
At 22:49 hours CAD 5939784 coded Green 2 (30 minute response)
At 22:51 hours the CAT team rang back (9 minutes)
At 23:19 hours a DCA arrived on scene. Response time 37 minutes
At 23:20 hours CAD 5939853 not coded caller said “it’s here and hung up”
On 26th October, 2013
At 01:25 hours CAD 5940081 coded Red 2 (8 minute response)
At 01:35 hours an FRV arrived on scene. Response time 10 minutes
This was for a female at the address and patient was treated on scene
Investigation
Report: At 22:42 hours 999 call CAD 5939761 was received and coded 04B01A
(assault) Green 3 (triage within 20 minutes)
The EMD noted on the CAD ‘male attacked’
The code 04B01A represents a patient who is conscious and breathing with a
possibly dangerous body area injured.
At 22:45 hours the call was correctly passed to nurse triage
At 22:53 hours it is noted on the CAD ‘duplicate call from police is Green 2
and the first call was upgraded to Green 2
At 22:58 hours the CAT team noted on the CAD ‘patient has been assaulted
query with what, neighbour says patient has a head wound to the back of his
head which pressure is being applied to. Needs assessment call back advice
given and the call was upgraded to a Green 1 response.
At 23:00 hours an FRV was mobile to the scene. ETA 21 minutes having
come clear in scene of another call
At 23:12 hours the FRV was stood down. Reason:- nearer vehicle
At 23:19 hours the DCA arrived on scene. Response time 37 minutes
At 23:39 hours the DCA left scene with the patient for Leicester Royal
Infirmary
At 23:49 hours the DCA arrived at the hospital
This call was covered by the ---------- dispatch desk and below is taken from
the Leicestershire resource log:25 Oct 2013 19:23 hours SHORTAGES TONIGHT:S/CREW TECH NARBOROUGH 1830/0630
S/CREW ECA NARBOROUGH 1930/0730
Below is taken from the PDM’s resource log:25 Oct 2013 20:23 hours 2 x FRV and 3.5 x DCA short across Leicestershire overnight. No
team leader cover from midnight (on duty team leader currently covering tactical cell).
Daily performance figures for Leicestershire on 25/10/2013
A8 = 71%
G1 = 78%
G2 = 88%
scope of the
concern
The first call was correctly coded as a Green 3 for triage within 20 minutes
(call attached)
The CAT team rang back after 9 minutes and upgraded the call to a Green 1
response.
The delay was then caused by waiting for a resource to become available and
distance to travel on this Friday evening.
If yes what?
Action:
Deadline:
Concluded:
Action:
Deadline:
Concluded:
Learning Identified
Coordinator:
Coordinator:
Type: Wrong destination
Category: Service Delivery
Harm Rate: 1
Area/Divisional: Leics
Source: Letter
R2
Summary: Patient Not Taken To Hospital Requested
Case Details: Pt underegoing treatment at GGH but was taken to the Royal instead. Family want to know why she
was not taken there first. Also state transfer to GGH took a long time. Was there any delay from the Trust for the
transfer. Lead is Hospital for response
• Why was the patient not taken straight to GGH?
• Was there a delay in the Emergency Transfer from LRI to GGH, if so why?
Timeline of Events
Date and Time
Event
18/09/13
06:07
06:08
999 call received to --- year old female with chest pain ?heart attack
Community First Response (CFR) desk checks Resource Allocation (Res/Alloc) – no CFR in
area
Call coded R2 (10D01)
Fast Response Vehicle (FRV) assigned
Dispatch Officer notes in CAD: allocation due to using facilities
FRV requests Amber backup
Double Crewed Ambulance (DCA) assigned
DCA arrives scene
FRV clears scene
06:10
06:11
06:13
06:21
06:22
06:31
06:50
07:04
07:17
07:42
DCA leaves scene
DCA arrives LRI
DCA clears LRI
18:24
18:25
18:27
18:45
19:13
19:21
20:00
999 call received to the patient for emergency transfer to GGH from LRI
DO checks Res/Alloc
DO checks Res/Alloc
DCA assigned and arrives scene
DCA leaves scene
DCA arrives GGH
DCA clears GGH
Service Issues
Divisional Resource Log:
17:17 – Sister at LRI requesting OSM contact her
18:07 – Division holding 5 emergency calls coded G2 (response within 30 minutes)
18:20 - some crews still requiring meal breaks. High demand of calls. Still 6x g2 waiting.
(emergency) transfers today - at least 8 transfers from the LRI
High volume of p1
On the 18/9/13, at 06:07, a 999 call was received to a patient believed to be having a heart attack. The call was
coded as R2, requiring an on scene response from the Trust within 8 minutes.
At 06:13 a Fast Response Vehicle (FRV) arrived on scene achieving the timescale required. The FRV then requests
amber Backup. According to the Dispatch Deployment Framework, May 2013, this indicates that the patient is in
serious, but not immediately life threatening condition. This requires that the Dispatch Officer (DO) assigns the
next available Double Crewed Ambulance (DCA), not attending an uncovered higher priority R2 call or Red backup
request. This allocated DCA will then attend using visual and audible warning systems. The DO assigned a DCA
which arrived on scene at 06:31. The DOs actions were correct in all actions.
On initial examination of area maps shows that GGH was 1.7 miles from the patient’s home address, whereas LRI is
3.4 miles. The Trust policy is that a 999 emergency patient needs to be taken to the nearest receiving hospital to
be stabilised. The patient in question was undergoing treatment from the GGH, and due to this the family would
like to know why the patient was not taken to GGH directly.
Based on the above points it would, initially, appear that the patient should have been taken to GGH as it was
closer. The Clinical Team Mentor (CTM) was asked to review the crew’s decision to take the patient to LRI with
consideration to this information. The CTM states that GGH has strict protocols on admittance, and that though it
was the closer hospital, acceptance would be dependent on the Chief Complaint and clinical findings. As the
patient was reported to have “nausea/vomiting” the CTM states that the patient would not have met the GGH
admittance criteria. Due to this the patient was taken to the correct hospital, LRI. This is a not a Trust policy but
one implemented by GGH that the Trust must comply with.
The patient’s family have also asked why there was such a delay in transferring the patient to the GGH with a
Gastrointestinal (stomach or intestinal area) bleed. The patient arrived at LRI 07:17, with a 999 booking (P1) made
to transfer her at 18:24. This was 11 hours and 7 minutes later. The call was coded as requiring a R2, 8 minute
response. The DO assigned a DCA that had just handed over a patient at LRI Emergency Department to this call.
The DCA did not arrive on scene until 21 minutes after the call was placed. Examination of the Resource Logs (RL)
shows that at this time the Division was dealing with a high number of P1 transfers, with 8 coming from LRI. This
was noted as it had an impact on the Divisions ability to respond to calls in the area.
Conclusion
Why was the patient not taken straight to GGH?
The patient was not taken straight to GGH as this hospital has strict admittance protocols, and though it was the
closer hospital, acceptance would be dependent on the Chief Complaint and clinical findings. The Clinical Team
Mentor (CTM) states as the patient was reported to have “nausea/vomiting” the patient would not have met the
GGH admittance criteria so would have to attend LRI initially. This is a requirement of the Hospital, not of the
Trust and so the DCA acted correctly by complying with GGH’s protocols.
Was there a delay in the Emergency Transfer from LRI to GGH, if so why?
The Trust received a 999 booking to transfer the patient to GGH 11 hours and 7 minutes after she arrived at LRI.
At the time this was received the Division was dealing with a high number of 999 bookings from hospitals, 8 of
which were from LRI. This had a knock on effect to the Divisions ability to respond to this patient, and to other
calls in the area. Due to this the Dispatch Officer assigned a vehicle to this call as soon as it cleared from LRI after
handing over a patient. This meant that the DCA was not marked as arriving on scene until 13 minutes after the
required timescale. The DO acted correctly in this matter, but due to the delay the Trust failed in its duty of care
for this patient.
Date Resolved:
Grade: Negligible
Status: Unresolved
None
Evidence Gathered
XXX
identified.
PALS Form
PALS/13/00554
FC/2013/118
Enquirer Name:
Correspondence
Address:
Response required:
Enquirer phone no:
Enquirer category:
Type of concern:
Date of incident:
Not stated
Letter
Email
Phone
Mobile:
General Public
Innapropriate Driving Actions
09/11/2013
------------------- is an advanced driver and observed our FRV
driving, in his opinion, in a dangerous manner and has also
informed the Police.
Description:
----------------- could see the FRV in his rear mirror and the FRV
was about ten cars back. ----------------- Indicated left but
continued at a steady pace and then he noticed that the FRV
was overtaking the stream of cars but the three vehicles
travelling in the opposite direction had to break and stop as
there was not enough room for him to overtake.
Also vehicles on ----------------- side also had to break and stop.
This happended in Corby between Oathley Hay Roundabout and
Cottingham roundabout Near the Watertower on a single
carriageway travelling towards Market Harborough Saturday 9th
November at 10:40 am.
---------------- requires feedback.
Incident Location:
Patient Name:
Patient Address:
Patient phone no:
Patient Deceased:
Date Received:
Date due back:
PALS Coordinator:
Initial grading:
Area:
Service Delivery:
Purchaser:
Investigator:
How Received:
Acknowledge date:
Logged by:
11/11/2013
09/12/2013
Negligible
Operational Road Staff
1.
2.
3.
Telephone Call
11/11/2013
CONTACTS:
Julie Cowburn
PALS Coordinator
NORTH DIVISION
Service NHS Trust
North Division
Centre
Kingsway
Derby
DE22 3XB
Tel:01332 372441 Ext 241
Mob:07971 323730
Email:
[email protected]
Karen Long
PALS & Service
– EAST DIVISION
Service
East Division HQ
Bracebridge Heath
Lincoln
LN4 2HL
Tel: 01522 832628
Mob: 07773 793008
Email:
[email protected]
Kathi Tomlinson
DIVISION
East Division HQ
Bracebridge Heath
Lincoln
LN4 2HL
Tel: 01522 832628
Mob: 07800648563
Email:
[email protected]
Chronology of On 9th November, 2013
Events: At 10:43 hours CAD 5974892 coded Red 1 (8 minute response)
At 10:47 hours FRV 4930 was mobile to the scene
At 10:58 hours the FRV arrived on scene
IO additional information: the above job would have the member of staff
travelling in the wrong direction to that described by the complainant. The
previous incident attended was call ref. 5974782, and this would have the
FRV travelling in the correct direction between 10:34 and 10:45 to an --- year
old male who had suffered a fall.
Investigation Using the CAD’s archive vehicle tracking system I have been unable to see a
Report: vehicle tracking on that road at this time.
FRV 4930 was in Corby at this time but not tracking
Based at Market Harborough
Crewed by -----------------The IO had a conversation with the member of staff’s Team Leader in respect
of this complaint. The member of staff was involved in a serious road traffic
collision some years ago and is felt by the Team Leader to be one of the
safest drivers in the Trust in view of his past experience. In view of the
uncertainty regarding the identity of the driver described by the complainant it
was not felt appropriate to interview the member of staff but a conversation
would be had with him.
Conclusion - The out of performance officers report states:- 4930 not tracking, no MDT.
answering the
scope of the A response will be sent to the complainant advising that our vehicle tracking
concern systems do not have a vehicle in the vicinity, but we have identified the
potential driver and this has been flagged up to his line manager.
If yes what?
Action:
Deadline:
Concluded:
Action:
Deadline:
Concluded:
Learning Identified
Coordinator:
Coordinator:
Type: Clinical
Category: Non-Conveyance
Source: Email
Harm Rate: Moderate
Initial Call Coding: G2
Area/Divisional: East Division Patient Outcome: Fractured Femur
Base: Spalding
Summary: Missed Fractured Femur
Case Details: On 27.9.2013 the --- year old patient fell. A 999 ambulance was called and attended. Following
assessment of the patient she was advised that no x-ray was required and to take pain killers.
At 5.00pm later that day the patient was reported to have gone in to delayed shock, she was dizzy and sick. The
husband called 999 again and was referred to Clinical Assessment Team (CAT).
The Patient’s husband states they were told the patient did not need x-ray, to continue with pain relief and consult
with their GP. The Patient then attended their GP surgery where the GP looked at the left leg; no clothing was
removed, the knee was moved around and the husband indicats was not a thorough examination. The husband
asked again about an x-ray and was prescribed to keep the leg mobile and given strong pain killers.
On the 1.10.2013 and 2.10.2013 the patient was unable to get out of bed. On the 3.10.13 feeling better the patient
got out of bed, got dressed and started to come downstairs. At the second step she couldn't go either up or down
the stairs and called 999 for assistance. The patient was taken to the emergency department (ED)and informed she
had a broken femur.
•
•
•
•
•
•
Was the first call correctly handled?
Was the treatment on scene correct?
What treatment options were discussed with the patient?
Did the patient agree to this course of action?
Were the second, and third, call correctly handled?
Were the CAT assessments correct?
Timeline of Events
Date and Time
Event
27 Sept 2013
13:26
13:27
13:28
13:31
13:42
13:54
14:50
999 call received to --- year old female who has fallen
Double crewed ambulance (DCA) assigned that had been mobile to base for meal break
Call coded G2 (17B01G) – response required within 30 minutes
DCA stood down correctly
Another DCA assigned correctly
DCA arrives on scene – 28 minutes after call received
DCA clears scene – Patient treated on scene
19:19
19:21
19:24
20:51
20:52
3 Oct 2013
10:59
11:03
11:42
11:42
11:47
12:18
12:20
12:35
13:04
13:26
13:54
nd
2 999 call received – fall earlier now in pain in groin, dizzy pain when walks
Call coded G4 (17A02) – suitable for triage by Clinical Assessment Team (CAT) within 60
minutes
Computer Aided Dispatch notes: caller thinks she may have injured her hip
CAT triage notes: pt is alert and responding with pain in hip and groin. Is able to weight
bare and mobilise up to toilet. Caller referred to GP
CAT triage notes: advised on pain relief as pt is mobilising up and down stairs to toilet
advised if any worsening contact ooh (out of hours) gp or 999
New call received to patient who is stuck on the stairs and can’t move
Call coded G4 (26A07) and submitted to CAT for further assessment within 60 minutes
CAT triage notes: upgraded to G2 call on CAD 5884863
CAT triage notes: Had a fall a few days ago, pt says she has extensive bruising to left inner
thigh and groin area. Pt has been resting in bed today felt better tried to get down the
stairs but has got stuck on the 2nd step down and is unable to get up or down stairs now
due to pain in her groin/hip. Also has swelling to knee where she had a knee replacement
10/12 ago
Out of performance reason set in CAD: G2 call, DCAs in meal break window
DCA assigned
DCA mobile
DCA arrives scene
DCA leaves scene
DCA arrives QE hospital
DCA clears hospital
On the 27 September 2013, at 13:26, a 999 call was received to a --- year old female who had fallen. The call was
coded as G2, requiring a Trust resource arrive on scene within 30 minutes. The call has been audited as correctly
handled. At 13:27 the Dispatch Officer (DO) assigned a Double Crewed Ambulance (DCA), but when the coding
was established the DO then stood this vehicle down from the call. The DO acted correctly in this matter as the
DCA assigned was within its meal break window. This action complied with the Dispatch Deployment Framework,
May 2013, which states no vehicle can be assigned to a G2 call within the last 30 minutes of its shift. At 13:42 the
DO assigned another DCA. This DCA arrived on scene at 13:54, achieving the 30 minutes timescale required.
Whilst on scene the DCA assessed the patient. The DCA established that the patient was able to move the leg, and
there was no rotation or shortening. The electronic Patient Report Form (ePRF) notes that the patient was able to
walk about unaided with no change in pain levels. According to the Joint Royal College Ambulance Liaison
Committee (JRCALC) the most common limb injury encountered within elderly patients is a fracture to the neck of
the femur (top of the thigh bone). The typical presentation for this is shortening and external rotation, and pain in
hip and knee being reported.
Based on the ePRF this patient displayed none of these indicating symptom and the DCA believed that the patient
had soft tissue injuries only. The Clinical Team Mentor (CTM) was asked to review the ePRF. The CTM states that
“any fall from standing in this age group should have a high index of suspicion for a #NOF (fracture to the neck of
femur), particularly when the fall is onto concrete.” The CTM stated it was not unusual for a patient to be able to
walk for several weeks on such an injury without shortening or rotation.
The CTM clarified he would also not have suspected a to the femur itself from this height. He states it would take
more force to fracture the neck of femur than a fall from standing could usually cause. The CTM further explained
that in such cases he would expected pain; deformity; bruising or discolouration. Without these indicators the
CTM feels it would have been very difficult for the attending DCA to identify a fractured femur, especially as the
mechanism of injury would not have indicated it either. The CTM concludes by stating the DCA should make every
effort to encourage the patient to travel, and that the ePRF notes do not detail whether the patient was given
sufficient information to make an informed decision.
The Location Manager (LM) was consulted regards to the term “informed consent” and states that the DCA should
“highlight potential risks attached to non-transportation - but only if aware of an evident injury.” The DCA gave
advise based on the observations they had so the patient could make an informed decision. Based on their clinical
observations the DCA acted appropriately. The ePRF shows that the patient did not want to go to hospital, and so
the DCA gave her worsening advise, and told her to go see her Doctor. The patient signed the ePRF, agreeing to
this treatment plan and was left in the care of her husband. The patient’s letter of complaint confirms that she did
not wish to travel to hospital. The patient was noted, on the ePRF, as having capacity. This has been confirmed
with the patient’s husband during the investigation. The husband has no concerns about his wife’s mental
capacity, and agrees that she was cognisant to give consent. The ePRF shows the patient was given sufficient
information to make an informed choice to remain at home, and she was adequately safety netted by the DCA.
The transporting DCA’s ePRF, on the 3 October, also confirms that the patient had no shortening or rotation.
At 19:19 the patient’s husband called 999 again, stating the patient had pain in her groin and was dizzy with pain
when she walked. The call was coded as a G4 call, indicating that the patient was suitable for further triage by a
member of the Clinical Assessment Team (CAT) within 60 minutes. The call has been audited as correctly handled.
The CAT assessor called back at 20:34, 7 minutes outside of the timescale required. The CAT Assessor notes in the
Computer Aided Dispatch (CAD) record that the patient is mobilising up and down stairs, given guidance with pain
relief, and advised to contact Out of hours Doctor if there is not improvement. A Clinical review of this assessment
finds that the call was handled well, but that as the patient was described as worsening, ill and grey looking the
advice given was incorrect. The Clinical review states that a 2 hour ambulance would have been the correct action.
On 3 October 2013, at 10:59, a call was received for this patient to state the patient was now stuck on the stairs
and could not move. This call was coded G4 – suitable for further triage by the Clinical assessment team within 60
minutes. This call was audited as correctly handled, and the CAT assessment timescale was achieved. The CAT
then upgraded the call to a G2, but this 30 minute on scene timescale was not achieved. The DCA for this call
arrived on scene 23 minutes outside the required time scale.
Conclusion
Was the first call correctly handled?
Yes, the call was correctly handled. It was coded as a G2 call, requiring a Trust response within 30 minutes. That
timescale was achieved.
Was the treatment on scene correct?
Yes, based on the symptoms displayed by the patient the treatment on scene was correct. The Joint Royal College
Ambulance Liaison Committee (JRCALC) states that the most common limb injury encountered in elderly patients
is a fracture to the neck of femur (top of the thigh bone). JRCALC state that the typical presentation of this
fracture is a shortening of the leg, with external rotation of the foot. The attending Double Crewed Ambulance
(DCA) have documented on the electronic Patient Report Form (ePRF) that the patient had neither of these classic
signs, and that was able to walk unaided with no change in pain level. The Clinical Team Mentor (CTM) confirms
that this would be an injury that would be more indicative with the mechanism of injury. The CTM does not
believe it would have been possible to identify the injury on scene. Due to this the DCA advised the patient based
on these finding, and acted appropriately.
What treatment options were discussed with the patient?
