Assessments and management of injuries
20. Mr O complains ambulance staff did not correctly assess and treat his injuries following his fall down the stairs. He says his arm was clearly broken but was not adequately supported, and this caused him pain. We are sorry to hear of the injuries Mr O sustained and the challenges he has since faced in his recovery. We understand this has been a very worrying time for him and his family.
21. The Trust said its crew treated Mr O’s arm fracture by applying a vacuum splint. A vacuum splint is like a cushion filled with air that is put around the injured body part. The air is then sucked out to tighten the splint in place to provide support. The crew also administered pain relief.
22. The Trust said the crew assessed Mr O for neck and chest injuries. It said the crew did not suspect any hidden injuries and they should have. It said the rest of the assessments and treatment provided were appropriate.
23. When assessing a person for injuries following trauma, the JRCALC guidance says a primary survey should first be done to identify whether a patient has a life threatening, time dependent injury. This involves checking the airway, breathing, and circulation. It says the spine should be kept immobile until it has been cleared.
24. Once the primary survey is complete, there should be secondary survey as appropriate. This includes a head to toe assessment, taking account of how the injury happened, to decide which areas of the body are likely to have been injured.
25. The records show the details of the primary assessment the ambulance crew carried out. This included assessing Mr O’s level of consciousness, pain score, respiratory rate, temperature, and blood pressure. Mr O was not assessed to have a life-threatening injury and so the crew carried out their secondary assessment.
26. Mr O had a graze to his head and some bleeding to his ear. This led to the crew assessing him for head trauma. The injuries identified were minor and did not require treatment.
27. Mr O was also assessed for a hip injury, and it is documented he had no pain and was able to move his legs. The crew also assessed his neck, back, chest, abdomen, arms, and shoulders. They also carried out a breathing assessment.
28. The crew recorded Mr O had no spinal pain, no hip pain, no shortness of breath, and he was able to move his legs. They documented he had a band of muscular pain across his shoulders and an obvious fracture to his left humerus (the bone of the upper arm). They noted his clinical history, and that he had drunk alcohol the night before.
29. Mr O and his daughter doubt if the assessments were done as documented in the records. They say Mr O was sat on the floor, leaning against a relative, and so the crew could not have checked his back as they should have. Miss O commented a crew member just touched his neck and said he had no fractures.
30. We understand that finding out how serious his injuries were on arrival to hospital must have been a shock for Mr O and his family. We can see this led to questions about how the crew missed these injuries. We have carefully considered the available evidence to reach a view on this.
31. To carry out a neck and spinal assessment, the JRCALC guidance says the clinician should use a light touch to check how this feels to the patient, and to assess responses to pain. The paramedic who assessed Mr O said they positioned themselves to be on level with him. No obstructions are detailed in them being able to carry out the assessment from this position.
32. The paramedic said they felt down Mr O’s spine from the base of his skull to the base of his spine. When Mr O did not report any pain, they asked him to perform head movements. The record confirms the assessment as, ‘c-spine clear, no spinal pain on palpation’. This means that when the paramedic pressed on Mr O’s spine, he did not report pain.
33. There is a consistency across all the accounts that Mr O was sat on the floor, at the foot of the stairs, which is the position he landed in after his fall. The records do not say exactly where the family members were stood.
34. Following careful consideration, we think the action to feel down Mr O’s spine, from the neck to the base, could reasonably have been done by a person crouching/ sitting on a level to Mr O, whether directly in front of him, or to one side. We also consider that even if a family member had been stood behind Mr O, this would not have necessarily blocked the paramedic from reaching to touch his spine.
35. We do not discount Mr O’s concerns, but from the accounts given by both parties, we are of the view that Mr O being seated on the floor would not have prevented the crew from completing their assessment. We consider the detail contained in the records of the assessments are persuasive and contain the information we would expect to see.
36. We have carefully considered Mr O’s questions about whether the ambulance crew could have appropriately assessed him. From the available evidence, we do not consider the actions documented by the crew are incompatible with how Mr O was positioned. We have therefore not seen reason to discount the records.
37. As set out above, the ambulance crew carried out several assessments to check Mr O for any injuries caused by his fall. They did not identify that Mr O was reporting any spinal or neck pain, and for this reason, did not have any concern that he could mobilise.
