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Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.1628/01-02
Complaint against London Ambulance Service NHS Trust
Summary of Case
Mr N had an accident at home in the early hours which caused a deep gash to his head and bleeding. Not realising the seriousness of his injury, he went to bed. At around 1.00pm, he was feeling unwell and sought help from a neighbour, who telephoned for an ambulance at 1.27pm. The ambulance arrived at 1.51pm. The ambulance crew, who were not paramedics but comprised a qualified technician and a trainee, stayed a while at the scene and waited for another crew they had called to assist them in lifting him. As Mr N’s condition deteriorated and the other crew had not arrived, the first crew enlisted the help of other people present to lift him into their ambulance. The second crew arrived just afterwards. The ambulance left for hospital at 2.20pm, and arrived at 2.25pm. Mr N suffered the first of two cardiac arrests and, although resuscitated and placed on life support, he never regained consciousness and died. Mr N’s parents complained that the crew’s treatment of Mr N was inadequate and, particularly, that they had delayed unduly in taking him to hospital.
Findings
After taking advice from two professional assessors, the Ombudsman had no doubt that Mr N had needed to be taken to hospital speedily to have the best chance of survival, although she could not definitely conclude that a more prompt arrival at hospital would have prevented his death: the exact cause of death was uncertain. The Ombudsman cast doubt on the accuracy of the initial Glasgow Coma Score reading recorded by the trainee technician, and had concerns about the time taken to place Mr N in the ambulance and transport him to hospital. Much of that delay was as a result of a decision to immobilise him because of concerns that he might have sustained a neck or spinal injury. However, the evidence to eliminate that likelihood had been available and, therefore, it was difficult to conclude that the crew acted in accordance with national guidance/protocols. The Ombudsman also expressed concern about the division of labour between the more experienced crew member and the trainee. The trainee provided the large part of the care to Mr N, even after he had been acknowledged to be deteriorating seriously. The Ombudsman recognised that, as both crew members were technicians and not paramedics, there was a limit to the intervention which they could have carried out. However, as they were about to leave the scene, a second paramedic crew arrived; yet, neither of the second crew was asked to travel with Mr N in the ambulance. The Ombudsman upheld the complaint
Remedy
The Trust apologised. They agreed that, in circumstances where serious or critical events are apparent, the qualified ambulance technician, and not the trainee, should take the lead in the management of patients; and that emphasis should be given during staff training to the identification of time-critical patients and weighing up the risks and benefits of calling for back-up crews.
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