The DCA discussed treatment for a soft tissue injury, pain medications and seeing her own GP. As there were no
indicators to show that this was a fracture to the femur the DCA gave advice based on their observations.
Did the patient agree to this course of action?
Yes, patient has confirmed in her letter that she did not want to go to hospital that day.
Were the second, and third call, correctly handled?
Yes. The call has been audited as correctly handled when it was coded a G4 – suitable for further triage by a
member of the Clinical Assessment Team (CAT). The CAT assessor, for the third call, arranged for a G2 ambulance
to attend the patient. The 30 minute timescale was not achieved, with the DCA arriving 23 minutes outside of this
timescale. Due to this delay the Trust failed in its duty of care.
Were the CAT assessments correct?
No. The first CAT assessment has been reviewed and found to be incorrectly handled. The patient was reported
to have worsened, and that the patient should have been assigned a 2 hour ambulance. Due to this the Trust
failed in its duty of care to this patient.
Date Resolved:
Grade: Moderate
Status: Unresolved
Letter Date:
None
Evidence Gathered
CAD SOE 5870645
CAD SOE 5871371
CAD SOE 5884756
CAD SOE 5884863
CAT audit
Orig PALS report
PRF 5870645
5884863
WAV file calls
identified.
Source: Letter
Final Contact Date: 9 December 2013
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: 5
Extension: XX
Red 2
Patient Outcome:
Patient deceased
Summary: Stroke Pt-Delayed Transport & Treatment
Case Details: Patient, -------------------, had a major stroke.
Wife says it took 25 minutes for FRV to arrive, another 10 mins for DCA to arrive, 10 mins for them to transfer pt
into ambulance and then crew didnt take him to the nearest A&E. Pt died 6/11/13.
• Why did it take 25 minutes to get a resource to the patient
• Why was patient not taken to the nearest A&E department
TOR agreed by:
Complainant
Crew Stood Down:
No. If No state rationale: EOC delay
Healthcare Decisions Panel (HDP) referral: No. All clinical incidents must be referred to HDP where clinicians are
registered. If No state rationale: EOC delay
Being Open
XX you must include a rationale why you have not been in contact XX
Timeline of Events
Date and Time
Event
2 Nov 2013
10:27
10:28
new call received, call ref. 5957533, on behalf of a male who has suffered a stroke.
call assessed as 28C01L, stroke, patient not alert, stroke just happened. Red 2 eight
minute response.
resource 0012, double crewed ambulance (DCA), allocated and mobile to incident.
resource 0012 leaves scene with patient. Resource 0030 calls clear.
resource 0012 arrives at hospital.
10:30
10:32
10:47
10:58
11:08
11:40
12:03
Handling of emergency call: the call was received at 10:27 and was assessed as a Red 2 eight minute response. A
DCA was allocated at 10:30 but this was an estimated 43 minutes from the scene. A solo responder was allocated
at 10:32 and this was 28 minutes from the scene. The solo responder was the first resource to arrive at 10:47, 20
minutes after receipt of the emergency call. The DCA arrived 11 minutes later. The response was outside both the
eight minute and 19 minute timeframes.
Care and treatment of the patient: The patient was transported to the Stroke unit at Northampton General
Hospital. The estimated travel time to this unit is 41 minutes under normal road conditions, and the actual journey
time was 32 minutes. The journey to Kettering hospital was an estimated 17 minutes under normal road
conditions. The patient was taken to Northampton General in line with protocols in place within Northamptonshire
hospitals for stroke patients, in view of the advanced care available.
Conclusion
The response was outside both the eight minute and 19 minutes targets due to the positioning of available
resources and the distance they had to travel. The decision to take the patient to the specialist Stroke unit at
Northampton General Hospital was in line with hospital protocols.
Date Resolved: 9 December 2013
Status: Resolved
Grade: Moderate
No recommendations to be made on this occasion. The delay was due to the distances the nearest available
resources had to travel to the patient, and protocols were followed in taking the patient to the Stroke unit at
Northampton General Hospital in preference to Kettering General Hospital.
Evidence Gathered
CAD report
Northamptonshire Stroke pathway advice
identified.
PALS Form
PALS/13/00535
FC/2013/121
Not stated
Letter
Email
Phone
Mobile:
General Public
Other
Delayed Response for RED 2
PALS/13/00535
Enquirer Name:
Correspondence
Address:
Response required:
Enquirer phone no:
Enquirer category:
Type of concern:
Date of incident:
Description:
Incident Location:
Patient Name:
Patient Address:
Patient phone no:
Patient Deceased:
Date Received:
Date due back:
PALS Coordinator:
Initial grading:
Area:
Service Delivery:
Purchaser:
Investigator:
How Received:
Acknowledge date:
Logged by:
05/11/2013
02/12/2013
Moderate
North Division - Derby South
EOC
Division PALS North
1.
2.
3.
Email
05/11/2013
CONTACTS:
Julie Cowburn
PALS Coordinator
NORTH DIVISION
Service NHS Trust
North Division
Centre
Kingsway
Derby
DE22 3XB
Tel:01332 372441 Ext 241
Mob:07971 323730
Email:
[email protected]
Karen Long
PALS & Service
– EAST DIVISION
Service
East Division HQ
Bracebridge Heath
Lincoln
LN4 2HL
Tel: 01522 832628
Mob: 07773 793008
Email:
[email protected]
Kathi Tomlinson
DIVISION
East Division HQ
Bracebridge Heath
Lincoln
LN4 2HL
Tel: 01522 832628
Mob: 07800648563
Email:
[email protected]
Chronology of On 14th October, 2013
Events: At 13:58 hours CAD 5911906 coded Red 2 (8 minute response)
At 14:15 hours the DCA arrived on scene. Response time 17 minutes (this
was an auto at scene and not when they were at the job centre itself)
At 14:26 hours CAD 5911968 not coded as ambulance arrived
Investigation
Report: At 13:58 hours 999 call CAD 5911907 was received and coded 17D03
(falls) Red 2 (8 minute response)
The EMD noted on the CAD ‘fallen, patient is on the second floor’
At 13:58 hours a 2nd 999 call CAD 5911906 was received and coded
31D02 (unconscious/fainting) Red 2 (8 minute response)
The EMD noted on the CAD ‘collapsed’
This call was stopped as a duplicate of the above call
At 14:15 hours the DCA arrived on scene. Response time 17 minutes (this
was an auto at scene time and not when they were at the job centre itself)
At 14:19 hours the EMD noted on the CAD ‘job centre is opposite revolution
bar’
At 14:20 hours the dispatch desk sent a message (MDT) to the crew ‘job
centre is opposite revolution bar, next to ------- on ------------- itself, 2 people
waiting on street, big green sign outside door’
At 14:26 hours a 3rd 999 call CAD 5911968 was received and not coded
The EMD noted on the CAD ‘ambulance arrived’
This call was stopped as a duplicate of the first call
At 15:23 hours the DCA left scene with the patient for Royal Derby Hospital
At 16:17 hours it is noted on the CAD ‘crew update patient into resus, a lot of
blood loss from head injury’
This call was covered by the Derbyhire dispatch desk and there is nothing of
relevance in the Derbyshire or PDM resource logs
Daily performance figures for Derbyshire on 14/10/2013
A8 = 66%
G1 = 83%
G2 = 94%
Conclusion - The calls were correctly coded Red 2 and the correct location recorded on the
answering the CAD.
scope of the
concern The out of performance officers report states:- nearest available resource sent
from Belper.
The delay was originally caused by the nearest available resource being 17
minutes away and then the crew not locating the job centre once they were in
the area.
If yes what?
Action:
Deadline:
Concluded:
Action:
Deadline:
Concluded:
Learning Identified
Coordinator:
Coordinator:
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
Red 1
Patient Outcome:
patient deceased
Summary: Delayed Response - Pt Died
Case Details: 40 minute delayed response to pt having a suspected heart attack. Patients son was doing CPR whilst
he waited but pt died before crew arrived.
Ref:
• Why was there a delay of 40 minutes before the crew arrived on scene?
TOR agreed by:
Complainant (MP)
Date: 05/12/2013
Crew Stood Down:
Being Open
Initial Contact Date: 5 December 2013
Timeline of Events
Date and Time
Event
8 Dec 2012
03:48
03:48
new call received call ref. 4946842 on behalf of a --- year old male who is unconscious.
call assessed as 31D01, unconscious, agonal/ineffective breathing, requiring an eight
minute response.
resource 2415, double crewed ambulance, allocated and mobile to the incident.
03:48
04:06
04:10
04:18
04:28
05:14
Handling of emergency call: the first resource on scene arrived 22 minutes after receipt of the emergency call,
which was outside both the eight and 19 minute targets.
The call taker remained on the line throughout the period between receipt of the emergency call and arrival of the
first response on scene, talking the caller and the patient’s son through the resuscitation procedure.
The delay in response was due to the distance the resources had to travel to reach the patient.
Conclusion
Grade: Moderate
Status: Resolved
Letter Date: 13 December 2013
There are no recommendations to be made on this occasion
Evidence Gathered
CAD report
Audio files for calls
identified.
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Public Place
Green 2
Area/Divisional:
Patient Outcome:
Fractured
tibia/fibula
Extension: XX
Summary: Delayed Response-Serious Broken Leg
Case Details: Delayed response to footballer with a seriously broken leg.
Why did it take so long, where were the Newark ambulances, and how are calls graded?
• Why did it take so long for an ambulance to arrive?
• Were the emergency calls correctly coded?
TOR agreed by:
Complainant
Date: 5/12/2013
Crew Stood Down:
Being Open
Timeline of Events
Date and Time
Event
24 Nov 2013
12:08
new call received call ref. 6012122 on behalf of a patient who has suffered a football
injury, broken leg.
resource 7317, double crewed ambulance (DCA) allocated and mobile to incident.
call assessed as 30B01, traumatic injuries, possibly dangerous body area, allocated a Green
2 30 minute response. Resource 7317 stood down from incident, Green 2 code.
further call received, call ref. 6012175. Allocated a Green 2 30 minute response.
call ref. 6012175 stopped as a duplicate of call ref. 6012122.
resource AMV09, double crewed ambulance, allocated to incident.
resource AMV09 mobile to incident.
further call received, call ref. 6012207. Allocated a Green 2 30 minute response.
further call received, call ref. 6012227. Allocated a Green 4 response, return call from
nurse within 60 minutes.
further call received, call ref. 6012245. Patient with a broken leg suffering from
hypothermia.
call ref. 6012245 stopped as a duplicate of call ref. 6012122, crew travelling from Lincoln
and will be there as soon as possible, delayed as we are busy.
resource AMV09 arrives on scene.
resource AMV09 leaves scene with patient.
resource AMV09 arrives at hospital with the patient.
resource AMV09 hand patient over to hospital staff.
resource AMV09 calls clear at the hospital.
12:10
12:12
12:35
12:41
12:49
12:51
12:51
13:01
13:07
13:07
13:09
13:10
13:20
14:09
15:03
15:28
15:37
Handling of emergency calls: The calls were correctly coded, with a Green 2 30 minute response being appropriate
from the information provided.
The first emergency call was received at 12:08 hrs. The responding resource arrived on scene at 13:20 which was a
response time of one hour and 12 minutes. The target timeframe of 30 minutes was not met on this occasion.
10:59 Notts holding one Green 2 call and two urgent calls.
11:24 Notts holding eight Green 2 calls.
12:40 Delays at Queens Medical Centre (QMC), seven resources waiting, longest 50 minutes.
12:46 Notts holding eight Green 2 calls, three Urgent calls plus two transfers.
13:27 Update from QMC, six crews have been waiting 40 minutes.
13:47 Notts holding four Green 2 calls and five urgent calls.
Entries from the Nottinghamshire dispatch desk (NOTTS):
09:52 holding one Green 1 call, one Green 2 call, two Green 4 calls and three Urgent calls.
12:12 holding two Green 2 calls and one transfer.
12:36 holding one back up and two Green 2 calls.
12:58 holding one Red 2 call, three Green 2 calls and three urgent calls.
Conclusion
The emergency calls were correctly coded, and the delayed response was due to high demand for emergency
responses on the day of the incident.
Status: Resolved
Grade: Moderate
No recommendation to be made on this occasion.
Evidence Gathered
CAD reports
Call audits
Resource log entries.
identified.
Source: PALS Office
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Two hour doctor’s urgent Area/Divisional: North, Nottinghamshire
Base: Patient's Care home
Patient Outcome:
Patient
4/2/2013
Extension: XX
deceased
Summary: Delayed Response&CareManagement-Sepsis
Case Details: I am writing to get a full picture of the circumstances which led to the death of our Mother the late ---------------- on 4.2.2013.
-------------------------- of the --------------------------------------------------------- called for an ambulance at 14.15 on Friday
1st February 2013 he informed a diagnosis of sepsis?UTI.
"does the response time seem appropriate in the circumstances of the diagnosis?
My complaint is that I do not believe the response was timely enough with regard to the severity of the symptoms.
The ambulance response is one of the many catalogues of failure that lead to the swift death of my Mother. I
made a safeguarding investigation referral due to the fact that the circumstances surrounding Mum's illness were
exacerbated by a total lack of care.
Further, when the paramedics arrived they also diagnosed suspected sepsis. They thought that -------- was
severely dehydrated. When taking Mum to the hospital in the ambulance we discussed the state she was found in,
to which the Ambulance guy didn't seem to be at all shocked, and he said he comes across such cases regularly.
Did they record any of this in their reports? As I recall their call out job number was ominously 666.
Were any issues raised as a safeguarding concern? If not why not?
Did the handover from the Ambulance crew to Accident & Emergency pass over details as to disgraceful,
undignified condition that -------- was found in at ------------?
Further, I would like timeline information for other calls made to the ambulance service prior to our Mothers
admission to QMC as below, i.e. time of call received and arrival time of ambulance.
Calls made to attend to ----------------- at --------------------------------------------------------- as follows:
24th December 2012 to attend as -------- had fallen
29th December 2012 to attend as -------- had again fallen
4th January 2013 call made by ---------- to admit -------- to hospital
• Why was there such a long delay in getting an ambulance to the patient?
• Was the response appropriate given the patient’s condition?
• Did the ambulance crews report the condition in which the patient was found?
• Was the patient’s condition relayed to hospital staff as part of the handover?
• Did the crew(S) raise a safeguarding concern?
TOR agreed by:
Complainant
Date: 09/12/2013
Crew Stood Down:
Being Open
Initial Contact Date: 10 December 2013
Timeline of Events
Date and Time
Event
01/02/2013
14:18
New call received, call ref. 5296666, on behalf of an -- year old female with a diagnosis of
sepsis and query UTI. Response requested within two hours, patient to be moved by carry
chair.
16:39
17:18
17:19
17:37
18:14
18:15
18:19
18:55
19:00
19:15
return call made to doctor’s surgery as we had been unable y to fulfil this request.
Extension of one hour agreed by GP with upgrade to an emergency if this new deadline is
exceeded.
resource AM13, double crewed ambulance (DCA) allocated to incident.
resource AM13 mobile to incident.
resource AM13 arrives on scene.
CAD message: crew requesting Paramedic in view of patient’s poorly condition.
resource 9311, DCA, allocated and mobile to incident.
resource 9311 leaves scene with the patient.
Date and Time
Event
24/12/2012
22:58
22:59
00:05
00:06
00:17
02:13
new call received, call ref. 5200574, on behalf of an --- year old female who has collapsed.
call assessed as 26D01, sick person, not alert, and allocated a Green 2 30 minutes
response.
resource 9331, solo responder, allocated and mobile to incident.
resource 9311 stood down and diverted to a Red 1 cardiac arrest.
further call received, call ref. 5200706. Patient is now not alert.
call upgraded to a Red 2 emergency as patient not alert following second call received. Call
5200706 stopped as a duplicate of call ref. 5200574.
resource 8934, solo responder, allocated to incident.
resource 8934 calls clear from scene, patient treated on scene.
Date and Time
Event
29/12/2012
17:36
new call received, call ref. 5213245, on behalf of a patient who is on the floor. The patient
is an --- year old female.
call assessed as 26A08, sick person, other pain, and allocated a Green 4 response, call back
from a clinician within 60 minutes.
CAD message: patient has been on the floor for a while, no infections, keysafe code 7923.
call stopped as a duplicate of new call created, call ref. 5213308, Green 2 30 minute
response.
CAD message: patient is on the floor complaining of pain in her back. She has also been
incontinent.
resource 8118, DCA, allocated to incident.
resource 8118 stood down and allocated to a Red 1 cardiac arrest.
resource 3012, DCA, allocated and mobile to the incident.
further call received, call ref. 5213434. Stopped as duplicate of call ref. 5213308 as crew
are already travelling.
resource 3012 calls clear from the scene. Patient treated on scene.
23:28
23:31
23:59
00:03
17:37
17:38
17:58
18:02
18:23
18:24
18:37
18:43
18:49
18:50
19:56
Date and Time
Event
04/01/2013
13:47
new call received, call ref. 5229405, requesting an ambulance within two hours,
authorised by GP. Diagnosis acute confusional state, possible UTI.
resource VAS23, DCA, allocated and mobile to scene.
resource VAS23 arrives on scene.
resource VAS23 leaves scene with the patient.
resource VAS23 arrives at hospital.
resource VAS23 hand patient over to hospital staff.
16:25
16:49
17:18
17:35
17:54
Handling of urgent call 01/02/2013: the call was received at 14:18 with a request for a two hour response. An
extension was requested at 16:39, and the responding resource arrived at 17:37 which was a response time of
three hours and 19 minutes. This was outside the target response time of two hours.
Handling of emergency calls 24/12/2012: the first call was received at 22:58 and the responding resource arrived
at 00:17, which was a response time of one hour and 19 minutes. The target timeframe of 30 minutes was not
met. The calls were correctly coded.
Handling of emergency calls 29/12/2012: the first call was received at 17:36 and the responding resource arrived
at 18:50, which was a response time of one hour and 14 minutes. The target response time of 30 minutes
(allocated at 17:58) was not met. The calls were correctly coded.
Handling of emergency call on 04/01/2013: the call was received at 13:47 for a two hour response, and the
responding resource arrived at 16:49 which was a response of three hours and two minutes. The target response
of two hours was not met.
Care and treatment of patient on 01/02/2013: the request for an ambulance within two hours was made by
Clinical Navigation Services. A diagnosis of possible sepsis and possible UTI was given, but no specific medical
concerns were raised. As the request originated from a healthcare professional we did not undertake an
assessment of the patient’s condition.
As we were unable to fulfil the two hour request, the GP was contacted and he granted an extension of a further
one hour. The GP was of the opinion that the patient would be ok to wait up to one hour more. When the first
responding resource arrived they found the patient to be in a poorly condition and Paramedic back up was
requested. This back up arrived shortly afterwards and the patient was transported to hospital after observations
and examinations had been undertaken.
The patient report forms do record the patient observations on arrival of the first responding crew and the back up
crew, and the fact that the patient had been incontinent of faeces. This information was also relayed to the
hospital staff on handover. The crews did not complete a safeguarding concern relating to this incident.
Notes from NOTTS resource log 24/12/2012:
12:55 North holding two Red response back-ups, one Green 1 call and four Green 2 calls.
17:58 Notts North currently holding two Green 2 calls.
Notes from PDM resource log 29/12/2012:
15:13 Notts holding two Red 2 calls, 10 Green 2 calls and three Green3/4 calls.
18:39 Notts holding one Red 2 transfer, seven Green 2 calls, one Green 4 call and 14 Urgent calls.
14:33 holding 10 Green 2 calls in Notts South.
18:36 Notts South holding one Green 1 back up, one Green 1 call, three Green 2 calls, one Green 3 call and four
Urgent calls.
18:43 Notts North holding one Red 2 transfer, and five Green 2 calls.
19:32 Notts South holding four Red 2 calls, two hot back up calls, three Green 2 calls and four Urgent calls.
13:07 Notts holding seven Green 2 calls and 10 Urgent calls.
