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April 2019

Date: 10 May 2019

  • Details:

    The patient was suffering with stomach cramps and vomiting. The 111 service was called and a 999 ambulance was requested.  The ambulance did not arrive until six hours later. It was reported that the paramedic was abrupt, made them feel like time wasters and didn’t carry out a full examination. The crew advised it was food poisoning and that it would take its course. The next day another ambulance attended, the patient was examined straight away and taken to hospital with a necrotic, twisted bowel.

  • Findings:

    As part of the investigation, the investigating manager reviewed the Electronic Patient Care Record (EPCR), received statements from both crew members and met with the complainant and patient to clarify points within the complaint. The investigation findings were then presented to the area clinical lead who liaised with the patient safety officer to arrange a Clinical Variation Panel Level 1 with the two crew members. The investigation found that the examination carried out by the paramedic could have been a lot more extensive and thorough. It was identified in the questioning with the patient by the investigating manager that the patient had had their appendix removed during their childhood and the adhesions from this were believed to be the cause of the necrotic bowel. It was also highlighted that the communication style used by both the clinicians was perceived as unacceptable and uncaring by the patient and complainant. 

  • Lesson learnt / action taken:

    Following the Clinical Variation Panel Level 1, both clinicians have taken on further study to improve the knowledge and practice of an abdominal examination to aid their decision making. They will also review their history taking of future patients to make it more specified to the medical complaint ensuring all relevant history is obtained. Both the crew members reflected and have obtained greater understanding of how body language, tone of voice and eye contact can be perceived by patients and their families. They have both agreed that they would never want a patient to feel uncomfortable and that they are wasting their time.

    The crew apologised to the patient and complainant that they made them feel that way.

  • Date:
    01 April 2019