Date: 30 September 2015
The patient went over the handle bars of his bike and wanted to know why the Paramedic did not dress his wound and also why the Paramedic did not complete any neurological observations or check his ribs or wrists. A fracture was found following an x ray at the hospital. The patient had to persuade the Paramedic to take him to hospital.
The Investigating Manager interviewed the member of staff and reviewed the Patient Care Record completed at the time. The paramedic advised that he did not dress the wound as he did not want to disturb the clot that had formed and wanted this to be done in a sterile hospital environment. The Patient Care Record completed by the Paramedic documents that he assessed the patient’s chest and cleared his cervical spine for tenderness or pain. These examinations carried out suggest that an appropriate assessment of the upper body took place.
The paramedic took a set of neurological observations documenting that the patient had motor reaction, sensory and circulation in all four limbs. His pupils were also observed to be equal and reacting to light indicating that there was no time-critical neurological trauma that required immediate intervention. The Paramedic assessed the patient’s wrist and found no evidence of fracture at that time and concluded that conveyance to A&E was not required at that time.
- Lesson learnt / action taken:
Apologies provided to the patient. Awareness of attitude and communication issues raised with the member of staff.
- Date:29 September 2015