12:56 in Overcapacity actions 1 and 2.
15:37 in Overcapacity to action 3.
12:27 Notts holding four Green 2 calls.
19:09 Notts holding three hot back-up calls, four Green 2 calls and nine Urgent calls.
12:40 Notts south holding five Green 2 calls.
15:49 Notts South holding one Amber back-up and three Green 2 calls.
18:50 Notts South holding three Red 2 calls, five Green 2 calls, one Green back-up, three out of time Urgent
transfers and four other Urgent calls.
20:00 Notts South holding two Red 2 calls, four Green 2 calls, five Urgent calls and one routine call.
Conclusion
The target timeframe was not met on the four occasions raised by the complainant, and this will be acknowledged
in the response letter. The patient’s poorly condition was identified by the first responding crew on 1 Feb 2013,
and Paramedic back up was requested to monitor the patient. As the original request came from a healthcare
professional an assessment of the patient’s condition was not undertaken by the call taker.
Grade: Moderate
Status: Resolved
There are no recommendations to be made on this occasion. The delayed response was due to demand for
emergency responses and the actions of the crew were appropriate.
Evidence Gathered
CAD reports
Entries from resource logs for 24/12/2012, 29/12/2012, 04/01/2013 and 01/02/2013
Patient report form for 01/02/2013
Audio files of calls received
identified.
Type: EOC Issue
Category:
Delayed response
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: EOC
Extension: XX
Red 2
Area/Divisional: EOC
Patient Outcome:
patient deceased
Summary: 45 Mins Delay-Stroke Pt. Now Terminal
Case Details: 45 minute delayed response to elderly patient who was found on the floor after a stroke. Patient
now paralysed down one side, unable to speak or swallow, is not going to recover and is receiving "end of life
care".
TOR agreed by:
Complainant
Date: 10 December 2013
Crew Stood Down:
Timeline of Events
Date and Time
Event
25 Nov 2013
10:16
new call received on behalf of an --- year old male who had fallen and suffered a head
wound.
call assessed as 17D03, falls, patient not alert, and coded as a Red 2 eight minute
response.
call passed to a clinician to continue monitoring of patient.
resource 4831, solo responder, allocated to the incident. Estimated to be 26 minutes from
the incident.
resource 4831 mobile to the incident.
resource 7612, double crewed ambulance, allocated to incident. Estimated to be four
minutes from the incident.
resource 4831 stood down as a nearer vehicle has become available.
resource 7612 arrives at the hospital.
crew of resource 7612 hand patient over to hospital staff.
10:18
10:32
10:39
10:40
10:54
10:55
10:56
11:02
11:26
11:35
11:40
Handling of the emergency call: the call was correctly coded as a Red 2 eight minute response. The call was
received at 10:16 and the responding resource arrived at 11:02, which was a response of 46 minutes. This was
outside the timeframes of eight and 19 minutes.
Care and treatment of the patient: the call taker asked a series of questions to establish the patient’s condition,
and was advised that the patient had suffered an unwitnessed fall and had sustained a head wound. The patient
had attended hospital the previous day with a suspected stroke, but he had later been discharged after
examination and observations. He had been diagnosed with a UTI and been prescribed antibiotics. The call taker
stayed on the line with the caller and then transferred the call to a clinician who undertook further assessments
pending the arrival of the ambulance crew. The clinician raised the possibility that the patient may have suffered a
stroke and she cleared the line once the responding ambulance arrived. The ambulance crew assessed that patient
as quickly as possible and then transferred him to hospital. The crew suggested taking the patient to Northampton
General Hospital in line with stroke care pathway guidelines but they were told to take him to Kettering Hospital
which was nearer.
Resource 7612 had been allocated to an emergency at 09:00 in Thrapston. They attended the incident and
transported the patient to hospital, arriving at Kettering General at 10:30. After handing the patient over to
hospital staff the crew called clear at 10:54, at which time they were allocated to this incident. A resource already
travelling to the patient was stood down as the attending resource was nearer.
Notes from the Performance Delivery Manager (PDM) resource log:
09:01 Northants holding two amber response calls and four Green 2 calls.
09:14 Northants invoking actions one and two of the overcapacity plan.
Notes from Northamptonshire Dispatch (NH) resource log:
10:20 Northants north holding two red 2 calls in the Kettering area.
Conclusion
The delay was caused by high demand for emergency responses. The first available response was dispatched to the
patient and this was stood down in favour of a nearer response which became available.
Grade: Moderate
Status: Resolved
Evidence Gathered
CAD report
Audio files for emergency call
Resource logs
identified.
Source: Letter
Final Contact Date: 3 January 2014
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Public Place
Extension: XX
Green 2
Area/Divisional: EOC
Patient Outcome:
Fully recovered
Summary: 2Hour Delay-Elderly Pt Fall Public Place
Case Details: Elderly patient fell down the steps whilst getting out of a coach at approx. 4:30pm.
It took many 999 calls and over 2 hours before an ambulance arrived. Patient was extremely cold by then.
Once they had arrived, the ambulance crew were extremely helpful and efficient.
IR1 - U1718.
------------- aware due to by-standers contacting local radio.
• Why was it not possible to give an estimated arrival time for the ambulance?
• Why was the caller advised that calls were not prioritised?
TOR agreed by:
Complainant
Crew Stood Down:
Date: 10/12/2013
Being Open
Consent Required: Yes Consent Date: Consent forwarded with original complaint correspondence.
Timeline of Events
Date and Time
Event
28/11/2013
At 16:30 hours 999 call CAD 6022025 was received and coded 17B01 (falls) Green 2 (30 minute response)
The EMD noted on the CAD 'fallen down steps on a coach onto the road, head injury, patient is on the
pavement'
At 16:54 hours a 2nd 999 call CAD 6022086 was received and coded 17B01G (falls) Green 2 (30 minute
response)
The EMD noted on the CAD 'fallen off a step'
At 17:23 hours a 3rd 999 call CAD 6022156 was received and coded 17B01G (falls) Green 2 (30 minute
response)
The EMD noted on the CAD 'female fallen off the bus, doctor on scene'
At 17:36 hours the CAT team upgraded the call to a Green 1 response due to the length of time the patient
had been waiting outside
At 17:53 hours a 4th 999 call CAD 6022213 was received and coded 17A02G (falls) Green 2 (30 minute
response)
The EMD noted on the CAD 'fallen from coach'
At 18:26 hours a DCA was mobile to the scene. ETA 20 minutes having come clear on scene of an RTC
At 18:42 hours the DCA arrived on scene. Response time 2 hrs 12 minutes
At 19:10 hours the DCA informed EOC 'Doctor on scene very unhappy with response as patient on the floor,
crew to do IR1'
At 19:13 hours the DCA left scene with the patient for Queens Medical Centre
At 19:58 hours the patient was handed over to clinical staff
At 20:06 hours the DCA was clear at the hospital- no staff available (30 minute turnaround)
Handling of emergency call: Green 2 was the correct response code for these calls, the CAT team upgraded to
Green 1 after 1 hour and six minutes due to the length of time the patient had been waiting outside. The delay
was caused by high demand and higher priority calls with Nottinghamshire in Overcapacity plan actions 1 and
2.
The responding resource arrived on scene at 18:42, which was a response time of two hours and 12 minutes.
This was considerably in excess of the target timeframe of 30 minutes.
Demand for available resources:
This call was covered by the Notts South dispatch desk and below is taken from the Nottinghamshire resource
log:28 Nov 2013 16:51 hours NOTTS SOUTH HOLDING:- 1 x R2, 2 x G1 & 5 x G2
28 Nov 2013 17:05 hours NOTTS SOUTH HOLDING:- 1 x R1, 2 x G1 & 8 x G2
Below is taken from the PDM's resource log:28 Nov 2013 16:50 hours Nottingham holding:- 1 x R2 from QMC, 2 x G1, 6 x G2, 6 x Urgent last 60, 5 x
Urgent in time. CMP 1+2 in place
28 Nov 2013 18:15 hours Notts holding:- 8 x Back up, 1 x R2, 1 x G1, 4 x G2, 3 x Urgent last 60 & 9 x Urgent in
time
Daily performance figures for Nottinghamshire on 28/11/2013
A8 = 61%
G1 = 51%
G2 = 67%
The complainant has advised that the crew of the responding resource advised her that they had been on a
lower priority call immediately before they were allocated to this incident. In fact the resource had just attended
a three car road traffic collision. They attended the scene but were subsequently stood down as not required,
as other resources were conveying the patients to hospital. The resource was allocated to the road traffic
collision after it became available following a break, and seconds before it could be allocated to this incident.
Conclusion
The response was outside the 30 minute timeframe, upgraded to 20 minutes at 17:36. The resource arrived after
two hours and 12 minutes. The delay was due to demand for emergency resources on the day of the incident.
Date Resolved: 3 January 2014
Status: Resolved
Grade: Moderate
Letter Date: 3 January 2014
There are no recommendations to be made on this occasion
Evidence Gathered
CAD reports
Call audits
Resource log entries
identified.
Type: Telephone Call From General Public
Category: Other
Source: Email
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate: N/A
Base: EMAS Trust HQ
Extension: XX
Green 2
Area/Divisional: EOC Nottingham
Patient Outcome:
N/a
Summary: Handling Of 999 Call - Pt On The Floor
Case Details: Pt seemed unconcious laying on the ground. 2 girls had rung 999. Enquirer took over the phone call
and was told that an ambulance was not on its way yet. Enquirer believes that the call taker was rude so he
disconnected the call and took the pt to hospital himself in his car.
Will go to the Ombudsman if not satisfied with response.
• Was the call handled appropriately by the call taker?
TOR agreed by:
Complainant
Date: 13/12/2013
Crew Stood Down:
investigation.
No. If No state rationale: EOC staff, suspended from duties pending internal disciplinary
•
•
Staff support and involvement: ---,EMD. Staff member suspended from duties for this and another incident
pending internal disciplinary investigation.
Healthcare Decisions Panel (HDP) referral: No. All clinical incidents must be referred to HDP where
clinicians are registered. If No state rationale: EOC issue
Being Open
Timeline of Events
Date and Time
Event
8 Dec 2013
18:11
new call received call ref. 6048100 on behalf of a male who has taken an overdose of
Vodka and antifreeze. Call dropped and return call made by call taker.
call assessed as 23C01I, overdose/poisoning, not alert, intentional, and allocated a Green
2 30 minute response.
ambulance cancelled, patient being conveyed by car.
18:13
18:22
Handling of emergency call: the call taker deviated from the AMPDS process in a number of areas during the call.
In addition, no reassurance was given to the initial caller or to the complainant who took over the phone call, and a
number of inappropriate comments were made by the call taker:
“He would have trouble standing anyway with two bottles of Vodka inside him”
“He’s probably drunk and can’t hear you”
“He’s probably passed out through the drink”
“No not yet we are very busy”
“That is your opinion, we have got a lower priority”
“We have got higher priorities to deal with in the area”
The customer service offered during the call was considerably below that expected, and the member of staff has
been suspended from duty following this incident pending an internal disciplinary investigation.
Conclusion
Grade: Minor
Status: Resolved
The member of staff has been suspended from duty pending an internal disciplinary investigation.
Evidence Gathered
CAD report
Audio file of emergency call
identified.
Final Contact Date: 08/01/ 2014
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: EMAS Trust HQ
Extension: XX
XX
Patient Outcome:
XX
Summary: Delay & Time On Scene-Was PALS/13/500
Case Details: Enquirer was in great pain and called 111 who advised that would get an ambulance to respond.
Nothing happened so the enquirer called 999 and the call taker explained that 111 had not requested an
ambulance for her (she had taken this up with 111)
A paramedic eventually arrived and was 'gobsmacked' by her condition. She was in graet pain and had no pulse in
her hand.
The paramedic requested back up but the ambulance took ages to respond and had to come from Nottingham.
There appeared to be no urgency by the crew. The crew told the patient that they had done 2 jobs on the way to
her.
One went to get a chair but waited in the ambulance for the rain 'to stop a bit'
The enquirer was taken to the ambulance whose path was blocked by the FRV who was completeing paperwork.
The ambulance then went 'the scenic route' to hospital which took much longer than it should have.
The enquirers husband travelled in his car behind them and kept flashing his lights as they were going the wrong
way.
The enquirer is concerned that the response was far too long and it took too long to get her to hospital where she
nearly died.
CAD ref: 5912615
Crew: 3730, 3012
• Why had the back up ambulance attend two other jobs on their way to the patient?
• Why did the crew show no urgency on scene?
• Why did the ambulance take the long route to the hospital?
TOR agreed by:
Complainant
Crew Stood Down:
No. If No state rationale: EOC delay and non-clinical issue.
registered. If No state rationale: non clinical issue and EOC delay.
Being Open
Timeline of Events
Date and Time
Event
14 Oct 2013
At 19:37 hours 999 call CAD 5912615 was received and coded 10D04 (chest pains) Red 2 (eight
minute response)
nd
The EMD noted on the CAD ‘2 call, severe in pain, car waiting at top to guide crew in, pain in arm,
shaking earlier on, CA patient lost spleen 3 years ago, 111 booked ambulance’
At 19:39 hours the dispatch officer noted on the CAD ‘we have not received a first call for this address’
At 19:40 hours an FRV was mobile to the scene. ETA 12 minutes, resource 3730.
At 19:49 hours the FRV arrived on scene. Response time 12 minutes
At 20:03 hours a double crewed ambulance (DCA) was mobile to the scene, resource 3012. ETA 18
minutes having come clear on scene of another call
At 20:04 hours the DCA was stood down and diverted to CAD 5912664 a cardiac arrest call
At 20:07 hours it is noted on the CAD ‘crew required Amber response’
At 20:12 hours the DCA was reallocated to the incident, having been stood down from the cardiac arrest
as a GP was now on scene and had pronounced the patient as deceased. ETA 25 minutes.
At 20:47 hours the DCA arrived on scene. Response time 1 hrs 10 minutes
At 21:22 hours the DCA left scene with the patient for Royal Derby Hospital
Handling of emergency call: the call was correctly coded as a Red 2 eight minute response. The first response on
scene arrived 12 minutes after receipt of the call, exceeding the eight minute target timeframe. The back-up
response arrived on scene one hour and ten minutes after receipt of the emergency call.
Entries from the Performance Delivery Manager (PDM) and Derbyshire divisional (DERBYS) dispatch logs:
DERBYS resource log:
18:57 hours SOUTH ON DUTY 19/07 NO SHORTAGES TO REPORT
19:08 hours SOUTH - NO DCA's BACK FOR START OF SHIFT FOR.....
MICKELOVER 19/07 CREW
LONG EATON 19/07 CREW
ILKESTON 19/07 CREW
ASHBOURNE 19/07 CREW
PDM resource log:
19:09 hours DERBYS HOLDING:- 2 x Green 2 calls & 5 x URGENT calls.
Care and treatment of the patient: The crew of the back-up response advised that the weather on the night in
question was really bad for visibility due to the down pour of rain. The crew were travelling from a location which
according to route planner takes approximately 38 minutes to reach the patients address.
The crew arrived on scene at 20:47 therefore taking 35 minutes to reach the destination using blue lights and sirens.
One crew member went out to get the carry chair from the vehicle and whilst at the vehicle manoeuvred the vehicle
to a better position for bringing the patient out of the house. Whilst completing this the rain started coming even
heavier therefore the staff member remained in the ambulance for a few minutes to see if the rain eased any as
otherwise the carry chair and the blanket would have been soaked and not suitable for transporting the patient.
Whilst one crew member completed the above the other was receiving a thorough hand over from the Community
Paramedic on scene. The patient was then moved to the ambulance on the carry chair.
The crew left scene at 21:22 and arrived at hospital at 21:54 taking 32 minutes (according to AA route planner this
journey should take approximately 25 minutes). The crew were following satellite navigation as they are unfamiliar
with the area and the sat nav took them the quickest route in miles but not road speed. The crew spoke to the
patient’s husband at the hospital and explained that they are not familiar with the area so unfortunately they had to
travel the route that the sat nav took them and they had not seen him flashing his lights as the driver was
concentrating on the road due to the poor visibility and road conditions.
The crew apologise for any upset or concerns caused by their actions.
Conclusion
The delay in sending a back-up resource was due to demand for emergency responses and no ambulances being
available at the time of the incident.
The actions of the crew were taken with full consideration of the safety and comfort of the patient.
Date Resolved: 8 January 2014 Status: Resolved
Grade: Minor
Evidence Gathered
CAD report
Statements from attending crew
identified.
Type: Control Call-Back Issue
Source: PALS Office
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: East Division HQ
Extension: XX
Green 3
Area/Divisional: EOC Lincoln
Patient Outcome:
Admitted to hospital
Summary: Call Handling-BrainTumour Pt Had Stroke
Case Details: Patient has a grade 4 brain tumour, was slurring speech, right arm paralysed and severe nose bleed.
Mum rang 999 and thought an ambulance was coming. EOC rang her back to assess and Mum was angry that an
ambulance hadnt been dispatched yet so said she would transport patient herself.
Whilst at Louth hospital, patient was to be transferred to Scunthorpe hospital by ambulance. Crew did not seem to
realise that it was supposed to be a blue light transfer and they dropped someone else off on the way.
CAD 6057201
• Why was an ambulance not sent straight away?
• Why did the ambulance crew question the decision to take the patient to Scunthorpe?
• Why did the ambulance make a detour to drop off a member of staff?
• Why were lights and sirens not used for the journey to Scunthorpe?
TOR agreed by:
Complainant
Date: 18 Dec 2014
Crew Stood Down:
No. If No state rationale: non clinical issue
registered. If No state rationale
Being Open
Timeline of Events
Date and Time
Event
12 Dec 2013
12:40
new call received on behalf of a patient who has a brain tumour. Pain in right hand side
and patient having a massive nose bleed.
resource 6210, double crewed ambulance (DCA) allocated to the incident.
resource RA066, community first responder, allocated to the incident.
Call assessed as 21A02, haemorrhage/lacerations, nosebleed, patient under 35 with
serious haemorrhage, allocated Green 3 coding, return call by clinician within 20 minutes.
Resources 6210 and RA066 stood down from incident.
return call from clinician.
CAD message: Called to assess but caller hung up before I could assess. States she will take
the patient herself.
CAD message: called to assess. Caller angry as she states she had not been told a clinician
would call her back. Caller hung up advising she will take the patient herself.
new call received to provide an ambulance under emergency conditions to transport a
patient from Louth County Hospital to Scunthorpe General Hospital.
resource 6412, double crewed ambulance (DCA) allocated and mobile to the incident.
resource 6412 arrives at Louth County Hospital.
resource 6412 leaves Louth County Hospital with the patient.
resource 6412 arrives at Scunthorpe General Hospital.
crew of resource 6412 hand patient over to hospital staff.
12:40
12:41
12:43
12:52
12:59
13:02
15:11
15:12
15:16
15:36
16:30
16:48
Handling of emergency call: the call was correctly coded as a Green 3, return call by clinician within 20 minutes.
The clinician made the return call 12 minutes later, and the caller stated she would take the patient to hospital
herself.
At the end of the emergency call the call taker advised the caller that a clinician would be calling back. It would
appear that this information was not passed on to the patient’s mother who had handed the call over to a third
party.
When the clinician did place a return call, the patient’s mother was annoyed that she was unaware a return call
would be made. She was under the impression that an ambulance was on its way, and she advised that she would
take the patient to hospital herself. The call was then terminated.
Care and treatment of the patient: the attending crew have confirmed that a discussion did take place with
hospital staff regarding the most appropriate destination to take the patient. This was because Lincoln hospital
was nearer by some 20 minutes, and they were seeking clarification in the best interests of the patient.
The crew have confirmed that on the day of the incident they were accompanied by a member of staff undergoing
a phased return to work after maternity leave. As it was not necessary for her to travel to Scunthorpe, and the
ambulance was passing the road in which the ambulance station was located, the member of staff was dropped at
the junction. This involved no detour from their route and a stop of a matter of seconds.
