Decision Report 202209883

Summary

C complained about the care and treatment that their spouse (A) received from Scottish Ambulance Service (SAS). C called for an ambulance after A fell from a height at home. A was assisted to their feet after an initial check and then walked to the ambulance for further checks. After returning to the house, A became pale and reported a brief loss of sight. It was decided A should be transferred to hospital where they were later diagnosed with a broken pelvis.

C said that one of the crew members was rude and dismissive when they had tried to describe the height A had fallen from. C complained that SAS had not fully assessed A, failed to consider the accounts given by eyewitnesses and unreasonably concluded that A could remain at home and take painkillers. A was clear that they did not want to go to hospital, however, C considered the crew failed to recognise A was in shock.

In responding to the complaint, SAS advised that a full assessment had been carried out. It was also noted A did not initially wish to be transferred to hospital and had declined to be immobilised on a spinal board. The response advised of actions for learning and improvement which would be taken with the crew in response to C’s complaint. This included actions in relation to the mechanism of injury (in this case a fall from height), moving and handling, consideration of silver trauma (the impact of trauma on older patients), and communication with patients and relatives.

C was unhappy with this response and brought their complaint to us. We took independent advice from a senior paramedic adviser. We found that SAS failed to undertake a reasonable assessment of A as they did not act in keeping with the Joint Royal College Ambulance Liaison Committee guidance on Spinal and Spinal cord injury. In particular, there was a failure to immobilise A at the scene given the mechanism of injury. We also considered that SAS failed to reasonably document the incident, consider A’s age and the effects of ‘silver trauma’ and to correctly calculate the National Early Warning Score. SAS did not document any discussion about the risks/benefits associated with immobilisation or fully record A’s reported initial refusal to comply with treatment or to be transferred to hospital. Finally, we noted a failure to document a pain score before and after analgesia had been given. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to provide a reasonable standard of care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The patient record should be completed in full to reflect the presenting condition/mechanism of injury; the assessment and observations undertaken including NEWS, pain score, the accounts of eye witnesses and consideration of other relevant factors such as age; and the patient’s decision regarding treatment and the information shared to inform this decision.

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.