38. Our paramedic adviser has commented the ambulance crew did not appropriately assess Mr O because they did not consider he may have hidden injuries. The Trust also identified this through its investigation and confirmed Mr O should have been immobilised at the scene. We have considered this part of the complaint separately below.
39. Apart from the lack of consideration of hidden injuries, we consider the assessments the ambulance crew completed were appropriate, relevant, and carried out in line with the JRCALC guidance. Our paramedic adviser has said the records show they took a logical and thorough approach.
40. In terms of the treatment provided for the injuries identified by the ambulance crew, they saw immediately that Mr O had an injury to his left arm that was causing him pain. While carrying out their assessment, they administered Entonox for pain relief. Entonox is a gas a patient can inhale to relieve pain. It is reported that Mr O did not find this helpful, and this was stopped shortly after the crew finished applying the splint.
41. JRCALC guidance says pain relief is usually administered incrementally, starting with the use of one drug and checking its effectiveness. Mr O was given intravenous morphine when he boarded the ambulance. Morphine sulphate can be given to patients with severe pain, and choice of pain relief should be ‘guided by clinical judgement’.
42. Our adviser has commented that morphine can make a person drowsy and unsteady on their feet. This means it can make it more challenging to move them to the ambulance. If they are able to make it the vehicle before this is administered, this can be the better and safer option.
43. We consider the choices of pain relief, and the way these were administered, were appropriate and in line with JRACLC guidance. For this reason, we have no concern about the management of his pain.
44. Considering the crew’s decision to apply a vacuum splint to his arm, JRCALC guidance says self-splintage (a patient supporting the limb themselves), a sling, vacuum splint, or a box splint (a splint made a soft form that is wrapped around the injury) can all be considered as options for an injury to the humerus. The best option for an individual will be based on their circumstances and the clinical judgement of the crew.
45. The application of a vacuum splint falls within the guidance of suitable choices for supporting an injured humerus. In consideration of JRCALC guidance, we consider the decision to apply a vacuum splint was appropriate.
46. We are sorry for the distress Mr O and his family have told us they have suffered. We understand they have serious concern about the care Mr O received from the ambulance crew. Although the crew did not consider if Mr O could have hidden injuries, which we address below, we have not seen any other concerns in their assessment and management of Mr O’s identified injuries. We hope we have been able to clearly explain why we have reached this view and that this will bring some reassurance to Mr O.
Lack of immobilisation
47. Mr O complains he should have been immobilised for his journey to hospital. Miss O has told us she was shocked the ambulance crew did not do this. It has since caused the family significant concern as they have questioned if this made the injury worse and slowed Mr O’s recovery.
48. The Trust has agreed the ambulance crew should have immobilised Mr O and this was missed. It explained the indications for immobilisation were his distracting arm injury, his age, and that he had drunk alcohol in the hours before the accident. It did not consider the overall care he received had any impact on his injury or recovery but did acknowledge the distress he was caused.
49. NICE guidelines for spinal injury: assessment and initial management NG41 (NICE guidance NG41) say that when clinicians are assessing a patient for a suspected spinal injury, they should consider factors that include a significant distracting injury and if the person is under the influence of drugs or alcohol. If any of these factors are met, they should ‘carry out full in-line spinal immobilisation’.
50. The guidance also says that a person is at high risk for a cervical spine [neck] injury if there is a ‘dangerous mechanism of injury’. It describes this as a fall from a height greater than one metre, or five steps. If a person is at high risk of a cervical spine injury, they should be immobilised.
51. JRCALC guidance contains an immobilisation algorithm for clinicians to follow when assessing a patient for a spinal and/or spinal cord injury. Relevant to Mr O’s case, it says each of the following criteria should result in an ambulance crew immobilising the patient’s whole spine: • if they are under the influence of alcohol • if there has been a fall from a height of more than one metre or five steps • if the patient has a distracting injury.
52. When the crew first spoke to Mr O, they asked if he had recently drunk any alcohol. They documented he had drunk a moderate amount around four hours before his fall. Mr O told us he had two drinks before going to bed the night before and this had not affected him.