The crew have confirmed that blue lights were used throughout the journey, and sirens were employed as
appropriate. It may not have been evident in the back of the ambulance that blue lights were being utilised as the
blinds were drawn.
Conclusion
The emergency call was correctly coded, and the call taker did confirm that a clinician would be making a return
call. Unfortunately this information was not passed on to the patient’s mother.
The crew did have a discussion about the most appropriate destination for the patient. This was done in the
patient’s best interests. A member of staff was allowed to leave the ambulance en route to Scunthorpe but this
involved no detour, and blue lights were utilised throughout the journey with sirens employed appropriately.
Grade: Moderate
Status: Resolved
Evidence Gathered
CAD reports
Audio files of emergency call and clinician call
Statements from attending crew members.
identified.
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Public Place
Extension: XX
Green 2
Area/Divisional:
Patient Outcome:
Unknown
Summary: Delayed Response
Case Details: Enquirers grand mother fell in -------------------- in the --------------------------------- and injured her upper
arm.
It was two hours before a paramedic arrived and another half hour wait for a DCA.
The wait has worsened her condition.
When the crew/ paramedic arrived thay said that this should have been a red response from the start.
Why was the response so long?
The enquirer is insisting that this is dealt with as an FC.
CAD ref: 6059892
• Why was there such a long wait for an ambulance response?
TOR agreed by:
Complainant
Crew Stood Down:
Date: 17/12/2013
Being Open
Timeline of Events
Date and Time
Event
13/12/2013
13:34
13:35
new call received on behalf of a --- year old female patient who has fallen.
call assessed as 17B01G, falls, possibly dangerous body area, patient on the floor.
Allocated a Green 2 30 minute response.
CAD message: no phone number to call patient back on, shoulder and leg pain, can’t feel
arm.
new call received, call ref. 6059946.
call ref. 6059946 stopped as a duplicate of this call.
CAD message: unable to put me through to someone with the patient, unable to do
welfare call.
call 6060094 stopped as a duplicate of this call.
CAD message: unable to call back to patient, condition now not known, upgraded to a
Green 1 20 minute response in line with protocols.
call ref. 6060162 stopped as a duplicate of this call.
CAD message: crew required amber response.
resource 2418, double crewed ambulance, allocated to incident. Estimated to be 22
minutes from scene.
resource 9117, double crewed ambulance, allocated and mobile to incident. Nearer
resource. Resource 2418 stood down.
CAD message: call from patient’s grandson to complain about the delay in treatment for
his grandmother.
resource 9117 hands patient over to hospital staff.
13:37
13:57
14:34
14:36
14:54
15:01
15:04
15:18
15:18
15:20
15:25
15:29
15:33
15:57
15:58
15:59
16:05
16:05
16:30
16:40
16:56
17:32
Handling of emergency call: the call was correctly coded as a Green 2 30 minute response, and correctly upgraded
to Green 1 when the welfare call was not possible. The first resource arrived one hour and 51 minutes after receipt
of the emergency call, exceeding the 30 minute timeframe.
Notes from Performance Delivery Manager (PDM) and Derbyshire (DERBYS) resource logs.
PDM resource log:
11:34 Derby in overcapacity, actions 1 and 2.
11:39 Derby holding 10 x Green 2 calls and eight urgent calls.
13:18 Derby holding one Green 1 call, four Green 2 calls and 11 urgent calls.
15:27 Derby holding six Green 1 calls, ten Green 2 calls and two urgent calls.
19:07 Derby holding three Red 2 calls, five Green 2 calls and six urgent calls.
11:12 holding two Red 2 back-ups and an auto back-up, plus an amber back-up, one Green 1 and one Green 2 call.
11:31 six uncovered Red 2 calls in Derby South.
11:36 North holding two Amber back-ups and six Green 2 calls.
12:22 North holding six Green 2 calls.
13:42 South holding six Green 2 calls.
14:43 Holding one Red 2 call, one Green 1 call, nine Green 2 calls and nine Urgent calls, all in South.
15:00 Holding two Red 2 calls, two Green 1 calls and nine Green 2 calls.
17:09 Six Green 2 calls holding in Derby South.
18:14 Holding one Red 2 call, one Green 1 call, three Green 2 calls and six Urgent calls.
Conclusion
The delay in response was due to high demand for emergency responses on the day of the incident. The division
was in overcapacity throughout the day.
Date Resolved: 16 Jan 2014
Grade: Moderate
Status: Resolved
Letter Date: 16 Jan 2014
Evidence Gathered
CAD report
Resource log information
Call audit.
identified.
Category: Attitude Of Staff - Operationa
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Public Place
Extension: XX
Red 2
Area/Divisional: Nottinghamshire
Patient Outcome: Transported to A&E
Summary: Paramedic Attitude & Paracetamol Dose
Case Details: ---------- old patient has spells where she holds her breath. Mum can cope with these but on this
occasion it happened whilst paying in a shop, and passers-by called 999.
Mum very unhappy with attitude of FRV paramedic.
Paramedic gave pt 2 syringes of paracetamol without asking mum whether she had already had some - which she
had 5ml one hour previously. As baby is smaller than average, Mum thinks that this was unacceptable.
• Why was the patient administered medication without consultation?
• Why did the Paramedic insist patient should attend hospital?
TOR agreed by:
Complainant
Date: 17/12/2013
Crew Stood Down:
•
Staff support and involvement: XX Name, (initial) – Paramedic Skill level, EE date: IPR date:
State what support staff have been given and by whom (using the job title not names)
Healthcare Decisions Panel (HDP) referral: Yes/No. All clinical incidents must be referred to HDP where clinicians
are registered. If No state rationale
Being Open
Timeline of Events
Date and Time
Event
9 Dec 2013
13:31
13:32
13:32
new call received on behalf of a ------------------ female who is choking.
call assessed as 11D02, choking, patient not alert. Allocated a Red 2 eight minute
response.
CAD message: patient choking and now gone blue.
CAD message: FRV on scene, crew required amber response please. Resource 8326,
double crewed ambulance, allocated to incident.
13:33
13:34
13:40
13:42
13:43
14:06
14:23
14:24
14:37
15:17
Handling of emergency call: the call was received at 13:31 and was correctly coded as a Red 2 eight minute
response. The first responding resource arrived on scene at 13:40 which was nine minutes after receipt of the
emergency call. This was one minute outside the eight minute target timeframe.
Care and treatment of the patient: the responding Paramedic advised that she was allocated to attend the incident
where it was reported that an infant was choking. En route to the location she was further advised that the patient
was not alert and going blue, and then just before she arrived she was told that the infant was no longer choking.
On arrival she encountered the patient and her mother, and she was advised that the infant was fine now and the
mother wanted to take her home. However the Paramedic advised that she wanted to check the patient over, and
the mother and child went back into the store. A member of staff at the store advised that the mother’s shopping
would be taken care of in the meantime.
The Paramedic advised that the patient was still very distressed, and her mother was attempting to calm her. It
was established that the infant had started to choke whilst eating a Smartie, and members of the public had
intervened and performed back slaps and abdominal thrusts on her. The Paramedic began to take a medical
history while the mother comforted the child, and it was established that the patient had episodes of breath
holding to the point where she stopped breathing. However the Paramedic was still mindful that the patient had
appeared to be choking on this occasion, and she also wanted to check that the bystander interventions had not
had any adverse effect. At this stage the patient was still very distressed and this impeded the Paramedic in taking
initial observations.
The Paramedic explained to the mother that in view of the child’s age and the possibility that she could have
aspirated the sweet into her lungs she wanted to arrange for transport to hospital so further tests could be
undertaken. The Paramedic lent the mother her telephone so she could contact her family, and the Paramedic
attempted to try and undertake a visual examination of the child. However the child became increasingly
distressed and she was handed back to her mother.
The Paramedic continued to try and take observations, which were written on an unused glove prior to them being
transferred to a patient report form. The Paramedic arranged for a member of staff at the store to get a dummy to
try and pacify the child, but this had little effect on calming her. The mother continued to try and cam the child,
after which the Paramedic intended to undertake a more detailed examination including listening to the child’s
chest. As the dummy was not pacifying the child the Paramedic suggested administering Calpol in case the child
was suffering any pain from the sweet or the bystander interventions. She returned to the ambulance vehicle and
obtained a 5ml sachet of Calpol which she loaded in a syringe in two attempts. The mother then gave the Calpol to
her child. At no point did the mother advise that the child had been given some Calpol about an hour before, and if
the Paramedic had been told this she would not have administered the medication.
The back-up crew arrived about the same time as the patient’s father and grandparents, and the reason for the
child’s conveyance to hospital was explained to family members. The Paramedic gave a full handover to the backup crew and she handed over the glove on which she had recorded some initial observations. At some point whilst
discussing the logistics of getting the patient to hospital and the family, shopping and vehicles to where they
needed to be the Paramedic made comment about the frozen items in the shopping. She had already commented
on this earlier in what was supposed to be a lighthearted comment with no offence or upset intended. The patient
was then transported to hospital in her mother’s arms by the back-up crew.
The Paramedic also advised that a couple of days after the incident she received a telephone call from the child’s
mother expressing her dissatisfaction with her daughter’s treatment. The mother advised that she had spent some
hours in the accident and emergency department and her daughter had not required an x-ray. The mother also
advised that she was upset with the attitude and comments of the Paramedic, who said that these were in no way
meant to cause offence. The Paramedic confirmed that she was happy with the care and treatment she had given
to the patient.
Conclusion
Grade: Moderate
Status: Resolved
There are no recommendations to make on this occasion
Evidence Gathered
Statement from Paramedic
CAD report
PRF
identified.
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
XX
Patient Outcome:
XX
Summary: Delay- 21 Weeks Pregnant.Baby Died
Case Details: Pt was 21 weeks pregnant. She suffered pain and bleeding so husband rang 999. Ambulance took 1
hour 20 minutes to arrive and Patient went into labour whilst waiting. By the time ambulance had arrived, baby
had been born and had died.
• Why did it take so long to send an ambulance?
TOR agreed by:
Complainant
Date: 18/12/2013
Crew Stood Down:
Being Open
Timeline of Events
Date and Time
Event
17/11/2013
01:32
01:37
new call received on behalf of a female who is suffering a PV bleed, 5 months pregnant.
Call assessed as 24D03, Pregnancy/childbirth/Miscarriage, imminent delivery, gestation
greater than or equal to five months/20 weeks. Allocated a Green 2 30 minute response.
further call received, call ref. 5994127. Stopped as a duplicate of this call.
further call received, call ref. 5994151.
CAD message: number incorrect, unable to welfare call. (Caller was on a further call to
EMAS at this time).
resource 3414, double crewed ambulance (DCA) allocated and mobile to this call.
02:04
02:20
02:32
02:41
02:47
03:14
03:22
04:30
Handling of emergency calls: the emergency calls received were all correctly coded as Green 2 30 minute response.
On the third call received at 02:20 the call taker stayed on the line until the arrival of the ambulance crew at 02:47
talking the caller through the birth of the baby. The first responding resource arrived on scene one hour and 15
minutes after receipt of the first emergency call, missing the target timeframe of 30 minutes for this category of
call.
Care and treatment of the patient:
When the third call was received from the patient’s husband, the call taker remained on the call from 02:20 until
the ambulance crew arrived at 02:47. During this time the call taker talked the patient’s husband through the
delivery of the baby, although there was some confusion establishing whether the baby had been fully delivered
and whether he/she was breathing. At the time the crew arrived on scene it was advised by the patient’s husband
that the baby was fully delivered and was breathing. However the Patient Report Form records that there were no
signs of life from the baby and that the placenta had only been partly delivered. The crew transported the patient
and baby to the labour suite at the Queens Medical Centre in Nottingham.
Notes from Nottinghamshire dispatchers resource log (NOTTS):
01:33 Notts south holding five Green 2 calls.
02:38 Notts South holding eight Green 2 calls.
Conclusion
The delayed response was due to high demand for emergency responses on the day of the incident. The
emergency calls were correctly coded.
Grade: Moderate
Status: Resolved
Evidence Gathered
CAD reports
Call audits
Patient report form
Resource log notes
identified.
Source: Email
Final Contact Date: 14 March 2014
Delays Incurred
Reason for Delay: Unable to trace incident details
New Agreed Date: 14/03/2014
Harm Rate:
N/A
Base: A&E Department/MIU/MAU
Extension: unable to trace incident details
Area/Divisional: A&E Department/MIU/MAU
Patient Outcome:
N/A
Summary: Staff Allegedly Dragged Patient To The Floor
Case Details: Child Protection Case Conference with Leicestershire Children's Safeguarding team. Enquirer made
allegations in the meeting that on the evening 10-11-2013 and early hours of 11-11-2013 she attended ED at
Kettering via ambulance CAD 5978391, that she had become angry and upset that the police had taken her son
into care, that she threw a pot tea cup, across the emergency department hitting a toilet door.
She then alleges that she was dragged to the floor by a Paramedic and had her hair pulled back. She cannot
identify the Paramedic as it was not the same crew member that brought her into the ED. The incident was
witnessed by ED Nursing staff, and other EMAS staff.
Reported by Locality Quality Manager, South Division.
• Why was the patient physically restrained by a member of EMAS staff.
TOR agreed by:
Complainant
Date: 24 Dec 2014
Crew Stood Down:
No. If No state rationale: unable to trace incident details
registered. If No state rationale: unable to trace incident details
Being Open
Timeline of Events
Date and Time
Event
10 November 2013
Incident Number not applicable
The complaint relates to an incident that ------------------ advises occurred between 19:00 and 23:00 on 10
November 2013. ------------ had been taken to Kettering General Hospital after she had fallen at home (call ref.
5978391). The conveying crew had arrived at Kettering Hospital A&E department at 18:53 and they called clear at
19:29.
------------- has advised that she believes the incident happened at approximately 19:30 hrs. She advised that she
had become distressed after the Police arrived at the accident and emergency department to take her child into
care and she had thrown a tea cup across the department. Immediately after this she was dragged to the floor by a
member of EMAS staff and her hair was pulled back.
Following an investigation the investigation officer can find no details of this incident. The following actions have
been taken to try and identify the member of staff involved:
The investigation officer(IO) has spoken to the PALS department at KGH, and they have liaised with the A&E
department. The hospital has no records relating to this incident.
The IO has checked if there is CCTV available of the incident ( there is none)
Contact was made with Northants Police to see if they have any information about the incident (they do not).
The IO has spoken to the complainant to drill down on the timeframes, and she has advised that the incident
happened on 10 November between 19:00 and 23:00.
An approach was made to the management team in Division to see if any of them had knowledge of this incident.
The Locality Manager suggested two possible names. The IO checked the resource log which discounted one of
these two members of staff as his shift did not start until 22:00 on 10 November and he did not attend KGH until
02:15 on 11 November. The other member of staff has been approached by his Team Leader and he has no
knowledge of this incident..
Conclusion
Despite extensive investigation no details of this incident can be traced.
Date Resolved:
Status: Unresolved
Grade: Moderate
Letter Date: 14 March 2014
The investigation has been unable to identify any details of this incident.
Evidence Gathered
CAD report
Contact with the PALS department and A&E department at KGH.
Contact with all Divisional managers
Contact with Northants Police
identified.
Type: No Transport Provided
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: EMAS Trust HQ
Extension: XX
0
Green 4
Area/Divisional: EOC Derbyshire
Patient Outcome:
No harm/injuries
Summary: Pt Blacked Out In Shops.Did Not Send Amb
Case Details: -------------- had a black out whilst in ------------------------------------ CAD Ref 6060182. The security guard
call an ambulance and control advised we wouldn't be sending one. I can see -------------- has a complexed history
and she said she has lost all confidence in EMAS and is considering moving house just to be outside of our area and
if an EMAS crew does attend her she will refuse to be treated unless there is a social worker or carer with her.
She advised -------------------- was supposed to visit her some time ago to discuss her case but she said this did not
happen.
• Why was an ambulance not sent to help the patient?
TOR agreed by:
Complainant
Crew Stood Down:
No. If No state rationale: EOC issue
Date: 23/12/2013
registered. If No state rationale: EOC issue
Being Open
Timeline of Events
Date and Time
Event
13 Dec 2013
15:24
15:24
15:26
new call received call ref. 6060182 on behalf of a female patient who has fainted.
location established, ----------------------------------------------------------------.
call assessed as 31A01, unconscious/fainting, fainting episode and alert, patient over 35.
Allocated a Green 4 code, call back from clinician within 60 minutes. CMP script read.
EOC in overcapacity plan to Action 3, caller advised that no ambulance will be sent.
Instructions given for patient to visit their GP, call 111 or make their own way to the
nearest accident and emergency department.
15:28
Handling of emergency call: the call was correctly assessed as a Green 4. This would normally mean a return call
from a clinician within 60 minutes. However the Capacity Management Plan was in operation up to Action 3, and
this meant that Green 4 calls for patients between 5 and 69 years of age are advised that an ambulance will not be
sent. This information was delivered to the caller along with further advice that the patient should contact their
GP, call 111 or go along to their nearest accident and emergency department. This is the correct procedure in
these circumstances.
Notes from the Performance Delivery Manager (PDM) and Derbyshire dispatch desk (DERBYS) resource logs.
Notes from PDM log:
11:39 Derbys holding ten Green 2 calls and eight Urgent calls.
13:18 Derbys holding one Green 1 call, four Green 2 calls and 11 Urgent calls.
13:56 Capacity Management Plan (CMP) action 3 for Trust.
15:27 Derbys holding six Green 1 calls, ten Green 2 calls and 20 Urgent calls.
19:07 Derbys holding three Red 2 calls, three Green 1 calls, two Green 2 calls, two Green 4 calls and six Urgent
calls.
Notes from DERBYS log:
11:31 six uncovered Red 2 calls in Derby south
11:36 Derby North holding two Amber back-ups and six Green 2 calls.
12:30 one uncovered Green 1 call and five uncovered Green 2 calls in Derby South.
13:42 uncovered Red 2 calls and six uncovered Green 2 calls.
14:43 one uncovered Red 2 call. One uncovered Green 1 call and nine Green 2 calls.
15:00 Uncovered two Red 2 calls, two Green 1 calls and nine Green 2 calls.
17:09 six uncovered Green 2 calls in Derby South.
Ongoing care of patient: the patient has commented that she was expecting a visit from a Divisional Manager to
discuss her ongoing concerns and this had not yet happened. This will be investigated on the patient’s behalf and
the result will be communicated to her.
Conclusion
Following assessment of the patient’s condition the call was assessed as a Green 4 response. As the EOC was
operating under Capacity Management Plan action 3 at the time the appropriate advice was given to the caller
that an ambulance would not be required, and safety netting was delivered.
Grade: Minor
Status: Resolved
Internal records will be checked to ascertain if the patient is due to receive a visit from a Divisional manager to
discuss her ongoing care needs.
Evidence Gathered
CAD reports
Audio file of call
Capacity Management Plan
identified.
Source: PALS Office
Final Contact Date:
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: EMAS Trust HQ
Green 3
Patient Outcome:
Transported
to
ED
Extension: XX
Summary: Delay - 13 Month Old Breathing Problem
Case Details: Our ------------- daughter was taken ill on whilst holidaying at -------------------------------------------. Having
taken her to the medical centre on site, trained nurses thought it necessary to call an ambulance with a
temperature of 29.7 degrees celsius, heart rate of 200, sats of 88% (requiring the administration of oxygen during
our wait time), rapid breathing and recession of the airway. The call was made at 1300 and "we" were told we
were given the highest priority (given the age of the child and symptoms) and dealt with as if it was a private
residence calling. After 20 minutes an ambulance had yet to be allocated, two further calls ensued to establish an
ETA. The ambulance arrived on scene at 1415, one and quarter hours after it had been called. This led to huge
anxiety in an already extremely stressful situation and could have been to the ultimate detriment of our child's
well being. The response time was wholly inexcusable, unacceptable and fell woefully short of the government
response time of 8mins.
