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Case ref:201100875
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Date:February 2012
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Body:Scottish Ambulance Service
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment; diagnosis
Summary
An MSP complained on behalf of Mrs A about the Scottish Ambulance Service (SAS). Mrs C's husband (Mr A) suffered a heart attack and the SAS were asked to dispatch an ambulance. The ambulance crew gave Mr A aspirin and carried out an ECG (electrocardiograph). It is normal practice for ECG results to be transmitted to the Golden Jubilee Hospital, which provides specialist emergency treatment for heart attack patients. However, on this occasion, the ambulance crew were unable to transmit the results. The paramedic who attended Mr A phoned the Golden Jubilee for advice, as per the protocol for such situations. He was advised that he could take Mr A to the Golden Jubilee if he was having a heart attack, otherwise he should be redirected to a local Accident and Emergency unit.
The paramedic understood that the correct procedure at that time was to take patients to the Vale of Leven Hospital for initial assessment. He did this, but, upon confirmation that Mr A was having a heart attack, staff at the Vale of Leven redirected him to the Golden Jubilee. By the time Mr A arrived at the Golden Jubilee, another patient had arrived and was treated before him. Mr A did not recover from his heart attack and died three weeks later.
We found that the equipment provided in the ambulance was not properly configured and prevented the ambulance crew from transmitting Mr A's ECG results to the Golden Jubilee. The protocol in place at the time of this incident required ambulance crews to take patients showing signs of a heart attack to the Golden Jubilee in the first instance. We found that the paramedic was not aware of the correct protocol and incorrectly decided to take Mr A to the Vale of Leven, delaying his treatment.
Recommendations
We recommended that the Scottish Ambulance Service:
• apologise to Mrs A and her family for the issues highlighted in this decision notice; and
• consider establishing a standard form of words with PCI (Percutaneous Coronary Intervention) centres to avoid any confusion as to what action ambulance crews are being advised to take.