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February 2014 - case study 1

Date: 01 February 2014

  • Details:

    The patient suffered complications after a home birth. The midwife in attendance called for an ambulance which took over an hour to arrive, despite two calls from the midwife stressing the severity of the patient’s condition.

  • Findings:

    Two calls were received over a period of half an hour and triaged by Call Handlers as requiring a ‘Green 4’ response. Calls coded as Green 4 may require further telephone assessment by a Nurse/Paramedic/Emergency Care Practitioner within 60 minutes, or a non-blue light emergency response within 90 minutes. The investigation revealed that both calls were incorrectly coded. The Call Handlers used the ‘haemorrhage’ algorithm to guide their questioning and determine the priority of the call, but the ‘Health Care Professional’ algorithm should have been used, which allows the healthcare professional to select the priority of response required.

  • Lesson learnt / action taken:

    The investigation indicated that the Trust’s instruction for Call Handlers using the ‘Health Care Professional’ algorithm is not clear enough and can be misunderstood by staff. A review of the instruction will take place though the Health Emergency Operations Governance Committee and clear guidance will be issued.

  • Date:
    01 February 2014