In addition to your original concern, you have asked for the following information:
A transcript of all the calls including the clinical assessment team (CAT) call
Resource levels in North Nottinghamshire on 20 November 2013.
Location of all North Nottinghamshire resources at the time of this emergency.
The frequency of instigation of the capacity management plan (CMP)in the North
Nottinghamshire area.
• Why was there such a delay in sending an ambulance?
TOR agreed by:
Complainant
Date: 23/12/2013
Crew Stood Down:
Being Open
Timeline of Events
On 20th November, 2013
At 14:13 hours a DCA arrived on scene. Total response time 1 hr 11 minutes
At 13:02 hours 999 call CAD 6002215 was received and coded 06C01A (breathing problems) Green 3
(triage within 20 minutes)
The EMD noted on the CAD ‘DIB, registered nurse with patient’
At 13:04 hours an FRV was mobile to the scene. ETA 8 minutes
At 13:04 hours the call was passed to nurse triage
At 13:05 hours the FRV was stood down. Reason:- Green 3
At 13:27 hours the CAT team stopped this call as a duplicate of the upgraded call
At 13:27 hours the CAT team created CAD 6002271 and coded the call 06C01A (breathing problems)
upgraded to Green 2 (30 minute response)
The CAT team noted on the CAD ‘asthmatic infant, SOB, o2 in situ, nurse on scene, upgraded to Green 2’
At 13:54 hours a DCA was mobile to the scene. ETA 18 minutes having come clear at Kings Mill Hospital
nd
At 14:00 hours a 2 999 call CAD 6002356 was received and coded 06D01A (breathing problems)
Red 2 (8 minute response)
nd
The EMD noted on the CAD ‘2 call DIB’
This call was correctly stopped as a duplicate of the above call
At 14:13 hours the DCA arrived on scene. Total response time 1 hr 11 minutes
rd
At 14:15 hours a 3 999 call CAD 6002400 was received and coded 06C01 (breathing problems)
Green 3 (triage within 20 minutes)
The EMD noted on the CAD ‘DIB, ambulance on scene’
This call was stopped as a duplicate call
At 14:29 hours the hospital was made aware this patient was coming in
At 14:30 hours the DCA left scene with the patient for Kings Mill Hospital
At 14:53 hours the patient was handed over to clinical staff
Handling of emergency calls: The first emergency call was correctly assessed as a green 3 response from the
information provided. Following a return call from a clinician the response was upgraded to a Green 2 30 minute
response, and following the second emergency call at 14:00 the call was upgraded again to a Red 2 response – the
resource was already en route to the patient at this point. The ambulance arrived on scene while the third call was
in progress.
.
This call was covered by the Notts North dispatch desk and below is taken from the Nottinghamshire resource log:20 Nov 2013 14:16 hours NOTTS NORTH HOLDING:1 x AUTO BACK UP, 2 x AMBER BACK UPS, 2 x G2'S
Below is taken from the PDM’s resource log:20 Nov 2013 10:04 hours HOLDING NOTTS:- 2 x G1, 5 x G2, 3 x URGENTS (1 x YELLOW) CMP - NOTTS
ARE NOW CMP 1 & 2
20 Nov 2013 11:25 hours HOLDING NOTTS:- 2 x G2, 4 x URGENTS
CMP - NOTTS ARE NOW ONLY HOLDING 2 x QUALIFYING CALLS, CMP REVOKED.
14:32 Notts in CMP actions 1 and 2
Conclusion
The delay in response was due to high demand for emergency responses on the day of the incident. The
complainant is under the impression that the call was coded as an eight minute emergency from the outset.
Grade: Minor
Status: Resolved
Evidence Gathered
CAD reports
Audio files for calls
Resource log notes
Resource and demand data
identified.
Type: Clinical
Category: Diagnosis Problems
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Red 2/Red 2
Base: Patient's work/house
Patient Outcome:
Admitted
to
hospital
Extension: XX
Summary: Patient Assessment Diagnosis
Case Details: On 16 Deccember complainants wife collapsed at work (-------------------------------------------------------------------------) . He put his wife in the recovery position and called 999. A first responder arrived followed by a crew
and they diagnosed sinusitis and advised the patient to see her GP for stronger pain relief. The patient was not
transported.
On 18 December patient was still unwell with headache and stiff neck and so they called the GP who advised to
call 999 from the home address.
Ambulance attended and they were advised that the patient had some sort of viral infection and again were
advised to see GP for stronger pain relief. Patient was not transported.
On 19 December the complainant took his wife to the GP who advised that she should go to hospital so he took
him there himself.The patient was later diagnosed with a brain aneurysm and is still very ill. The complainant is
very concerned that his wife was misdiagnosed by 2 crews and is insisting that this is dealt with as a formal
complaint.
• Why was the patient left at home on two occasions?
• Was the care and treatment of the patient appropriate on each occasion?
TOR agreed by:
Complainant
Crew Stood Down:
No. If No state rationale: no risk to patients identified.
•
Staff support and involvement: TS Paramedic, CS W
Being Open
Timeline of Events
Date and Time
Event
16 Dec 2013
13:26
13:26
13:27
13:29
new call received on behalf of a female patient who has collapsed.
resource 6732, solo responder, allocated to the incident.
call assessed as 18C03, headache, speech problems, allocated a Green 3 code, call back by
clinician within 20 minutes. Resource 6732 stood down from incident.
call assessed as 28C03L, stroke, speech problems, less than one hour ago. Allocated a Red
2 eight minute response. Stand down of resource 6732 cancelled.
CAD message: The stroke diagnostic results indicate no positive evidence of a stroke.
Resource 6718 mobile to the incident. Resource RA198, LIVES responder, also allocated
and mobile to the incident.
call assessed as 10C04, chest pain, breathing normally.
resource RA198 arrives on scene.
resource RA198 calls clear from the scene.
CAD message: treated on scene, patient going to see her GP, problem more with sinuses
than chest pain.
13:29
13:30
13:31
13:32
13:35
13:37
13:38
13:45
14:13
14:21
14:22
18 Dec 2013
08:53
08:54
08:55
08:57
10:03
new call received on behalf of a female patient.
call assessed as 10D01, chest pain, not alert. Allocated a Red 2 eight minute response.
resource 6718 calls clear from the scene. Patient treated on scene.
Handling of emergency calls: both calls were correctly coded, and allocated a Red 2 eight minute response. On 16
December the first resource on scene arrived nine minutes after receipt of the emergency call. This missed the
eight minute target but met the 19 minute target. On 18 December the responding resource arrived four minutes
after receipt of the emergency call, meeting the eight minute target.
Care and treatment of the patient 16 December: a clinical review of the patient report form (PRF) confirms that
all relevant observations were documented except pain score. All values within normal parameters but the patient
was showing slight pyrexia. Two sets of observations were completed. Contemporaneous record documents chief
complaint consistent with clinician’s impression. Relevant history was gathered, although no pertinent negatives
were documented. Clinical decision making was evident and there was evidence of suitable clinical examination
taking place. The PRF documentation supports the diagnosis and clinical decision and the treatment was appropriate
given the patient’s presenting condition. There was an appropriate referral given presenting condition, however
referral to the GP as opposed to simple advice to contact the GP would have been a more effective safety net.
Care and treatment of the patient 18 December: All relevant observations were documented. All values were
within normal parameters but the patient was showing slight pyrexia. Two sets of observations were completed.
Contemporaneous record documents chief complaint but no clinical impression was documented. Some evidence of
red flags (three days of headache and neck stiffness and repeated access to and Health Care Professional). Relevant
history gathered but it appears the attending clinician has not acted upon red flag symptoms. There is evidence of
suitable clinical examination taking place. PRF documentation highlights three potential red flag symptoms. Clinical
decision to refer to alternative Health Care Professional is not supported. The treatment recommended was not
appropriate given the patient’s presenting condition and the patient should have been transported to the hospital
accident and emergency department. Whilst the clinician documents contact with the GP surgery, there is no
information regarding who was spoken to and what details were passed to surgery.
Whilst our second attendance details areas where we have fallen short (not acting upon documented red-flag
presentations) by not transporting the patient to the accident and emergency department, there is evidence on both
occasions of relevant assessments and some limited safety netting. In addition, whilst we may have potentially
delayed treatment, there is no evidence as yet that this has led to a worsened outcome for the patient.
Conclusion
Based on the presenting condition of the patient and the medical history and observations taken, the decision to
leave the patient at home on 16 December seems appropriate and the attending crew put some safety netting in
place by referring the patient to her GP.
The decision to leave the patient at home on 18 December is not supported by the patient’s presenting condition,
recent medical history and observations. There was evidence of red flags (three days of headaches and neck
stiffness and repeated referrals to health care professionals) and the patient should have been transferred to
hospital for further assessment.
Date Resolved: 24 Jan 2014
Grade: Moderate
Status: Resolved
Letter Date: 24 Jan 2014
Action: File note discussion with the attending crew from 18 December 2013
Improvement: confirmation of the identification and recognition of red flags and the action which needs to be
taken.
Outcome Detail: Increased awareness of action to be taken when red flags are identified.
For:
Deadline: 28 February 2014
Evidence: File note.
Evidence Gathered
CAD reports
Patient report forms
Clinical opinion of care and treatment given
identified.
Category: Attitude Of Staff - Operationa
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Nursing Home
Red 2
Area/Divisional:
Patient Outcome:
Extension: XX
Summary: Crew Attitude
Case Details: EMAS crew attended care home patient after a call from the GP. The nurse at the care home felt that
the EMAS crew were dismissive of her and undermined her decision making and care of the patient. The nurse
wants a formal investigation into this incident.
• Why did the ambulance crew question the care of the patient?
• Why did the ambulance crew not consider the feelings of the patient?
TOR agreed by:
Complainant
Date: 07/01/2014
Crew Stood Down:
registered. If No state rationale: non clinical issue
Being Open
Timeline of Events
Date and Time
Event
16/12/2013
13:59
14:00
new call received on behalf of a female patient in acute respiratory distress.
call assessed as 06D02, breathing problems, difficulty speaking between breaths.
Allocated a Red 2 eight minute response.
CAD message: doctor with the patient.
resource 8931 stood down from incident: nearer vehicle.
crew of 3522 hands patient over to hospital staff.
CAD message: crew referring this patient to safeguarding.
14:00
14:01
14:02
14:03
14:03
14:04
14:08
14:41
15:00
15:11
15:13
Handling of emergency call: the call was correctly coded as a Red 2 eight minute emergency. The responding crew
arrived nine minutes after receipt of the emergency call, which was outside the eight minute timeframe but inside
the 19 minute timeframe.
Care and treatment of the patient: the responding crew were immediately concerned that an emergency
ambulance had not been requested earlier for the patient, who had a respiratory rate of 32 and she appeared to
be in respiratory distress. A GP was on scene and also commented on how poorly the patient looked on her arrival.
The staff at the care home advised that the patient had been unwell since the previous evening, and as she
seemed worse that morning salbutamol and Flixotide had been administered. This seemed to have little effect and
a doctor’s visit had been requested. The crew expressed their concerns to the nurse at the care home, but this was
done out of concern for the patient. A full set of observations was taken and these showed the patient to have a
respiratory rate of 36 and oxygen saturation level of 91% which was treated with a salbutamol nebuliser and
oxygen. A further reading following administration showed the level to have risen to 96%. The patient’s GCS was
11, with the patient in the advanced stages of dementia and unable to communicate. This also prevented a pain
score from being recorded. The patient had recently completed a course of antibiotics but it was not clear when
this was.
The crew transferred the patient to the ambulance and transported her under emergency conditions to the
Queens Medical Centre resus department. In view of their concerns about the delay in the request for an
emergency ambulance, the crew submitted a safeguarding referral for the patient.
Conclusion
The attending crew did question the decision not to ring for an emergency ambulance earlier on the day of the
incident, due to concerns about the patient’s presenting condition. A safeguarding referral was completed after
the incident in respect of this patient.
Grade: Moderate
Status: Resolved
Evidence Gathered
CAD report
Patient report form
Safeguarding referral
identified.
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Extension: XX
Green 1
Patient Outcome:
Made own way
Summary: Nephregenic Diabetes D&V - No DCA's
Case Details: --------------- male with nephregenic diabetes was vomiting and unable to keep fluids down. Rang 999.
FRV arrived and agreed that pt needed to go to hospital. Unfortunately, there were no double crewed ambulances
available to transport him.
Parents took pt to LRI in their own car. Pt deteriorated on route. Pt seen by doctor in resus and was admitted to
intensive care.
Pt has now made a full recovery.
• Why did the Paramedic start to take observations?
• Why were there no ambulances available?
TOR agreed by:
Complainant
Date: 08/01/2014
Crew Stood Down:
No. If No state rationale: non clinical issue.
registered. If No state rationale: non clinical issue (observations refused)
Being Open
Consent Required: Yes Consent Date:
Timeline of Events
Date and Time
Event
26 Dec 2014
10:44
new call received on behalf of a ------------------ male who has nephrogenic diabetes
insipidus. Patient has been vomiting since 04:00 and is getting dehydrated.
CAD message: patient needs glucose drip.
resource 4831, solo responder, allocated and mobile to incident.
CAD message: patient is really yellow and he has a kidney condition.
call assessed as 13C01, diabetic problems, patient not alert. Allocated a Green 1 20 minute
response.
CAD message: the patient has open access to the Leicester Royal Infirmary, and he needs a
non saline drip.
solo responder requests crew on amber response, and is advised that no resources are
available.
CAD message: patient has made own way in a car. The caller wanted an ambulance not a
Paramedic. Paramedic was refused the opportunity to take observations and the patient’s
mother did not want to wait for an ambulance. Patient’s mother wanted solo responder to
call hospital and let them know that the patient was coming.
CAD message: from 4831, family were pleasant but mum was obstructive in as much that
she would not allow solo responder to take full observations on the patient. He advised
that the patient was unwell and that an ambulance would be the best method of
transportation into hospital. He would wait on scene until the ambulance arrived.
However EMAS were k0 (no available resources) of double crewed ambulances (DCA’s) at
that time. The patient’s mother went against the solo responder’s advice and transported
the patient to Leicester Royal Infirmary in her own vehicle. Kettering General Hospital
would be the nearer hospital but the patient has had previous treatment at LRI and
previously had an open access card for admission. The solo responder has called LRI Resus
to alert them to the patient’s condition and to expect him shortly.
10:45
10:45
10:45
10:46
10:46
10:58
11:05
11:17
11:42
26 Dec 2013
11:20
11:27
11:28
Incident no. 6091361
new call received on behalf of patient.
CAD message: ambulance is required. The patient is acutely unwell and he needs a
dextrose drip.
Patient is very cold and shaking. Patient is yellow. Paramedic that attended the patient did
not understand the problem. The patient suffers from a very rare condition. Patient’s
11:44
11:47
11:48
11:52
11:51
mum thinks he needs to go into Resus. The patient is severely dehydrated and he needs
his glucose levels checking but this can only be done in Resus. The Paramedic who
attended said there were no ambulances available in Leicestershire. Patient’s mum and
dad asked us to notify Resus. Advised that we could not notify resus direct, but they
should pull over and wait for an ambulance if the patient was that poorly. Address given in
Oadby where the ambulance could be dispatched to.
further call received, call ref. 6091408. Patient is now losing consciousness.
CAD message: patient is sat in a car on the drive. Patient making own to LRI.
CAD message: patient was under the care of the Renal outreach clinic as an adolescent,
turned 17 this year. He has a kidney condition and he requires dextrose solution as soon
as he reaches hospital.
advised that there are still no ambulances available in the area. Mother is taking patient to
the LRI herself. Call stopped as a duplicate of call ref. 6091361.
No reference number – call made to patient’s father to ascertain where the patient is.
Approx five minutes from the LRI. Patient’s father advised that the solo responder has
spoken to a doctor in Resus and A&E reception and the Urgent Care centre have also been
alerted to patient’s arrival.
Handling of emergency calls: the first call ref. 6091291 was correctly coded as a Green 1 20 minute response, and
the responding resource arrived 14 minutes after the call was received. The second call 6091361 was also coded as
a Green 1 20 minute response, and we were still looking for a resource when the third call ref. 6091408 was
received 24 minutes later. As we had no available vehicle to dispatch the patient’s parents took him to hospital
themselves.
Care and treatment of the patient: the solo responder who arrived to help the patient began to gather a medical
history and take observations, but the patient’s mother advised that a blood sugar reading was not necessary as
the patient required dextrose fluids. The Paramedic contacted the Emergency Operations Centre (EOC) to request
an amber back-up but he was advised that no ambulances were available. He relayed this information to the
patient’s parents and advised he would wait on scene until the ambulance arrived. The Paramedic advised that the
patient should wait for the ambulance but the patient’s parents took the decision to transport him themselves.
The Paramedic placed a call to the Resus department at the hospital to advise them of the patient’s condition and
his imminent arrival. He also asked for reception and the Urgent Care Centre to be notified.
When further calls were received on the patient’s behalf the parents were advised that a resource would be
allocated as soon as possible but that one was not available immediately. The parents took the decision to
transport the patient to hospital.
Entries from the Performance Delivery Manager (PDM) and Leicestershire dispatch desk (LEICS) resource logs.
PDM log:
10:07 Capacity Management Plan actions one, two and three invoked for the day.
13:10 Leics holding three Green 2 calls and three Urgent calls.
15:41 Leics holding three green 2 calls.
LEICS log:
09:29 City holding one Priority 1 transfer, one Amber back-up and one Green 2 call.
10:38 Leics rural holding one Red 2 transfer, one Green 2 transfer and one Amber back-up response.
10:45 City holding one Amber back-up and one Green 2, all vehicles committed.
11:16 City holding one Amber back-up, one Green 1 call and two Green 2 calls.
11:57 City holding four Green 1 calls and one Green 2 call.
13:30 Rural holding three Green 2 calls, one Green 4 and one Urgent.
14:46 City holding two Red 2 calls, no crews or FRV’s.
Conclusion
The Paramedic who attended on the first call started to undertake observations but was stopped by the patient’s
mother. He contacted EOC for back-up but was advised that no vehicles were available. He advised that the
patient should wait for an ambulance but the patient’s parents took the decision to transport him themselves. The
Paramedic contacted the hospital to pre alert Resus, reception and the Urgent Care Centre.
When further calls were received there were no available resources, and the parents took the decision to travel to
hospital. A return call was made to the parents to advise them that the Paramedic had alerted the hospital. It
appears that the information was not passed on to reception.
Grade: Moderate
Status: Resolved
Evidence Gathered
CAD reports
Resource log data
Call audits
PRF
Information from Paramedic.
identified.
Source: Email
Final Contact Date:
Delays Incurred
Reason for Delay: Completion of Yorkshire Ambulance Service investigation
Harm Rate:
Base: EOC
Red 2
Area/Divisional: EOC/YAS
Patient Outcome:
transported to hospital
Extension: due to completion of YAS investigation
Summary: Delayed Response To Foetal Bradycardia
Case Details: ------------------------------------------------------------------------------------------------------------------,
Reported to -------------- 07 January 2014
Incident date: 05 November 2013 09.50 am
CAD 5965124. Patient:
Relating to a 55 minute delay in providing an emergency ambulance to a patient in a community ANC where the
midwife at -------------------------- had noted a foetal bradycardia. --------------------------- informed by midwife of
imminent admission. On arrival baby identified/confirmed as no heart beat. Mum no lasting physical aspects
Why was there a delay in responding?
Why did the ambulance go the wrong way?
This has been reported as an SI by CRH. STEIS 2013/32607 - Root cause not provided. --------- wrote to ----------- ---------- about the incident on the 6th November but having chased him today he did not receive the letter.
Initial scan looks to be no resource available. This was coded Red 2 and the response time was 38 minutes via a
YAS vehicle.
• Why was the ambulance delayed?
• Why did the ambulance take the longest route to get to the hospital?
TOR agreed by:
Complainant
Date: 14 January 2014
Crew Stood Down:
No. If No state rationale: EOC delay and non-clinical complaint
Being Open
Initial Contact Date: 14 January 2014
Timeline of Events
Date and Time
Event
5 Nov 2013
09:58
09:59
10:01
new call received on behalf of a female patient with pregnancy related issues.
