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March 2017

Date: 05 May 2017

  • Details:

    The patient was a palliative care patient and suffered a seizure. The paramedic arrived and needed to give Midazolam from the’ Just in Case’ medication left by the palliative care team. The paramedic had to call someone to get authority to give the drug but the advice and  authority took longer than expected. There was no complaint about the standard of care the paramedic gave just why it took so long to get this authorisation to adminster the medication to the patient.

  • Findings:

    As part of the investigation the Investigating Manager met with the complainant to discuss in more detail the concerns raised. Apologies were provided for not meeting their expectations. The paramedic was interviewed and the complaint discussed.  

    It was found that the information left in the patients care record did not include the use/indication that the paramedic needed to be able to administer the medication. The paramedic rang the Trust's Clinical Advice line for advice.  He did not receive advice for over an hour. An investigation for this delay took place. It was found that the numbers of staff providing advice was not sufficient, along with information that the crew needed was not available within the Directory of Services (DOS) for the Clinical Advice line staff. 

  • Lesson learnt / action taken:

    The paramedic has undertaken several E-learning modules in relation to End of Life Care. He also attended, along with a group of other Trust staff, an End of Life course organised by the education team at a hospice. The Trusts Clinical guidelines for End of Life Care written in 2010 were still current but these have since been reviewed and End of Life Care Strategy has now been written to work in line and in conjunction with community trusts across the region.  Staff numbers have been increased to answer the Clinical Advice line calls and information contained within the DOS has been updated.

  • Date:
    01 March 2017