53. Our paramedic adviser has explained, the reason it is important to check if a person has drunk alcohol is because it can affect how drugs, such as pain medication, work in the body. This would need to be factored in when deciding on dosages. Alcohol can also affect someone’s perception of the pain they can feel. This could then impact how they are able to respond to questions about pain during assessment of their injuries.
54. Identifying that Mr O had drunk an amount of alcohol in the hours before his fall should have led to a greater suspicion for a possible hidden injury, and to Mr O being immobilised, but this did not happen.
55. In terms of how far Mr O fell, the emergency call records say a family member said he had fallen ‘about seven or eight steps’ and had managed to come down the last two on his buttocks. The record made by the ambulance crew from the time of events says he fell approximately seven steps.
56. A later report, documented by the crew member, says Mr O told them he was about half way down when the incident occurred and he ‘descended approximately 7 steps on his back/ buttocks’.
57. When Mr O was assessed in hospital, he was triaged as suffering a major trauma with a ‘significant mechanism of injury’.
58. NICE guidance NG41 says a person being age 65 or older is a high-risk factor for a cervical spine injury. Mr O was 64 at the time of events, and so he does not quite meet the age criteria for being high risk. However, our orthopaedic adviser has commented that it would not be uncommon for a person Mr O’s age to have degenerative changes to his spine. This refers to the gradual wear and tear to the structure of the spine that can be caused by aging.
59. The Trust’s own investigation identified there should have been a higher suspicion of injury because of Mr O’s age. Even if the crew had determined he had a low impact fall, such as slipping down the steps rather than falling, an older adult is more prone to suffering a more serious injury in such circumstances.
60. From what is documented, the evidence supports Mr O had fallen at least five steps, even if he did manage to catch himself and soften the force of his fall for the final few steps. We consider the crew should have been more alert to the possibility of hidden injury caused by his fall, and the extra impact his age could have caused.
61. The ambulance records document the crew saw Mr O had an ‘obvious’ arm injury and this was causing him significant pain. This was a distracting injury. A distracting injury can affect how reliably a patient is able to respond to assessments of pain in other areas of their body. This should lead to consideration of other hidden injuries.
62. When assessing Mr O for injuries, particularly to his spine and neck, we consider the ambulance crew should have been alert to the criteria identified above. Mr O met three criteria for immobilisation, as set out in both in NICE guidance NG41 and JRCALC guidance. He had recently drunk alcohol, had fallen at least five steps, and had a distracting injury.
63. The crew did not consider these factors and did not immobilise Mr O for his journey to hospital. This was a failing in care. We have considered how Mr O says this has affected him, and the actions the Trust has since taken to address this.
64. Mr O has told us the Trust’s response has not been helpful because it made him feel like he has been a guinea pig. He says his care should have been right first time. Since the accident, his life has changed. He’s had to make alterations to his house to help with accessibility. He used to be very active, and now he struggles to leave the house. He cannot walk his dog up and down the hill he lives on, like he used to.
65. We are very sorry to hear of how Mr O has struggled with his mobility since his fall and how this has affected his day to day life. We understand this must be difficult for both his physical and emotional wellbeing.
66. On arrival to Hospital A, the ED team identified he had four fractured bones in his neck, seven fractured rib bones, a punctured lung and a fractured humerus. The extent of Mr O’s injuries meant he needed treatment at a major trauma centre, and he was transferred to Hospital B that afternoon.
67. We have considered if the care provided by the ambulance crew made these injuries worse and if this affected his recovery. To help us reach a view for this, we spoke to an orthopaedic adviser. We have also reviewed the assessments and treatment he had in hospital.
68. Immobilisation typically consists of a person being fitted with a hard collar and blocks taped to either side of the head to prevent movement of the neck. The patient will also be put on a backboard to protect the rest of the spine and keep it in alignment.
69. Our orthopaedic adviser has explained that Mr O had an unstable neck injury following his fall. Immobilisation stabilises the injury and prevents any further damage on the way to hospital. It stops the spine from moving any further, or a fracture further displacing. It helps prevent spinal cord or nerve issues developing, that could result in neurological problems.