CAD message: pregnant lady, heartbeat is low.
call assessed as 24D05, pregnancy/childbirth/miscarriage, high risk complications,
allocated a Red 2 eight minute response.
CAD message: take to Chesterfield Royal Hospital, Birth Centre.
Midwife recorded as being on scene.
contact made with Yorkshire Ambulance Service (YAS) to request their assistance as EMAS
had no vehicle available to send.
solo responder from YAS allocated to the incident.
Resource YAS, double crewed ambulance from Yorkshire Ambulance service, allocated and
mobile to the incident.
solo responder arrives on scene.
resource YAS arrives on scene.
resource YAS leaves scene with the patient.
resource YAS arrives at hospital with the patient.
resource YAS hands patient over to hospital staff.
10:01
10:01
10:06
10:07
10:16
10:18
10:36
10:47
11:08
11:17
Handling of the emergency call: the call was correctly coded as a Red 2 eight minute response. The first response
arrived on scene 20 minutes after receipt of the emergency call and the conveying response arrived on scene 38
minutes after receipt of the emergency call, failing to meet the eight or 19 minute targets. The resources sent
were the first available and were dispatched as soon as possible.
Care and treatment of the patient: on arrival at the Health Centre the DCA spent 11 minutes on scene. This
included receiving a handover from the Paramedic and transferring the patient to the ambulance. The journey to
the hospital took 21 minutes, and the member of staff driving the vehicle believes she took the most direct route
to the hospital via the -----------------------------. (On Google Maps this route is recorded as 8.4 miles with a journey
time of 19 minutes. An alternative route using the ------------------------------- is recorded as 7.8 miles with a journey
time of 18 minutes). The member of staff has stated that she drove at speeds suitable to the road conditions and
taking into consideration the fact that the midwife and Paramedic would have been moving about in the back of
the ambulance whilst monitoring the patient. There was a short delay on the journey negotiating road works near
to the Health Centre.
Notes from the Performance Delivery Manager (PDM), Nottinghamshire dispatch (NOTTS) and Derbyshire dispatch
(DERBYS) resource logs:
PDM log:
08:41 Derbyshire have a shortfall of two resources on the day shift. North Notts have a shortfall of five resources
on the day shift.
11:17 North Notts holding three Green 2 calls. Derbyshire holding a Green 2 call and four urgent calls.
Notts resource log:
08:23 holding two back-ups and one Green 2 call.
09:16 holding one back-up.
09:41 holding three back-ups.
10:02 holding two Green 2 calls.
10:13 holding two back-ups, seven Green 2 calls and one Green 4 call.
10:40 holding one back-up and three Green 2 calls.
11:14 holding one Green one call and three Green 2 calls.
11:37 holding six Green 2 calls and two Amber back-ups.
11:49 holding one Red 2 call and one back-up.
10:57 holding two Green 2 calls and one Green 4 call.
11:27 Holding one Green 2 call and seven Urgent calls.
Conclusion
Due to high demand for emergency responses EMAS did not have a vehicle available to send to the patient.
Assistance was requested from YAS, and they sent a solo responder who arrived 20 minutes after receipt of the
emergency call and a double crewed ambulance which arrived 38 minutes after receipt of the emergency call. This
failed to meet the eight and 19 minute targets.
The member of staff driving the vehicle believes that she took the shortest route to the hospital. Route planning
applications show another route to be 0.6 miles shorter. The on scene time for the back-up crew does not suggest
a lack of urgency or any significant delay on scene.
Date Resolved: 27 Feb 2014
Grade: Moderate
Status: Resolved
Letter Date: 27 Feb 2014
There are no recommendations to be made on this occasion. The delay in response was due to high demand for
emergency responses.
Evidence Gathered
CAD reports
Investigation report from YAS
Resource log information
Call audits
identified.
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Public Place
Green 2
Patient Outcome:
Extension: XX
Summary: Inappropriate Actions - Pt Fitting
Case Details: From pals: enquirer would like to complain about a member of staff from emas. Enquirer believes
that this member of staff was not able to notice the symptons of an individual goes through when suffering from
epilepsy fits therefore
1. She wasn't able to control matter and
2. Made the wrong decision thus causing a bigger impact when this could have been easily resolved.
Paramedic called the police causing patient to be handcuffed whilst in fitting state, feeling unwell, needing space
to move.
Question
"Can i ask what training the ambulance staffs goes through please? secondly as i have been handcuffed by the
police due to a wrongful decision made by the ambulance staff this has left me scares/brusing to my right wrist, as
well as not at work.
Another thing is if an individual is going through a fit is not to pressure them and give them space to maneuver or
lay me on my side so i do not choke on my own tongue or saliva which they didn't do for me. Instead they
surrounded me and as the handcuffs were cutting into my wright wrist i was asking them to release this and they
just smiled and said "no"
Enquirer not happy and wants to escalate to fc with the following outstanding questions:
------------- believes the crew did not know the signs and symptoms of a fit when they approached him.
------------- is not happy that eoc 'diagnosed' a fit when they have no knowledge of his medical history.
-------------- felt pressured by the crew to go to qmc when he just wanted to be left alone and did not want to go to
hospital. He was also distressed by the sarcastic comments made by the crew.
-------------- believes that he should not have been surrounded by several people, pushing and shoving him when he
had had a fit.
--------------is very unhappy that the crew called for police assistance.
--------------believes that the crew should have advised the police not to hand cuff him.
• Why was the patient diagnosed with a fit?
• What knowledge did the crew have of epilepsy?
• Why did the ambulance crew contact the Police?
• Why was the patient handcuffed?
• Why was the patient not given space to recover?
TOR agreed by:
Complainant
Date: 08/01/2014
Crew Stood Down:
No. If No state rationale: initial investigation raised no concerns.
registered. If No state rationale: initial investigation raised no concerns.
Being Open
Timeline of Events
Date and Time
Event
17 Dec 2013
11:13
11:13
11:16
new call received on behalf of a male appearing to be having a fit.
resource 3414, double crewed ambulance (DCA) allocated to incident.
call assessed as 12A01, Convulsions/fitting, not fitting now and breathing effectively.
Allocated a Green 2 30 minute response. Resource 3414 mobile to incident.
CAD message: Police rang to see if we had got the job – they are travelling as there is a
concern for safety.
CAD message: crew are on the phone to the Police asking for their attendance.
11:25
11:27
11:32
12:17
12:40
13:26
Handling of emergency call: the call was correctly coded as a Green 2 30 minute response. The caller advised that
the patient appeared to be having a fit, and was foaming at the mouth. Caller then advised that the fit was over,
and the call taker checked that the patient was breathing effectively. The caller advised that she was first aid
trained. The attending resource arrived on scene 12 minutes after receipt of the emergency call.
Care and treatment of the patient: The attending crew were advised that the patient had appeared to have a fit
based on the information given by the caller. The Police had also been notified of the incident by an unknown
party on scene and were travelling as there was a concern for the patient’s safety.
On arrival the crew observed a number of members of the public following a male across a park. They were
approached by another member of the public with a dog, and she advised that she had observed the gentleman
having a fit. The dog was the patient’s and it was handed over to the ambulance crew. On approaching the patient
he kept walking away from the crew, and he became verbally aggressive when they tried to calm him. The crew
followed the patient for some distance down a road and he continued to resist attempts to examine him. The crew
contacted the Police as they were concerned that the patient would wander into the road.
On arrival of the Police the patient became aggressive with them, but they managed to get him in the back of the
ambulance. The Police then asked if the patient had any identification on him and they tried to check his pockets.
The patient resisted this and the Police placed handcuffs on him. This was not at the request of the ambulance
crew. The patient was then conveyed to hospital with the Police in attendance.
In respect of the crew treating epilepsy they advised that they followed JRCALC guidelines and receive regular
updates on any changes within those guidelines.
Conclusion
The possible diagnosis of a fit was made on the basis of information given by the caller, who advised she was first
aid trained and she had experience of dealing with fits through a family member.
The crew on scene requested Police assistance due to safety concerns, and records show that the Police had
contacted the EOC prior to this request to advise they had been asked to attend the scene. The decision to
handcuff the patient was made by the Police with no input from the ambulance personnel.
Grade: Minor
Status: Resolved
There are no recommendations to be made in this instance.
Evidence Gathered
CAD report
PRF
Statements from crew members
identified.
Type: Delay For Back Up/Transporting
Source: Email
Final Contact Date: xxx
Harm Rate:
Base:
Area/Divisional: East
Patient Outcome: Unknown
Summary: A call was received for a patient who had fallen. On arrival of the First Response Vehicle an assessment
was made with a Double Crewed Ambulance (DCA) requested. It is felt there was a delayed response for the DCA
and the patient was taken to the wrong Hospital.
Case Details: Concerns relating to EMAS care
•
•
Why did the Double Crewed Ambulance arrive so late on scene?
Why was it not radioed on route to Grimsby to divert to Scunthorpe and the crew could
have turned around instead of off loading patient and then putting her back in the ambulance and making
a non sensible unnecessary journey to Scunthorpe?
TOR agreed by:
Via Email
Crew Stood Down:
No – Delay incident
•
Paramedic ,
Emergency Care Assistant,
EE date: 18 August 2013.
EE date: 13 January 2014.
IPR date: 29 September 2013.
IPR date: 2 July 2013.
Paramedic,
Student Paramedic
EE date: 1 July 2013. IPR date: 17 September 2013.
EE date: N/A
IPR date: N/A
All staff have been given support via their Team Leaders. They are also aware of the PAM assist route available to
them if required.
Being Open
Contact letter sent via email to complainant on 23 January 2014 also.
Timeline of Events
Date and Time
Event
29 December 2013
03:43
03:43
03:44
03:47
03:50
03:51
03:55
04:05
04:09
04:13
Unknown
04:33
04:36
04:38
04:50
04:52
Call received into Emergency Operations Centre (EOC) from the Police. Emergency
Medical Dispatcher (EMD) confirms patient has fallen in the bathroom. Call incorrectly
processed through the Advanced Medical Priority Dispatch System (AMPDS).
Dispatch Officer correctly accesses Resource Allocation (RES/ALL) function and assigns
First Response Vehicle (FRV) to attend job.
EMD makes outbound call to address where patient is and speaks with patient’s
daughter.
EMD processes call through AMPDS and correct response of 17D03, Red2, 8 minute face
to face contact gained.
EMD confirms someone is with the patient, clears the line and exits the call.
FRV arrives on scene of job.
FRV requests Red back up via radio to Control. Confirms the patient is unresponsive. DO
confirms currently Kilo zero meaning there are no Double Crewed Ambulances available.
The next one will be sent.
FRV radios Control to ask if DCA arranged as patient suffered a possible CVA (stroke).
Told still none available but two due to come clear at Hospital. FRV asks for open
channel message to be broadcast.
DO accesses RES/All function and correctly allocates next available DCA to attend the
address as Red backup.
DCA arrive on scene.
Pre alert made to Hospital 2 and advised to take to Hospital 1 to not delay.
DCA leaves scene towards Hospital.
FRV calls clear from scene.
DCA arrives at local Hospital 1.
DCA confirms turned away from local Hospital resuscitation area and sent to other
Hospital 2.
DO creates a new job as a Priority transfer due to the DCA being turned away from the
receiving Hospital.
04:53
05:24
05:50
New job created and DCA assigned.
DCA arrives at Hospital 2.
DCA clear from job.
A call was received into the Emergency Operations Centre (EOC) on 29 December 2013 at 03:43hrs. This call was
passed to the Ambulance service via the Police. The Police confirmed some basic details and gave the Emergency
Medical Dispatcher (EMD) a telephone number for where the patient was The EMD should have processed the call
through the Advanced Medical Priority Dispatch System (AMPDS) with the limited information provided by the
Police. Although the call was not processed correctly through AMPDS, the correct dispatch coding was achieved.
The EMD telephoned the number where the patient was and then processed the call through the AMPDS asking
for details from the person who was with the patient. AMPDS is a set of questions relating to a specific condition.
The answers given to these questions will determine the response which is made by the Ambulance service. On
this occasion, a Red2 8 minute face to face Ambulance response was gained. The patient was said to have fallen
and was not alert gaining the code of 17D03. The outbound call cannot be audited as per protocol; based on the
answers given during the call back the correct response code was gained.
A First Response Vehicle (FRV) was correctly allocated to attend this job by the Dispatch Officer (DO). The FRV was
the nearest available resource at the time the call was received into the EOC and arrived on scene with the patient
at 03:51hrs which is within the required 8 minute face to face Ambulance response time.
After an initial assessment of the patient, the Paramedic from the FRV requested a Red back up. The patient was
confirmed to be unresponsive. The DO confirmed that they were Kilo zero meaning no Double Crewed Ambulances
(DCA) were free to attend. The DO said the next DCA to come clear would be sent. A Red response back up is for a
DCA to also attend a detail as an emergency to allow conveyance of a patient. Once assigned they will travel under
emergency conditions and will not be diverted to another job unless it were to be a cardiac arrest call.
Ten minutes after the FRV requested a Red back up, they contacted the DO again via radio requesting an update.
The Paramedic from the FRV was told there were still no DCAs but two were due to come clear from the Hospital
and as soon as they did one would be assigned. Because of the delay and the fact the patient was presenting with
stroke symptoms (CVA), the Paramedic requested that an open channel message for assistance be broadcast. This
was done by the DO and no other crews offered their assistance.
At 04:09hrs, 4 minutes after the second call from the Paramedic; a DCA became clear at the Hospital. This vehicle
is correctly assigned by the DO to attend as Red backup. The DCA arrived on scene at 04:13hrs.
Prior to conveyance, a call was made to Hospital 2 with regards to the suspicion of a CVA. The Paramedic is told to
take the patient to the local Hospital which they do. The DCA arrives at Hospital 1 by 04:38hrs.
Within 2 minutes of arriving within the resuscitation area of Hospital 1, the crew are told the patient cannot be
dealt with there for a CVA and she needed to go to Hospital 2 for treatment. The crew load the patient back into
the DCA and start travelling to Hospital 2. The DO is informed as to what has happened. As the crew are travelling
to a different Hospital a new job as a Priority 1 transfer is correctly inputted by the DO.
A Clinical Bulletin was issued via East Midlands Ambulance Service (EMAS) on 17 October 2013 to confirm that
with effect from 4 November 2013 Hospital 1 would no longer be delivering hyper acute stroke services. Any FAST
positive patient would now need to be taken to Hospital 2.
The DCA arrived at Hospital 2 by 05:24hrs which is 51 minutes after they left scene and 32 minutes from Hospital
1. Had they left scene and gone straight to Hospital 2 from the address, the journey under normal road conditions
would take 46 minutes covering a distance of 33.4 miles.
It is 1.7 miles from Hospital 1 to the home address and 34.8 miles from Hospital 1 to Hospital 2.
Minimal delay was incurred at Hospital one due to the quick turnaround once the DCA arrived.
Conclusion
At the time of the incident requiring a back up Double Crewed Ambulance (DCA) there were none available. All
DCA resources were in attendance at jobs. The first DCA to become free after taking a patient to Hopsital was
allocated. This DCA arrived on scene 18 minutes after the request was made by the First Response Vehicle.
The crew correctly contacted the stoke unit at Hosptital 2 to be told to take their patient to Hospital 1 due to the
distance. The crew did this however Hospital 1 were not happy to take the patient and within minutes of arriving,
directed the crew to take the patient to the appropriate unit within Hospital 2. As the crew had already contacted
Hospital 2, there was no need to radio ahead for clarification.
From a Clinical Bulletin sent to all clinical staff on 17 October 2013, the crew should have been in a position to
question Hospital 2 due to there being no facilities at Hospital 1.
Recommendation
Team Leaders to
ensure all staff in
Lincs division aware
of changes to Hyper
Acute Stroke Unit
Action
Random checking to
be done on staff to
seek awareness; if
none
then
new
bulletin
to
be
disseminated.
Lead
Due Date
Evidence
Locality Quality
Manager (PB)
15
2014
Confirmation
email
of
completed action. Evidence
if bulletin resent.
Evidence Gathered
Sequence of events (SOE) for call.
SOE for Priority transfer by Dispatch Officer (DO)
Recordings of voice radio transmissions
Copies of recorded calls into and out of the Emergency Operations Centre
Clinical Bulletin regarding Hyper Acute Stroke Unit
Audit of call
March
Type: Inappropriate Destination
Source: Email
Final Contact Date:
Delays Incurred
Reason for Delay: None
Harm Rate:
Base: Public Place
Area/Divisional: Northamptonshire
Summary: Child Head Injury-Taken to the Wrong Hospital
Case Details: This incident occurred at a family event at a ---------------. The child ran down the -------------------followed by his Father who had given chase in attempt to stop him, this resulted in the Father falling on top of the
child. The childs mother saw what was happening and tried to assist both the father and child, she slipped and fell
on top of both of them.
An emergency call was placed and the Trust attended the scene where a double crewed ambulance (DCA)
transported the child to KGH. The child was examined and CT scans were conducted, these scans discovered
abnormalities. The child had been reported as vomiting by the crew.
• Were there any delays in arrival of the ambulance and why?
• Why was the child taken to KGH when symptomatic of a head injury?
• Do we have any formal protocols for head injury conveyance?
TOR agreed by: (CB) Quality and compliance manager (KGH)
Crew Stood Down:
No. Not Clinical
Date: 24 Jan 14
Staff support and involvement: EE date: 20 Sep 2012 IPR date: 17 May 2012
EE date: 29 Jul 2013 IPR date: None Recorded
Healthcare Decisions Panel (HDP) referral: No. Not clinical
•
Being Open
Initial Contact Date: 17 Jan 14
Consent Required: No
Timeline of Events
Date and Time
Event
12:31,33
12:33,37
12:40,32
12:42,37
12:43,53
12:44,08
12:52,26
13:02
13:26
13:53
Initial call received
Call coded correctly Green 2, 30 minute response time
Second call received in relation to this incident
Second call coded correctly Red 2, 8 minute response time
Resource allocated to the initial call and en route
Second call cancelled and first call upgraded due to duplication
Resource allocated to initial call arrives at the scene
Resource leaves scene, en route to KGH
Resource arrives KGH
Handover of patient complete
At 12:31 a call was received requesting assistance for a ------------ child, the call was coded correctly as Green 2,
requiring a response time of 30 minutes. This call was then duplicated 9 minutes later, the caller provided further
information which resulted with the second call being correctly graded Red 2, requiring a response time of 8
minutes. By the time a suitable resource was found to attend the second call a double crewed ambulance had
already been allocated to attend the first. The duplicated call was subsequently cancelled and the original call was
correctly upgraded to Red 2.
The ambulance that arrived at the scene at 12:52 was allocated for, and responding to, the initial Green 2 call
arriving 9 Minutes inside the required response time, this arrival time is however 2 minutes outside the required
response time for the second, upgraded, Red 2 call. The reason for this delay was due to the upgrading of the
initial call from Green 2 to Red 2.
There are no specific protocols for conveying a patient with a head injury however there are protocols for
conveying patients to major trauma centres and the treating/care of Paediatric patients, at the time the patient
was attended to by the crew there were no obvious signs of major traumas or head injury. In interview the
clinician stated that the choice of hospital was made in conjunction with the family. This course of action was
taken as they were not from the area. The chosen destination hospital was KGH as it was the one that could treat
the patient appropriately for the assessed injuries at the time and because it was closest to where the family was
staying. It should be noted that the clinician has also stated that he was prevented from carrying out an initial
assessment of the child, for some time, by the grandmother who was told to stop shouting at him by the child’s
mother. The child’s father described the patient as being dazed and wobbly directly after the incident however
upon arrival of the crew the child was alert and happy/smiling. The child did vomit on route to hospital as stated.
