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June 2017

Date: 28 July 2017

  • Details:

    The ambulance service was called out to a resident who had become unresponsive. A clinician arrived and gave the patient a shock because their ECG was showing a shockable rhythm. The clinician was informed that the patient had a DNACPR in place but he explained to the GP on scene that he has to treat if a possible recoverable rhythm is found. 

  • 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 reported that on arrival there was no CPR being carried out on the patient. He was instructed to attach the ECG monitor by the GP who was also in attendance to see was the heart rhythm was showing. The monitor was showing fine VF which the clinician observed was a reversible cause and they decided to carry out treatment to change this to a sustainable rhythm. The clinician explained his actions at the time to the GP and staff.  After the shock the rhythm changed and the treatment stopped.

  • Lesson learnt / action taken:

    The clinician discussed the incident with the Area Clinical Lead and it was made clear to him that treatment was not appropriate as the initial rhythm was not a reversible cause. The clinician was spoken to at length to gain a better understanding of the concept of DNACPR instructions and the difference between treatment and resuscitation.

  • Date:
    01 June 2017