70. The records do not show us exactly how Mr O’s spine was injured immediately after the fall, and before he was tested in hospital. To see if it is likely that the Trust’s failure to immobilise Mr O affected his injury, our orthopaedic adviser compared the ambulance crews’ assessment to the assessments carried out in hospital to see if there was a difference.
71. The ambulance assessment and hospital assessments show little difference in Mr O’s condition. They do not show any indication that Mr O’s injury was worsened by not being immobilised. There was no sign that, for example, he could move his limbs when the ambulance crew assessed him but could not by the time he reached hospital. There is also no evidence that he developed symptoms of neurological injury such as tingling or weakness in his legs during the journey.
72. Having considered the evidence, on balance, we think it is unlikely Mr O’s spinal injury was worsened by not being immobilised. This means it is likely Mr O’s difficulties with recovery and mobility would have been the same even if he had been immobilised for the journey to hospital.
73. Mr O required treatment and a period of care to treat his injuries, and we are sorry to hear of how distressing this has been for him and his family. We have not seen cause to conclude the Trust’s actions affected this. We hope our explanation of how we have reached this view will bring some reassurance to Mr O and his family.
74. Mr O has also said the lack of immobilisation caused him to suffer additional pain which meant he had to have increasing pain relief. When describing his journey to hospital, he said he was allowed to sit up on the stretcher in the ambulance and his arm was free to bang against the railings as the vehicle moved. We are sorry to hear this was painful for him.
75. Mr O should have been lying down and immobilised for the journey. While it is understandable that Mr O was in pain because of his injuries, if he been immobilised, this would have confined his movements. Our orthopaedic adviser has said this would likely have helped to reduce the acute pain he was suffering. It follows that the added pain caused by this lack of immobilisation meant Mr O needed greater pain relief.
76. We understand Mr O has also suffered a psychological impact from what took place and has flashbacks about what happened.
77. We cannot link the full emotional impact Mr O has suffered to the ambulance crew not immobilising him because the fall itself was a traumatic event. However, while we cannot link the lack of immobilisation to Mr O’s physical recovery, we appreciate the care he received has since caused him a period of distress, worry, and uncertainty as he has questioned how things could have been different.
78. In its investigation of this case, the Trust considered what could have caused the error. It identified that the JRCALC pocket book that crew can carry with them does not have the full guidance for assessing spinal injuries that is on the online JRCALC app. The app is not currently available on its computer devices, but it can be looked up on a smart phone.
79. The ambulance crew who attended to Mr O accepted that they made a mistake, and we can see they fully cooperated with the Trust’s investigation. The crew has since undergone learning and we have seen detailed reflection that includes reference to relevant national guidelines. The error may have been due to a gap in training, and we are reassured to see this has since been addressed.
80. While there has been appropriate individual learning, the Trust’s complaint response did not explain any wider learning it made from this complaint. the Trust has since told us that following Mr O’s complaint, it rolled out a ‘frail and injured person’ pathway. This allows its crew to seek guidance when they have concern about injuries an older person has sustained. It has also made sure its staff are referring to the JRCALC app for the most up-to-date guidance when assessing patients.
81. The Trust has not yet informed Mr O of these improvements or explained what difference these will make. We will ask it to do this so he can be assured of the difference his complaint has made to the Trust’s service.
82. Mr O seeks an apology as an outcome for his complaint. We can see the Trust has apologised that he was not immobilised and has acknowledged the emotional impact this has caused. However, it has not acknowledged the additional pain Mr O experienced. Mr O also seeks a financial payment to compensate him for the impact he suffered due to the mistake made in his care.
83. We have set out our recommendations below. We have made these in recognition of the actions the Trust has already taken, and what more it should do to put matters right.
Summary
84. The decision not to immobilise Mr O when transporting him to hospital does not meet the standards set out in NICE guidance NG41 or JRCALC guidance. This was a failing in care. We have not seen any other concerns with the assessments or treatment the crew provided.
85. We are sorry to hear how Mr O has struggled with his recovery, and the emotional impact these events have had on him. We consider the failing in care meant he suffered increased pain during the journey, and distress, worry, and uncertainty about how the care he received could have affected him. We hope the recommendations we have set out below will help bring some resolution to his concerns.