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May 2019

Date: 17 June 2019

  • Details:

    The husband of the patient reported that he was dismayed by the crew who attended his wife with the inappropriate comments they made and the incorrect diagnosis of his wife’s presenting symptoms. This resulted in the crew’s reluctance to convey her to hospital. Ten hours later his wife was in a critical condition with a strangulated small intestine and a bowel obstruction.

  • Findings:

    As part of the investigation, the investigating manager reviewed the Electronic Patient Care Records (EPCR) from both the crews and also received statements from them. The crew stated that they believed the patient was genuinely suffering from gastroenteritis and some of the symptoms the patient was experiencing were common to both gastroenteritis and a bowel obstruction. The patient’s pain had decreased prior to the crews arrival and they believed that some of the discomfort she was suffering was due to the constant retching whilst vomiting. The abdominal assessment they completed did not raise any ‘red flag symptoms’ and felt it was safe to leave the patient at home under supervision of her husband. The crew had also requested the attendance of the local emergency care practitioner (ECP) to attend to administer anti-sickness medication. The ECP attended and was in agreement with the crew’s decision not to convey the patient to hospital. The patient and her husband were provided with further medication and advice.

  • Lesson learnt / action taken:

    A clinical debrief was carried out with the crew surrounding the events of the incident. The crew have undertaken their own further training for completing abdominal assessments and they have acknowledged that the symptoms of a bowel obstruction and gastric infection are very similar and hard to distinguish between. The crew were also keen to undertake further training from a clinical tutor to help in their future assessments. This was arranged for the crew.

  • Date:
    01 May 2019