16. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen.
17. The HCPC standards say paramedics must:
• ‘know the limits of their practice and when to seek advice or refer to another professional • be able to work safely in challenging and unpredictable environments, including being able to take appropriate action to assess and manage risk • understand the need to respect and uphold the rights, dignity, values, and autonomy of service users’.
18. When the Trust investigated Mrs P’s complaint it fully accepted it had made a mistake. In its complaint responses it said it was not appropriate for the paramedics to move Mr P in the way they did. It said dragging him on a duvet and allowing him to go downstairs on his back lacked dignity and there were safer ways for him to be moved.
19. It explained a scoop was available and the paramedics should have used it. It also said if the paramedics thought obstacles in the home were stopping them from moving Mr P safely, they should have asked for specialist support from the Trust’s evacuation (EVAC) team.
20. The Trust explained the EVAC team give specialist support in difficult environments and have access to specialist equipment. This could have allowed Mr P to be moved in a safer and more dignified way. The EVAC team can also call for support from Fire and Rescue services when needed.
21. Based on the Trust’s explanation we consider the paramedics actions were not in line with the HCPC guidance. The paramedics did not get advice when needed, they used unsafe methods to move Mr P and did not uphold his dignity. This is a sign that something went wrong.
22. If we see signs that something went wrong, we look at whether this had a negative impact which the organisation has not put right.
23. Mrs P explained the Trust’s actions were upsetting. Her husband felt degraded and she felt helpless. We are sorry to hear this and we understand why it sadly made them feel this way.
24. Mrs P also says this experience meant her husband would not call for an ambulance when he became unwell at home on 3 February. His children travelled an hour to get to him and take him to hospital. Mrs P says this delayed Mr P getting the hospital care he needed. Mrs P thinks that if there had not been this delay, her husband may have survived or lived longer. She says this made her grief worse.
25. We understand why Mrs P has this worry. We thought about this carefully and we have not seen any signs to suggest that if the Trust’s earlier mistakes had not happened, the outcome would have been different.
26. It is possible Mr P could still have had a challenging and upsetting experience that would put him off calling for an ambulance again, even if the paramedics had requested EVAC support on 17 January. His experience would not have been undignified, but there may have been a long, uncomfortable wait for EVAC support, or the equipment used could still have caused feelings of helplessness and distress.
27. We also think that if Mr P had called an ambulance on 3 February, it may have taken just as long to get him to hospital because of waiting times or if there was a wait for EVAC support.
28. We cannot see any signs the mistakes on 17 January were the reason Mr P’s medical care was delayed on 3 February, or that it became a factor in his death. We do recognise this experience damaged his confidence in the ambulance service and left Mrs P with questions about the impact this had on her husband’s death, which added to her grief.
29. Our Principles say organisations should take steps to put things right when they make a mistake. We looked at whether the Trust has taken steps to put right the impact of its actions. When doing this we considered the specific outcomes Mrs P said she wanted to achieve by making the complaint.
30. Firstly, Mrs P told us she wants there to be a Trust funded publicity drive to improve the general public’s knowledge of the extra resources available. She feels people should know that services like EVAC exist and it should not be only paramedics who know.
31. We could not achieve this if we investigated the complaint further. A member of the public would not be able to request these specific resources. It would be up to the ambulance service to decide. In this case, the failing did not happen because of a lack of public awareness. These resources were available, but the paramedics wrongly chose not to use them.
32. This links with the other outcome Mrs P wants. She wants the Trust to make improvements to make sure these resources are used as soon as they are needed so the same mistakes are not repeated.
33. In its responses to the complaint the Trust provided a detailed explanation of what should have happened and the type of support the EVAC team could have given. It fully accepted what went wrong and the upset and concern this caused. It apologised to Mrs P ‘wholeheartedly and without reservation’ for the ‘upsetting and undignified experience’.
34. We can see this mistake happened because of an issue with the two paramedics. The Trust has addressed this with the paramedics involved so they can learn from it, and the paramedics reflected on what happened.
35. The HCPC guidance says reflection is an important part of clinical practice and part of a clinician’s continuing professional development. Reflection allows a clinician to analyse their practice and identify ways to improve.
36. We think the Trust has done enough to put right what happened in line with our Principles. We do not need to investigate this further or ask the Trust to do anything more.
37. We recognise how much Mrs P was affected by what happened to her husband. We hope this statement gives her some reassurance and helps her see how the Trust has taken this seriously and aims to improve.