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Selected Investigations Completed April - September 1997 > Part I, Case no. E.1437/95-96
Matters considered: Response to initial complaint, conduct of review panel, review panel's report
Complaint against: Durham County Ambulance Service NHS Trust
Summary of case
The parents of a 15 year-old girl who collapsed at a swimming pool on 2 March 1995 and died four days later complained about her treatment by Trust staff. The chief executive replied on 22 May but the parents remained dissatisfied. The Trust then established a panel—of which all the members came from outside the Trust—to review the girl's treatment. The panel produced its report on 27 September. The parents considered that the conduct of the review by the panel was unsatisfactory and that their written report failed to report their findings fully and accurately.
Findings
I found some grounds to criticise the chief executive's response to the parents but I did not uphold the majority of their complaints about that. I upheld some of their complaints about the conduct of the panel. In particular, I found that the panel made a serious mistake in concluding that blood gas measurements indicated that adequate resuscitation had been given. That was not a conclusion which could be drawn from the measurements taken. I criticised the panel's report for failing to make clear their finding that a paramedic had been wrong to try to intubate the girl (a technique to maintain the airway) before defibrillating her (a technique to restore the heart rhythm). They expressed their judgment on the point in professional terms, the force of which was not obvious to a lay reader. The chief executive of the Trust said that he had not recognised that the report was critical.
Remedy
The Trust apologised.
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