Ambulance trust staff caused avoidable pain and distress to elderly fall victim

Mr T had osteoporosis, arthritis and a history of falls. In summer 2013, he fell forwards while using his Zimmer frame at home and could not get up. An emergency medical technician (someone who is trained to provide emergency treatment but is not qualified to paramedic level) arrived in a rapid response vehicle in response to the 999 call. He assessed Mr T and asked for an ambulance to take him to hospital. The service was very busy and the ambulance dispatched to Mr T was then diverted to another call. A solo paramedic arrived in a car, and the technician and the paramedic helped Mr T up from the floor and sat him on a chair. When an ambulance arrived, the crew transferred Mr T using a carry chair and put him on a stretcher.

Investigations at hospital later showed that Mr T had an unstable fracture of his lower spine with spinal cord compression – he had broken his back. He died in hospital the following month.

Mr T's son, Mr W, complained that his father had been in extreme pain throughout and that staff who had attended the scene had done nothing about it. He said staff should have suspected spinal injury and taken precautions (such as using a spinal board and neck collar) before moving and transporting his father. Mr W was unhappy that the technician told his father he would have to wait for the ambulance as there were people worse off than him. He was also concerned with the route the ambulance took to the hospital which he said had many speed bumps that added to his father's pain.

Mr W was dissatisfied with the Ambulance Trust's two responses to his complaint and he complained to us.

What we found

Staff did not adequately assess Mr T for spinal injury before moving him into a sitting position. The paramedic, as the more senior clinician, should have taken charge and checked that it was appropriate to move Mr T.

Staff failed to adequately assess Mr T's pain and to offer any pain relief during the 1 hour and 40 minutes he spent in their care, even though they documented that he was complaining of back pain. These actions were not in line with relevant guidelines for pain management.

We could not say from the available evidence if there were failings in relation to the route taken to hospital. The technician's comment, as reported by Mr T's son, did not explain in a sensitive way the delay in the ambulance getting there, but we had no objective way of determining exactly what the technician said and how he said it.

Overall, we found failings in assessment and pain management. We partly upheld the complaint because the Trust had not fully acknowledged some of the failings in care and had not done enough to put things right.

Putting it right

The Trust gave feedback to the technician and said a manager would assess his practice. The Trust also gave feedback to the ambulance crew about pain relief and the need to continue assessing the patient. These actions were reasonable.

In line with our recommendations, the Trust shared our report with the staff involved so lessons could be learned, and considered what action to take in relation to the paramedic. The Trust also wrote to Mr W to acknowledge the failings in care and to explain what further action it would take. It paid £250 to Mr W in recognition of the impact of its failings in care.