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May 2014 -case study 1

Date: 30 April 2014

  • Details:

    A 999 call was made by a relative on behalf of a patient who had recently had a prostate biopsy and had become unwell, requesting an ambulance to take the patient to Hospital A where the patient was known and had been treated. The caller was informed that a clinician would call back. The clinician stated that an ambulance would be sent, but that if admission was required, this would be to the nearest A&E Department and not to Hospital A. The caller decided to take the patient by car to Hospital A, where septicaemia was diagnosed.

  • Findings:

    The investigation found that the call was correctly coded as Green 4, (requiring further telephone assessment by a clinician within 60 minutes or a non-blue light emergency response within 90 minutes). A call-back was made ten minutes after the initial call by an Emergency Care Practitioner (ECP) working on the Trust’s Clinical Support Desk (CSD). The ECP advised that it is normal practice, for patients to be conveyed to the nearest A&E and suggested that if attendance at a specific hospital was required the caller should contact that hospital and request that they book ambulance transport. It was found that the triage was rushed. An ambulance should have been sent and which hospital the patient would attend decided upon later.

  • Lesson learnt / action taken:

    It is not the decision of CSD staff to definitively decide on the A&E department a patient will be transported to: this decision should be taken by the attending ambulance crew once they have assessed the patient. The CSD staff member has been debriefed on the incident and learning points raised and addressed. A reminder that CSD staff should not decide where a patient will be taken by an ambulance crew in circumstances such as this.

  • Date:
    29 April 2014