Conclusion
Were there any delays in the ambulance arriving and why? There was a delay of approximately two minutes in
the ambulance arriving at the scene. The ambulance that attended the scene was initially allocated for and
responding to the first Green 2 call arriving 9 Minutes inside the required response time, this arrival time is however
outside the required response time for the second, upgraded, Red 2 call. The reason for this delay was due to the
upgrading of the initial call from Green 2 to Red 2 and the fact that when the call was upgraded the attending
ambulance was the nearest resource and already en route to the scene. If the response time is taken form when the
resource received the upgrade message then the response time was 8 minutes and 18 seconds due to the fact that it
was passed to the crew at 12:44,08 and the crew arrived at the scene at 12:52,26.
Are there any formal protocols for head injury conveyance? There are no formal protocols in place for head
injury conveyance. There are protocols, Standard Operating Procedures and Policy in place for the treatment of
Paediatric patients and Major Trauma patients . Protocols are also in place entitled Conveyance assessment guide.
Both this guide and the Paediatric Care Policy outline the requirements when staff are dealing with children and
states that Patients under 2 years old, where 999 was called, should always be seen the same day by an appropriate
healthcare professional (GP/Paediatric Nurse/ED) rather than discharged at scene with no follow up however
transport to the emergency department is not mandatory. A clinical review was conducted by the Locality Quality
Manager for Northamptonshire with no adverse findings.
Why was the child taken to KGH when clearly symptomatic of a head injury? The crew in this case did not
assess the patient as requiring specialist neurological care as there were no obvious signs and symptoms of a serious
head injury or major trauma. The clinicians involved have stated that they were aware that there was a paediatric
unit attached to the emergency department at KGH however were not aware if it was open at this time. Ultimately
the decision as to where the patient would be taken was made in consultation with the family due to the fact that
they were visiting the are a and KGH was the closest most convenient hospital that could treat the patient’s assessed
injuries at the time of transfer.
Evidence Gathered
CAD SoE
Call Audit
Call Recordings
PRF
Clinical Review
Conveyance Assessment and Management Guide
Paediatric Care Policy
MT SoP
identified.
Source: Email
Final Contact Date:
Delays Incurred
Harm Rate:
Base:
Area/Divisional: Derbyshire
Summary: Child Had A Deep Laceration-No Ambulance Sent
Case Details: The complainant states that a ----------------- girl had fallen from a tree and impaled her right thigh on
a broken tree branch sustaining a large, deep laceration to her thigh.
The complainant, who is a Doctor, rang 999 for assistance and states that she was told by the operator that there
were no ambulances available to attend due to high demand and, as the injury was not life threatening, told them
to go to a GP, a minor injuries unit or to make own arrangements to take her to hospital instead.
Patient's father arrived at the scene and took her to QMC A+E. She was taken to theatre for an emergency
debridement and closure by a plastic surgeon. She had torn a tendon and the femoral triangle was exposed.
• Explain how telephone operatives are trained and how they make their decisions.
• Is it standard practise to suggest that people make their own way to a GP?
• do you accept that in this instance an error was made what measures do you propose to avoid such errors
occurring in future?
TOR agreed by: Letter sent by complainant Dr (KW), family friend
Crew Stood Down:
No. Not clinical
•
Staff support and involvement: (JS) – EOC , EE date: 20 Nov 12 PDR date: 23 Oct 12
Healthcare Decisions Panel (HDP) referral: No. Not Clinical
Being Open
Timeline of Events
Date and Time
Event
15:44
15:45
15:48
15:51
16:22
16:23
Initial call received stating that the patient had fallen from a tree
Resources allocated, both Fast Response Vehicle (FRV) and Double Crewed Ambulance
(DCA) en route
Caller states that she is with the patient and that she is a doctor, further information is
provided by the caller that leads to the call being downgraded to Green 4 and passed for
triage
Due to the Green 4 grading of the call both resources were stood down
Triage (CK) contacts the caller who states that there was no need for an ambulance as the
patient was already being taken to A+E
Call stopped no further action required
At 15:44 a call was received by the trust stating that a -------------- girl had fallen out of a tree from a height of about
a metre sustaining a cut to the top of her thigh. The caller informed the operator that she was a doctor and that
the cut was deep but not actively bleeding she further stated that it didn’t look like any blood vessels had been
affected. The caller also stated that she was walking the patient. At 15:45 both FRV and DCA resources were
allocated to respond.
Further questioning by the call handler using Advanced Medical Priority Dispatch System (AMPDS) resulted in the
call being downgraded to Green 4 and passed for triage. At 15:51, due to the grading of the call, both resources
were stood down and redirected to other calls with higher grading’s. At 16:22 the triage nurse contacted the
caller and was informed that there was no need for the Trust to respond as the patients father was transporting
her to the hospital.
A call audit was requested in this case, this audit concluded that an incorrect response was allocated to this
incident and that an incorrect script was delivered. The call should have been dealt with as normal resulting in the
allocation of a resource with a Green 2 response code which requires a 30 minute response time.
Conclusion
Explain how telephone operatives are trained and how they make their decisions. To prioritise emergency calls
the Trust use AMPDS which is a telephone triage system used in the Emergency Operational Centre (EOC) by nonclinical trained call operatives. The aim of the system is to identify the reason for the emergency call, what level of
response the patient requires, and to give instructions whilst waiting for the response arrival or if an alternative
care pathway has been arranged. After selecting the appropriate chief complaint the Emergency Medical
Dispatcher will ask key questions, the answer to those questions will automatically prioritise the call and generate
a determinate descriptor level and code which in turn is attached to a response time.
Is it standard practise to suggest that people make their own way to a GP? It is not standard practice to suggest
that people make their own way to a GP or other health care provider. Any course of action that is required is
provided by AMPDS utilising all the aforementioned factors.
Do you accept that in this instance an error was made? In this case the evidence shows that an error was made
in the initial handling of the call. The Emergency Medical Dispatcher’s response to the call was incorrect resulting
in the wrong Dispatch Life Support link being followed, this deviation provided the patient with an incorrect
response.
What measures do you propose to avoid such errors occurring in future? Recommendations will be made for the
Emergency Medical Dispatcher to receive further training and mentoring.
Recommendation
Feedback to EMD
and further training
in relation to the
incident
Evidence Gathered
CAD SoE
Call Audit
Audio of Call
EOC Training Evidence
Action
Lead
Due Date
Evidence
Feedback
and
training with record
of conversation
Training team
28 Feb 14
Copy
of
record
conversation
of
Type: EOC Issue
Source: Email
Delays Incurred
Harm Rate: 1
Area/Divisional: Nottingham/North
Patient Outcome: Treated at Walk in Centre
Summary: Delay and Just Dropped off at a Walk-In Centre
Case Details: -------- gentleman who lives alone is unhappy with the service he got when he was unwell.
- An explanation as to why he had to wait so long for an ambulance to arrive
- An explanation why he was transported to the Nottingham Walk-In Centre and then just left
•
Why was there a delay?
•
Why was the patient left unattended at the walk in centre?
TOR agreed by: Letter sent by --- Complaints and Patient Experience Manager on behalf of complainant
Crew Stood Down:
No. None clinical issue
Staff support and involvement: Paramedic, EE date: 31 Oct 13 IPR date: 23 Mar 13
Emergency Care Assistant, EE date: 28 Nov 12 IPR date: None
Healthcare Decisions Panel (HDP) referral: No. None Clinical
•
Being Open
Initial Contact Date: 17 January 2014 with the Complaints and Patient Experience Manager. --- confirmed no
direct contact was to be made with the complainant. All communication to go through ---.
Timeline of Events
Date and Time
Event
23 Nov 13
11:16
11:16
11:27
11.36
11:40
12:42
14:56
15:39
15:44
16:18
16:23
Call received from 111 requesting assistance for a patient at address provided
Resource allocated and dispatched Red 2 8 minute response time
Resource arrives on scene, there are issues with locating the address and a call is made
by the attending clinician in order to locate the patient
At scene with the patient
Initial observations are conducted and a request for a transfer to the walk in centre made
Attempts being made to locate resource for transfer, non-emergency transport within 4
hours
Ambulance Car Service call sign allocated
Ambulance Car Service arrives with patient
Ambulance Car Service leaves scene to transfer patient to the Walk in Centre
Arrives at Walk in Centre
Handover of patient complete
On 23 Nov 2013 at 11:16 hrs a call was received, via the NHS 111, service to attend a --- year old male who was
complaining of a fever and dizziness. Information provided by the patient tends to show that he requested
assistance via 111 at 08:00 hrs. NHS 111 were contacted and have provided information that shows the only call
received to them from the complainant was timed at 11:13 hrs.
At 1127 hrs a Fast Response Vehicle (FRV) arrived in the area of the patients address, however found it difficult to
locate the exact address. By 11:40 hrs the patient had been located by the Paramedic and attended to. After
making initial observations of the patient the Paramedic requested transport to take him to the walk in centre for
further, non-emergency, treatment.
The transport was requested to attend within 4 hours as is protocol for non-emergency journeys and an
Ambulance Car Service (ACS) vehicle arrived within 3 hours. The patient was conveyed to the walk in centre and
handed over to the staff in order to receive the tests and treatment he required. It is not standard procedure for
the ACS staff to remain with the patient once the conveyance has been completed.
Conclusion
Why was there a delay? There is a discrepancy between the times the call was made to 111 a difference of
approximately 3 hours. The allocation of resource by the Trust for a Red 2 was not achieved having been passed
the call by 111 at 11:16hrs the Paramedic did not arrive with the patient until 11:37hrs. The Paramedic timings
indicate arriving in the vicinity of the patient within 11 minutes which is still outside the 8 minute target.
Why was the patient left unattended at the walk in centre? It is not standard procedure for the ACS staff to
remain with the patient once the conveyance has been completed.
Grade: Negligible
None
Evidence Gathered
Call Audit
PRF
CAD Log
NHS 111 Information
identified.
Source: Letter
Delays Incurred
Harm Rate:
Base:
Area/Divisional: Nottingham/North
Summary: CVA Patient - FRV Attitude & Delayed DCA
Case Details: A --- year old patient had suffered an unwitnessed fall. When family members arrived he had already
got up from the floor and sat on a chair. The family called 999 and requested that an ambulance attend. Once a
clinician had examined the patient he was descovered to be fast positive CVA. The patient’s family are unhappy
with the Fast Response Vehicle (FRV) Paramedic’s attitude, how long it took for the Double Crewed Ambulance
(DCA) to arrive. They have further questioned the Trust Standard Operating Procedures (SOPs) for stroke patients
• What was the delay in response?
• Explain the time delay between the initial call and treatment
• What is the Trust SOP for stroke patients?
• Is there a set response time for stroke patients?
• Was there a lack of interest from the Paramedic?
TOR agreed by: Letter sent by complainant, daughter of patient
Crew Stood Down:
No. None clinical
•
Staff support and involvement: (paramedic), EE date: 6 Aug 13 IPR date: None
(Technician), EE date: 8 Oct 13 IPR date: 5 Oct 12
(Technician), EE date: 25 Jun 13 IPR date: 5 Oct 12
Healthcare Decisions Panel (HDP) referral: No. None clinical
Being Open
Timeline of Events
Date and Time
Event
19:36
19:37
19:46
20:06
20:09
20:20
20:40
20:50
21:15
21:32
Call received requesting assistance for a patient who had fallen and was presenting with
slurred speech.
Resource allocated and dispatched, Green 2
FRV paramedic arrives at scene, initial observations conducted
Paramedic requests amber response
Resource allocated and dispatched
Resource stood down due to higher priority call (chest pain)
New resource allocated to attend
DCA arrives at scene
DCA leaves scene
DCA arrives at A + E having been told that City could not accept patient due to head injury
sustained in the fall
At 19:36 a call was received requesting assistance for a patient that had fallen and was presenting with slurred
speech. The caller stated that the fall had not been witnessed and that the patient had got himself up from the
floor and sat on a chair. At 19:37 a resource was allocated to attend a green 2 call with a response time of 30
minutes. At 19:46 FRV arrives at the scene and initial observations are carried out resulting in an amber response
being requested at 20:06. At 20:09 a resource was allocated to attend the scene but whilst en route was diverted
to a higher priority call. At 20:40 a new resource was allocated to attend arriving at the scene at 20:50. Attempts
were made by the attending Paramedic to get the patient admitted to the stroke unit at City hospital however, due
to a head injury sustained by the patient in the fall, the stroke unit denied admission and advised the DCA to take
the patient to another hospital.
The FRV Paramedic has been interviewed and the complainants concerns about his attitude were put to him. He
denied that he would have had a bad attitude but conceded that, although he couldn’t remember the incident, he
could have used some of the phrases mentioned in the complainants letter, but not in the context that the
complainant states. The Paramedic was requested to explain why he would ask for an amber response for a
patient who was fast positive, he could not. The Paramedic has denied having a lack of interest.
Conclusion
What was the delay in response? There was no delay in the Initial FRV response. This asset arrived within 10
minutes which is 20 minutes inside the required response time for a call that was correctly coded Green 2.
Explain the time delay between the initial call and treatment. The backup that was requested by the FRV at
20:06 was responding to an Amber request, this resource was diverted while en route to attend another life
threatening emergency call with a higher priority, Red, coding. This diversion resulted in a further resource having
to be found and allocated which was achieved at 20:40 arriving on scene 10 minutes later. The attending
Paramedic has been interviewed and cannot recall why he requested an amber response.
What is the Trust SOP for stroke patients? Stroke patients are to be transported to the stroke unit as soon as
possible. In this case the Paramedic attempted to have the patient admitted to City hospital but admission was
denied due to the head injury he had sustained in the fall. A clinical review was conducted by (WH) LQM who
states that once the stroke unit had denied admission the correct action was to take the patient to ED. In
interview the Paramedic stated that he always attempts to get stroke patients admitted to the City stroke unit.
Is there a set response time for stroke patients? The Trust’s policy states that stroke patients are to be treated as
time critical. All emergency calls where a stroke has been identified are coded Red and required to be responded
to within 8 minutes. The call audit in this case has found that the call was coded correctly in accordance with
Advanced Medical Priority Dispatch System (AMPDS) this system dictates the response required from the
information provided by the caller, the predominant information in this call was that the patient had fallen.
Evidence Gathered
CAD SoE
Call Audit
ePRF
Clinical Review
Stroke Care Policy Document
Type: Poor Service Delivery
Category: Other
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: EMAS Trust HQ
Extension: XX
Green 2
Area/Divisional: EOC EOC Nottingham
Patient Outcome:
Treated on scene
Summary: Handling Of 999 From Journalist
Case Details: Tthere was a man on the pavement outside of a resturant on ------------------------. He was surrounded
by the general public and covered with blankets. I arrived back at my office in -------------- a few hours later to see
the man still lying on the pavement. I was then concerned so called 999 to see if an ambulance had been booked. I
was asked obstructive questions such as "Who is the patients next of kin?" etc. I was not on scene with the man
and only wanted to check if the man had an Ambulance booked for him.
I have fed back to ----------- and he is not happy and wants to progress to FC.
His point is that all he wanted to know was, was an ambulance on route as he clearly knew that 999 had been
called for the patient.
He admitted that his office was only a few feet from the incident so I asked him why he didn't go out to the
patients side so he could provide the answers to our questions.
He stated that this wasn't the point of his call as he only wanted to know if an ambulance had been dispatched.
He has also denied that he said he was going to report this when clearly on the call he says ' I am obviously going
to write about this'.
• Why could the call taker not confirm we knew about this incident?
• Why could the call taker not confirm an ambulance had been sent?
TOR agreed by:
Complainant
Date: 10/01/2014
Crew Stood Down:
No. If No state rationale: EOC issue
registered. If No state rationale: EOC issue
Being Open
Timeline of Events
Date and Time
Event
07 Dec 2013
14:30
new call received on behalf of a male who is laid on the pavement. Caller wanted to know
if we were aware of this incident in --------------.
Address given as Post Office, Main Street, -------------.
Caller is unable to give any details regarding the patient other than to advise there are a
number of members of the public with him and he believes that we have been contacted
in relation to this incident. Call assessed as 32D01, unknown problem, life status
questionable, allocated a Red 1 eight minute response.
CAD Message: is this call near the Vets or café as we have two calls in the close vicinity?
CAD message: caller advised he works for the Nottingham Post and he will be writing
about this incident as the patient has been left on the floor for over an hour.
stopped as a duplicate of call reference 6044692.
14:32
14:38
14:40
14:40
14:42
Handling of the emergency call: the call taker attempted to gather information about the patient, but the caller
had no information other than the patient’s location. It was identified that there were two other calls in the close
vicinity but this information was not relayed to the caller. The call was assessed as red 1 eight minute response as
we could not gather any further information, but was then stopped as a duplicate of call reference 6044692.
Care and treatment of the patient: the Emergency Operations Centre was already aware of this patient as a result
of a call received at 13:40 and subsequent calls to chase up the arrival time of the ambulance. The call takers
explained that we were experiencing a high demand for emergency responses and apologised to the callers in
relation to that incident.
In respect of this complaint the caller became frustrated when the call taker attempted to follow procedures and
process the call through AMPDS. The address given was sufficiently different for it not to be immediately identified
as a duplicate call to an incident we were already aware of.
Conclusion
The call taker attempted to process the call through AMPDS, but the caller had no information to give apart from
an approximate location for the patient. After the call finished the incident was linked to an earlier call received on
behalf of the same patient.
Grade: Minor
Status: Resolved
Evidence Gathered
CAD reports
Call audio files
identified.
Category: Other
Source: Letter
Final Contact Date: 11 March 2014
Delays Incurred
Reason for Delay: Member of staff first on scene was absent through illness
Harm Rate:
Base: Public Place
Green 2
Patient Outcome:
Transported
to
A&E
Extension: Requested as first Paramedic on scene is absent through illness
Summary: RTC: Patient Care & Inappropriate Comments
Case Details: Patient was a pedestrian who was knocked over by a car. Patient says that the details of his
treatment have only come to light due to a Neurologist report in September 2013.
Patient wants to know why he didn't get proper care, including a neck brace.
Patient states that on arrival at hospital EMAS staff made inappropriate comments about him.
• Why was the patient not immobilised on scene?
• Why did the conveying staff make inappropriate comments to hospital staff on handover?
TOR agreed by:
Complainant
Crew Stood Down:
No. If No state rationale: in view of time elapsed since incident.
registered. If No state rationale: in view of time elapsed since incident and pending statement from first member
of crew
Being Open
Initial Contact Date: 23/01/2014 and 19/02/2014
Timeline of Events
Date and Time
Event
28 Apr 2012
21:32
21:32
21:33
new call received, call ref. 4595146, on behalf of a pedestrian who has been hit by a car.
resource 8633 mobile to incident. Call assessed as 29D02M, traffic/transportation
incidents, high mechanism, vehicle vs. pedestrian. Allocated a Green 2 30 minute
response. Patient is a 60 year old male who is conscious and breathing. Resource 8711,
double crewed ambulance, allocated to the incident
resource 8711 mobile to the incident. Resource 8633 arrives on scene.
resource 8633 calls clear from the incident.
21:34
21:43
22:00
22:01
22:09
22:33
Handling of emergency call: the call was allocated a Green 2 30 minute response. The first Paramedic on scene
arrived 11 minutes after receipt of the emergency call, achieving the 30 minute target.
Care and treatment of the patient: the crew of the back-up ambulance have documented that the Paramedic on
scene had already cleared the patient of any spinal injuries prior to their arrival.
The information that the patient had already been falling into the road when he collided with the car was given by
the driver of the vehicle, who was slowing for a junction and was travelling at very low speed. The information
regarding the consumption of alcohol and the amount consumed was gathered on scene by the ambulance
personnel from the patient, and this was important information to relay to staff at the hospital who were taking
over responsibility for his care.
The Paramedic who was first on scene had limited recollection of the incident due to the time elapsed but he did
recall that the patient was conscious throughout and this is evidenced on the PRF with a Glasgow Coma Scale (GCS)
score of 15 indicating full consciousness. The PRF also confirms that the Paramedic had undertaken a full spinal
assessment and had cleared the patient of any spinal injuries. The patient’s minor injuries were dressed and he
was conveyed to hospital for further assessment.
