April 2017

Date: 30 May 2017

  • Details:

    The patient was an End of Life patient with a DNR in place. An ambulance was called due to shortness of breath and low oxygen saturation. The patient was taken to hospital by the crew against the wishes of the family and care staff. The patient died an hour later. The decision to transport the patient to hospital caused a lot of distress to the patient, family and care staff.

  • Findings:

    As part of the investigation the investigating manager spoke to the complainant and apologised for the distress that was caused as a result of the incident. The complainant emphasised that she was keen for the Trust to learn from her experience to prevent other families having to experience the same situation in the future.

    The investigating manager reviewed all the documentation and spoke with the crew regarding the incident. The crew confirmed to the investigating manager that because of the clinical observations they diagnosed the patient as potentially suffering with sepsis. If caught early enough sepsis is treatable and because the patient wasn’t in cardiac arrest the crew believed she should be transported to hospital for treatment. 

  • Lesson learnt / action taken:

    Following reflection, the crew fully accept the family’s point of view that due to the patient’s age and her end of life diagnosis, she should have been allowed to pass away peacefully in her own bed in familiar surroundings. The crew have taken all the comments on board and in the future will make sure a full discussion takes place between the crew, family and care staff to ensure that the best interests of the patient are fully considered. 

  • Date:
    03 April 2017