July 2017

Date: 18 August 2017

  • Details:

    The complainant fell over and was knocked unconscious. The ambulance attended quickly and the complainant explained what had occurred. The complainant explained that their limbs were not working but the crew sat them up and pushed them forward to check their neck and spine. They made the complainant walk to the ambulance and sat them in a seat rather than properly immobilised on the stretcher. The complainant suffered a serious neck injury and had to spend two weeks laid flat on their back. 

  • Findings:

    As part of the investigation the investigating manager spoke to the complainant.

    The investigating manager also reviewed all the documentation and spoke with the crew regarding the incident.

    The clinician reflected on her actions in a debrief meeting with the investigating manager and an Area Clinical Lead. She believed that she had trivialised the complainant’s symptoms as an exacerbation of the complainant’s chronic arthritis.

  • Lesson learnt / action taken:

    Following a discussion of the event with the investigating manager and an Area Clinical Lead, the clinician completed a reflective account which involved extensive research into spinal cord injuries.

    The investigating manager has published this reflective account to the rest of the Trust so that fellow clinicians can share the learning and reduce to risk of a similar incident happening in the future. 

  • Date:
    01 July 2017