Decision report 201101396

Summary
Mr C had problems with his hip and used a walking aid. He fell while walking with a friend in the city centre. The police, who attended to Mr C first, called an ambulance. Mr C complained that the ambulance crew did not provide adequate care and treatment to him. Specifically Mr C said that the ambulance crew did not give him pain relief despite his requests; did not properly assess the injury to his leg; and did not take him to hospital despite his requests. Four days after falling in the city centre, Mr C fell at home and was taken to hospital, where he was diagnosed with a broken leg. Mr C felt that the break happened when he fell in the city centre.

We found from looking at the records, and taking advice from one of our professional medical advisers, that there was anecdotal evidence that Mr C did ask for pain relief. However, our adviser said it would not have been appropriate to administer it in the specific circumstances. We also found that the ambulance crew's record of the assessment of Mr C was inadequate and, given subsequent events, appeared to have been deficient. There was anecdotal evidence that Mr C did ask to be taken to hospital. We found the decision not to take Mr C to hospital was correct, based on the assessment carried out by the ambulance crew. However, given that the assessment was deficient, that decision could be questioned. Therefore, given the failings identified, we concluded that the ambulance crew did not provide adequate care and treatment to Mr C, and we upheld his complaint.

Recommendations
We recommended that the service:
• apologise to Mr C for the failure of the ambulance crew to provide him with adequate care and treatment; and
• ensure the ambulance crew refresh their knowledge of the relevant sections of the UK Ambulance Service Clinical Practice Guidelines relating to limb injury and pain management.