September 2017

Date: 11 October 2017

  • Details:

    A crew were called out to attend the complainant’s mother who was complaining of hip pain and suffering with confusion. The patient was lying on the cold tiled bathroom floor. The crew arrived and were convinced that the patient was a social care issue and did not need further assistance. They told the complainant that her mother’s observations were fine although the documentation stated she had an irregular heartbeat. The next day the patient was found seriously ill with multiple brakes to her leg due to a fall and extremely low potassium levels.  

  • Findings:

    As part of the investigation the Investigating Manager reviewed all the documentation and had a discussion with the complainant regarding the incident. The investigating manager met with the crew to discuss the incident before updating the complainant on the outcome of the discussion.

  • Lesson learnt / action taken:

    Following a discussion of the event with the Investigating Manager, the clinicians were given some feedback and guidance. The crew were reminded of the importance of consulting family members or carers when treating a patient to establish the normal behaviour and clinical presentation of the patient. The crew were also spoken to about the impact of discussing their findings, referrals and aftercare advice to family members and carers to avoid recurrences of ambulance attendances.

  • Date:
    01 September 2017