Incident

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June 2015 - case study 2

Date: 31 May 2015

  • Details:

    The complainant had called 999 and was advised to transfer the patient to the floor and start CPR. The complainant tried to explain that the patient had a DNACPR and an advanced care plan but the call handler was insistent and the complainant felt that she was not listened to properly. The complainant was also concerned that she went against the patient’s wishes by starting CPR.

  • Findings:

    The call was audited and raised a number of concerns. Incorrect instructions were provided about moving the patient and the call handler did not act on the information that the patient had a DNACPR.

  • Lesson learnt / action taken:

    Apology was given and call handler going through internal learning processes

  • Date:
    30 May 2015