Incident

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January 2019

Date: 13 February 2019

  • Details:

    The patient was receiving treatment for cancer and the patient’s temperature rose significantly causing concern. Following advice from the hospital the complainant telephoned for an ambulance. The call handler suggested that they either contact their GP the following day or take the patient to the hospital. The patient experienced significant delays on arrival at hospital and subsequently spent seven days in-patient due to a bacterial infection. They are now worried about this happening again.

  • Findings:

    The investigating manager reviewed the CAD notes, interviewed the call handler and call handler team leader and had the 999 call audited. The call was correctly coded as a category 5 for a further telephone assessment. Due to there currently being no specific protocol for triaging Sepsis nationally within the MPDS system the Trust has put its own standard operating procedure in place for 999 calls when Sepsis is suspected. If a caller states that the patient is suffering with or has suspected Sepsis then the call should be escalated to a clinical coordinator for review with consideration to upgrade the call category. The investigating manager identified that the standard operating procedure was not considered during the complainants call even though the information given was indicative that it should have been.

  • Lesson learnt / action taken:

    As a result of this complaint the standard operating procedure is to be amended to ensure key phrases and/or symptoms of Sepsis are included in the guidance for call handlers to instigate this process. The Trust is also in contact with the suppliers of MPDS about the feasibility of producing a specific protocol or screening tool for Sepsis.

  • Date:
    01 January 2019