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Case ref:202107689
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Date:August 2023
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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:Admission / discharge / transfer procedures
Summary
C complained that their spouse (A) was not properly assessed by Scottish Ambulance Service (SAS) paramedics and should have been conveyed to hospital, as they had a high temperature, was struggling to breathe, had a fever, a cough and a NEWS2 score of 5 (the system used to identify acutely ill patients). C felt paramedics dismissed A's high temperature due to the temperature in the room and that A should have been given oxygen. C also complained about SAS's handling of their complaint. SAS considered the assessment by paramedics was reasonable.
We took independent clinical advice from a paramedic. We found that while it was reasonable that paramedics did not administer oxygen, the paramedics did not follow the advice provided in the SAS Clinical Guidance for COVID-19 v5.0 guidelines, as A met the criteria for a referral to the Covid Hub and this was not considered by paramedics. We found paramedics did not appear to have considered or acted on warning signs for sepsis and there was no documented rationale for the decision to downgrade the NEWS2 score. We also found that the initial investigation and complaint response was lacking in detail and explanation.
As such, we upheld C's complaints.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology.
What we said should change to put things right in future:
- Patients presenting symptoms should be appropriately assessed, taking into account relevant SAS guidance. The presence of warning flags for sepsis, including NEWS2 scoring, should be appropriately assessed and acted on taking into account relevant guidance. If a decision is made not to act on warning flags or NEWS2 scoring in accordance with relevant guidance the reasoning for this should be recorded in the clinical documentation.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.