Conclusion
The patient had been cleared of having any spinal injury whilst on scene, and minor injuries had been treated and
dressed. Information was gathered about his consumption of alcohol and this information was relayed to hospital
staff.
Date Resolved: 11 March 2014 Status: Resolved
Grade: Moderate
Letter Date: 11 March 2014
Evidence Gathered
Patient Report form
CAD report
Statements from attending crew members.
identified.
Type: Poor Service Delivery
Source: Letter
Final Contact Date: 11 Feb 2014
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Red 2
Patient Outcome:
Admitted
to
hospital
Extension: XX
Summary: CVA - Time On Scene & Navigation
Case Details: The patient had a CVA. Clear directions to his house were given to control, but ambulance got lost.
Crew didnt seem to know which care pathway to use and spent a lot of time on scene discussing where to take
him.
Ambulance then went the wrong way to LRI.
• Why were the Paramedics unable to locate the address when specific instructions had been given to the call
taker?
• Why are there no care pathways in place for stroke victims and is there no provision for locations
positioned near to a number of facilities?
• Is it unusual for the patient’s family to have to drive the need for urgency and professionalism in ambulance
staff?
• Why were the ambulance staff unable to locate the Leicester Royal Infirmary? Should it not be a core skill to
have detailed knowledge of all accident and emergency departments in the region?
• Is it correct that the person driving the ambulance on this occasion was actually a control room call
handler? And if so was it acceptable to send them on an emergency call out?
• Why did the ambulance crew not have navigation equipment on board, particularly if it was known that the
driver was not an experienced member of ambulance crew? I understand that there was issue on the day
of this incident with a power cable.
•
•
•
•
How do you assure that the ambulance is fully equipped to start its operational shift?
Why did it take so long to decide which hospital to take the patient to?
Why was the patient sent to the Leicester Royal infirmary and not the City Hospital Nottingham?
With a case of TIA/suspected stroke, what are the guidelines for your staff? And if this is different for
suspected TIA’s please explain how?
TOR agreed by:
Complaint
Date: 23 Jan 2014
Crew Stood Down:
No. If No state rationale: non- medical issue
registered. If No state rationale: non-clinical issue
Being Open
Initial Contact Date: 23 Jan 2014
Timeline of Events
Date and Time
Event
17 Dec 2013
01:25
new call received, call ref. 6069047 on behalf of a male patient who is confused and is
unable to use his limbs properly. Call passed through 111 service and allocated a Red 2
eight minute response.
CAD message: further information to help with dispatch was described. Private road – the
house is opposite the Church as you come into the village near the ----------------------- – the
house is within 25 metres of this -----. Christmas lights will be on. Resource 4042 is mobile
to the incident.
CAD message: Amber response required.
01:26
01:26
01:35
01:43
01:44
01:45
02:03
02:31
02:38
03:08
03:35
Handling of emergency call: the call was correctly coded as a Red 2 eight minute emergency. The first attending
resource arrived ten minutes after receipt of the call, missing the eight minute target but achieving a response
within the 19 minute target. When the solo responder arrived on scene he sought further advice from the
Emergency Operations Centre (EOC) and he was given further instructions from the patient’s partner regarding the
location of the private road. He was at the time stopped adjacent to this and the patient’s partner proceeded
down to the road and confirmed the location. Following this incident the Paramedic has visited the location and
has taken photographic evidence confirming that the private road is unlit and not easy to find in the dark and the
sign for the private road is some 150-200 yards up the drive from the main road.
Care and treatment of the patient: on arrival with the patient the solo responder Paramedic began to take
observations and a medical history, and it was established that the patient’s symptoms had eased slightly. His
speech had returned but he still suffered weakness in his left arm, he had difficulty in swallowing and he had a
posterior headache. The Paramedic conducted a FAST test which he recorded as positive, and shortly after his
arrival the request was placed for back-up. When the back-up ambulance did arrive the Paramedic got out of the
vehicle and walked up the private road to confirm the location and then the driver, who is an Emergency care
assistant (ECA) reversed the ambulance up the driveway.
As the patient’s location was roughly equidistant between the stroke unit at City Hospital Nottingham and the unit
at the Leicester Royal Infirmary (LRI) the patient was asked if he had a preference and this was indicated to be
Nottingham. The Paramedic contacted the stroke unit at Nottingham City, and when the back-up crew arrived
(they were a crew based at -------------, Nottingham) they agreed that they thought this to be nearer. Initially City
hospital accepted the patient, but when the postcode was quoted the unit then advised that they believed the LRI
to be the more appropriate unit as it was likely that the patient would be transferred there anyway within 48
hours for any post treatment care. The Paramedic on the back-up crew also spoke to the stroke unit and advised
that the patient’s preference was to go there. Travelling to the Queens Medical Centre in Nottingham was briefly
discussed as an option to gain access to the stroke unit in Nottingham but in view of the patient’s symptoms this
was dismissed as not being a viable option. The EOC confirmed that the patient’s location was the same distance
from both hospitals.
With regard to the comment about meal breaks the first Paramedic on scene did recall that this was discussed but
it did not deflect from the patient’s care. It was acknowledged that it was possibly not the most appropriate place
for this conversation to take place. The Paramedic cannot recall any disagreement about who would speak to the
hospital but he advised that all discussions were held with the patient’s best interests and wishes in mind.
The ambulance staff do recall the patient’s partner suggested that he transport the patient. At this point the EOC
were confirming the distance between the patient’s location and the two hospitals, and the decision was made to
transport the patient to the LRI. The crew had to ensure they had agreement or otherwise from Nottingham that
they would accept the patient before they started to travel. Once the decision was made to travel to the LRI the
Paramedic who was first on scene placed a pre alert call so the hospital was expecting the patient.
Once the patient had been settled on the ambulance the crew set off for the LRI. The ECA had been there a couple
of times before, but she relied on the navigation equipment on the ambulance vehicle to negotiate the route.
(Journey time on Google maps is 29 minutes under normal road conditions. The crew’s journey time was 37
minutes).The ECA advised that the patient’s partner had offered to guide them to the hospital, but they set off
using the navigation equipment and the partner travelled behind in his car. En route to the hospital the signal did
briefly fail, and the ECA pulled over to re-establish the connection and the route. The journey did include taking an
exit onto the A6 signposted to Loughborough, and this is part of the recommended Google maps route. In respect
of the cable for the sat nav not being available, the ECA confirmed that the navigation equipment is hardwired into
the vehicle and no separate cable is required.
As the ambulance approached the LRI it stopped just outside -------------------- (this is approximately 200 yards from
the hospital) as another ambulance drew alongside. That vehicle was also going to the LRI so the ambulance
conveying the patient followed it in. Both members of the back-up crew stated that if they had travelled to
Nottingham City Hospital they would have done so using local knowledge, but as they are not as familiar with
Leicester they used the navigation equipment available on the ambulance.
Responses to complainant’s specific questions:
• Why were the Paramedics unable to locate the address when specific instructions had been given to the call
taker?
The solo responder Paramedic was given no additional details prior to arriving in the vicinity of the address. At this
point he contacted the EOC and further instructions from the patient’s partner were relayed to him. These were
that the private road was between ------------ and ---------------, and the entrance was next to the old schoolhouse.
The patient’s partner then proceeded down the drive to the main road and confirmed the location to the
Paramedic. When the back-up ambulance arrived the Paramedic walked up the private road to verify the location
and then the ECA reversed the ambulance up the road to the patient’s house.
• Why are there no care pathways in place for stroke victims and is there no provision for locations
positioned near to a number of facilities?
There are stroke care pathways in place for both Nottinghamshire and Leicestershire. The delay on scene was in
trying to get the patient accepted at the City Hospital in Nottingham, which was the same distance as that to the
LRI, in accordance with the patient’s preference.
• Is it unusual for the patient’s family to have to drive the need for urgency and professionalism in ambulance
staff?
The crew did not wish to give the impression that the decision to travel was driven by the patient’s partner. At that
point they were still trying to get the patient accepted at Nottingham in the best interests of the patient.
• Why were the ambulance staff unable to locate the Leicester Royal Infirmary? Should it not be a core skill to
have detailed knowledge of all accident and emergency departments in the region?
The crew relied on the navigation equipment and this guided them to the LRI by the best route possible. The signal
failed at one point causing a short delay while the ECA reprogrammed the unit. As the ambulance crews can often
operate outside of the area in which they are stationed they regularly use navigation equipment to reach
locations. The Trust area is 6450 square miles and a resource can find itself deployed to locations further and
further from its base throughout this area.
• Is it correct that the person driving the ambulance on this occasion was actually a control room call
handler? And if so was it acceptable to send them on an emergency call out?
The ECA volunteered the information that she had worked as a call handler in Control as part of general
conversation. This was between 2003 and 2005, and she has been qualified road staff for the last nine years.
• Why did the ambulance crew not have navigation equipment on board, particularly if it was known that the
driver was not an experienced member of ambulance crew? I understand that there was issue on the day
of this incident with a power cable.
There was navigation equipment on board the ambulance and this was used to complete the journey to the LRI.
The equipment is hardwired into the vehicle and no separate power cable is required. As does sometimes happen
with satellite navigation equipment the unit lost signal at one point and the route needed to be reprogrammed.
• How do you assure that the ambulance is fully equipped to start its operational shift?
At the start of each operational shift the ambulance crew are required to complete an inspection of the vehicle
and complete a checklist. This is to verify that the vehicle is roadworthy and all necessary equipment is present
and in good working order. If any defects or omissions are identified these are rectified immediately.
• Why did it take so long to decide which hospital to take the patient to?
The ambulance crew were attempting to get the patient accepted at the stroke unit in Nottingham, following one
of the two stroke care pathways they had available to them in view of the location and taking the patient’s wishes
into account. As the patient lived in Leicestershire the advice given was to take the patient to the LRI as it was
likely the patient would be transferred there from the City Hospital for post treatment care.
• Why was the patient sent to the Leicester Royal infirmary and not the City Hospital Nottingham?
Please see above response.
• With a case of TIA/suspected stroke, what are the guidelines for your staff? And if this is different for
suspected TIA’s please explain how?
The guidelines are to contact the dedicated stroke unit for that area and confirm acceptance of the patient. Due to
the patient being equidistant between two dedicated stroke units the patient’s wishes were also taken into
account. This would apply to any patient who has tested FAST positive for a suspected stroke or TIA unless there is
trauma confirmed or suspected. This is a specific injury suffered by the patient and this would be treated first at
the nearest accident and emergency unit.
Conclusion
The Paramedic was on scene 56 minutes until the patient left. The Paramedic and the back-up crew were on scene
together for 28 minutes, and much of this time was taken in trying to get the patient accepted at City Hospital in
Nottingham. The patient was initially accepted until the postcode was given, and then City Hospital directed the
patient to Leicester Royal Infirmary.
All of the attending members of staff have expressed their regret that the patient was unhappy with the care and
treatment they provided as they thought that good rapport had been built on the day of the incident and the
patient and his partner had expressed their gratitude for the crew’s actions.
Grade: Moderate
Status: Resolved
This incident is one of a number recently when the ambulance crew have been referred to the LRI as the patient
location has included a Leicestershire postcode. On some of these incidents the patient has been closer to the City
hospital than the LRI, and this has been highlighted to senior management within the organisation to be addressed
with the appropriate organisations.
Evidence Gathered
CAD reports
PRF
Statements from crew members
identified.
Source: Letter
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Public Place
Green 2
Area/Divisional: Nottinghamshire A&E Staff
Patient Outcome:
Extension: XX
Summary: Crew Told Patient To Make A Claim
Case Details: School student injured during a lesson. As the ambulance crew were wheeling the pt out, one of
them said "never mind ---------, where there's blame there's a claim". Headteacher feels that this was totally
unprofessional.
Also, the school have seen a rise in compensation claims through a firm of solicitors in -----------. Each one has been
after an ambulance has attended the school. Is there a direct link to this solicitors firm through EMAS employees?
• Why did a member of the ambulance crew make a comment regarding the possibility of making a
compensation claim against the Academy?
TOR agreed by:
Complainant
Date: 30/01/2014
Crew Stood Down:
registered. If No state rationale: non clinical issue
Being Open
Timeline of Events
Date and Time
Event
14 Jan 2014
11:34
11:34
11:35
new call received, call ref. 6135744, on behalf of a male who has fallen and hurt his back.
call assessed as 17B01G, falls, possibly dangerous body area, patient on the ground or
floor, and allocated a Green 2 30 minute response.
CAD message: patient has leg problems and is having physio. The patient is a --- year old
male. Resource 3110, double crewed ambulance, allocated and mobile to the incident.
resource 3433 calls clear from the incident.
11:36
11:38
11:47
12:17
12:20
12:37
13:19
Handling of emergency call: the call was correctly coded as a green 2 30 minute response. The first resource on
scene arrived four minutes after receipt of the call and the double crewed ambulance arrived 13 minutes after
receipt of the call.
Care and treatment of the patient: the complainant has raised no issues whatsoever regarding the care of the
patient, stating that crew members were all efficient in their care of the patient. The patient was immobilised in
accordance with procedures and pain relief was given to good effect.
Comment by staff member: The members of staff cannot recall making this comment. However the attending
member of staff on the back up crew advised that if the comment was made then it could possibly have been him
as he had most interaction with the patient. If it was said it would have been entirely made as a light-hearted
comment made to take the patient’s mind off his pain and any worries he had about his injury, and would not in
any way have been intended to encourage the patient to consider making a claim against the Academy. The
attending member of staff apologised if anything said at the scene was construed in this way.
Conclusion
None of the attending crew members can recall making the comment. However the attending member of the
back-up crew has acknowledged that this may be something he would say purely as a light-hearted comment
designed to calm the patient and distract him from his pain. The member of staff has apologised for any offence
caused and he will consider the appropriateness of his actions in future.
Grade: Minor
Status: Resolved
There are no further actions or recommendations to be made on this occasion.
Evidence Gathered
CAD report
Comments from members of staff.
identified.
Type: Damage To Vehicle/Property
Source: Email
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Base: Nursing Home
Green 1/Red 1
Area/Divisional: Nottinghamshire A&E Staff
Patient Outcome:
Extension: XX
Summary: Ambulance Damaged Pathway Slabs
Case Details: I have been asked by my Home Manager ------------- to submit the following complaints 1st COMPLAINT - 14th January 2014
Emergency Transport was ordered for one of our service users on the 13th January 2014, the transport was
directed to our new build where there is a transport bay for the ambulance to park.
For some reason the driver decided to back the ambulance down the narrow pathway leading from the allocated
bay. The ambulance driver took numerous attempts to try and get down the walkway- this is not for vehicles it is
for pedestrian use only. As you can see from the photo's attached there is oil spillage on the slabs.
I have attached some photo's of the pathway for you to look at re the damage. Our General Manager was present
at the time this incident occurred, she was absolutely horrified to witness this.
2nd Complaint -21st January 2014
Emergency Transport was called out for our service user , the ambulance was called due to her being in severe
pain and a high temperature.
---------------- was part of the crew that turned up on the ambulance and asked what pain relief this lady had
received, the pain relief was specified to him and his reply was there is not much more we can do for her. This
comment made the service user very frightened and was totally inappropriate ,which in turn caused a situation
which was totally unnecessary. There was an advanced nurse practitioner in the room at the time and she was
totally disgusted by his attitude.
• Why did the ambulance proceed down a pedestrian walkway causing damage to the paving slabs on 14
January?
• Why did the Paramedic advise that there was nothing more he could do for the patient on 21 January?
TOR agreed by:
Complainant
Date: 6/02/2014
Crew Stood Down:
No. If No state rationale: non clinical issues
registered. If No state rationale: non clinical issues.
Being Open
Timeline of Events
Date and Time
Event
Incident 1
14/01/2014
08:41
08:41
08:43
new call received on behalf of a patient with suspected sepsis.
resource 8616, double crewed ambulance, allocated and mobile to incident. Call assessed
as 06D04, breathing problems, patient clammy. Allocated a Green 1 20 minute response.
CAD message: patient is a bariatric patient and weighs over 25 stone.
08:45
08:46
09:02
09:40
10:05
10:46
Incident 2
14/01/2014
15:09
new call received on behalf of a female patient not breathing well. Call allocated a red 1
eight minute response. Resource 8432, solo responder, allocated to the incident.
resource 8432 mobile to the incident. CAD message: nurse is willing to look after the patient until help arrives.
CAD message: red response required.
16:27
16:28
16:50
17:44
Analysis of Findings Incident 1
Handling of emergency call: the call was assessed as requiring a Green 1 20 minute response. The first resource on
scene arrived five minutes after receipt of the emergency call, achieving the target.
Statement of member of staff driving the ambulance: the member of staff who was driving the double crewed
ambulance as back-up advised that while they were en route to the care home the crew were advised that the
patient was -----------------------------------------------------------------. On arrival at the care home the driver noticed that
the pathway from the disabled parking bay to the door of the facility was of considerable length and it sloped
upwards from the doors, and he made a dynamic risk assessment that it would be much safer if he moved the
ambulance vehicle down the pathway and this would provide a much safer environment in which to transfer the
patient on board. It did take a number of attempts to reverse down the driveway, and the driver was aware that in
completing the manoeuvre the nearside wheels did go over the grass at the top of the driveway. He apologised for
any damage caused but he did state that moving the patient safely and as quickly as possible was the crew’s
overriding priority. The driver was not aware of any oil spillage from the vehicle.
Analysis of Findings Incident 2
Handling of emergency call: the call was assessed as a Red response within eight minutes. The first response on
scene arrived 17 minutes after receipt of the emergency call, missing the eight minute target but achieving the 19
minute target.
Care and treatment of the patient: the first responder on scene undertook an initial assessment and medical
history, and a double crewed ambulance on red response was requested eight minutes after his arrival.
Medication was administered as pain relief in accordance with JRCALC guidelines after the solo responder
established what medication the patient had already received, and on arrival of the back-up crew the patient was
transferred to hospital.
Comment of solo responder: the solo responder does remember commenting that there was little more he could
do but clarified that this was in respect of pain relief and not in relation to the patient. He apologised that his
comment was taken as relating to care and treatment of the patient as this was not the case. He confirmed that it
was quickly established the patient needed to be transferred to hospital and he requested back-up on a red
response very shortly after his arrival.
Conclusion
In the first incident the member of staff does recall reversing over a grassy area whilst trying to manoeuvre the
ambulance to the doors of the home, and he apologised for any damage caused. He was not aware of any oil
spillage from the vehicle.
In the second incident the solo responder quickly assessed that the patient needed to be transferred to hospital
and he requested back-up on red response. After identifying that the patient had already been given medication
the Paramedic did state that there would not be much more he could do, but he confirmed that this comment
related to pain relief and not care and treatment. Addition pain relief was administered in line with JRCALC
guidelines.
Grade: Minor
Status: Resolved
Letter Date: 26 Feb 2014
Evidence Gathered
Cad reports
Statements of members of crew
Patient report forms
identified.
Type: Delayed Response To Hospital T
Source: Email
Delays Incurred
Reason for Delay:
New Agreed Date: XX
Harm Rate:
Priority 1
Base: Bassetlaw hospital
Patient Outcome:
Extension: XX
Summary: Delayed Emergency Transfer
Case Details: Emergency transfer booked for patient to go from Bassetlaw Hospital to Doncaster Royal Infirmary
for limb saving surgery. Ambulance took 75 minutes to arrive.
• Why did it take 75 minutes to provide an ambulance
TOR agreed by:
Complainant
Date: 5/02/2014
Crew Stood Down:
Yes/No. If No state rationale
•
Staff support and involvement: Healthcare Decisions Panel (HDP) referral: No. All clinical incidents must
be referred to HDP where clinicians are registered. If No state rationale: EOC delay
Being Open
Timeline of Event

Attachment 3 - East Midlands Ambulance Service NHS Trust

Transcription

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