You said, we did

 1

We received a complaint regarding why the caller was not directed to the nearest defibrillator when it was required.

During the investigation, it was identified that the closest defibrillator has been booked offline for an extended period and was appearing as not available for use.

The defibrillator process of alerting the custodian when it has been used and inputting the key word when it has been returned had not been followed. Feedback was shared with all call handlers regarding the importance of the procedure being followed in full.

In addition, following this incident the Trust implemented an automated function, sending a message to the custodian if a defibrillator is used. They can also inform electronically once it is returned and ready for use again. 

The Trust has an up-to-date record of whether defibrillators are ready for use in an emergency which will save time in accessing the devices and crucially help save lives.

 2

We received a complaint following the attendance to a patient who had previously had a stroke and was paralysed on one side of their body.

This case was reviewed by the patient safety team and did not meet the national criteria for what is classed as a serious incident. This investigation followed the Ambi process to ensure a more in-depth investigation and to gain learning.

A patient safety alert to all staff in the Trust has been sent. This identifies the importance of using the NEWS2 scoring process and the impact this has on decision making for patients.

 3

We received a complaint from the husband of a patient in regards to the Trust taking 90 minutes to attend to her following a serious fall. This complaint was also reviewed by the Parliamentary and Health Service Ombudsman.

From the investigation that took place it was highlighted that there were four calls received in relation to the incident. One error was identified on the second call where the incorrect protocol was selected, this was further reviewed to not affect the categorisation (outcome) of the call.

During the Parliamentary and Health Service Ombudsman investigation it was established that there was an error with the Advanced Medical Priority Dispatch System (AMPDS) protocols. This is the system that is used nationally to triage 999 calls for an ambulance response.

Protocol 17 (used for falls) should have prompted the call taker to ask which part of the body was injured, and follow up questions, including if the patient was having any trouble breathing. The version of the protocol on themain system (called ProQA) did not do that even though the prompt  is included on a ‘card copy’ version, which is available as a backup.

Although there were no specific failings, this complaint identified that the Trust had to rely on the AMPDS system. The problem was with the system itself rather than anything the call handlers or Trust did. Because of the learning from this complaint this issue will share learning on a worldwide scale.

The Parliamentary and Health Service Ombudsman have raised this issue with the International Academy of Emergency Medical Dispatch, the company that created and manages the system worldwide. It will include a fix in its next global update, which will be completed in July. The Ombudsman have also raised this with NHS England and Improvement to cascade the issue to all the ambulance services in England.