14. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong.
GCS assessment
15. Mrs A and her family say the crew did a GCS assessment but it was not done properly because it does not reflect their memory of Mrs A’s consciousness at the time. They say she was incoherent and whimpering when the first 999 call was made. Mrs A’s husband says she was talking ‘gobbledygook’.
16. The PRF states that Mrs A was sat in bed, eating and drinking as normal, with good colour but shaking, feeling unwell and beginning to panic. The PRF states she had a GCS score of 15 points out of 15. A score of 15 means the patient is fully awake, responsive and has no problems with thinking ability or memory.
17. Our adviser said it is possible that between the time of the 999 call and the time the ambulance crew arrived, Mrs A’s condition may have temporarily improved slightly. This could explain some of the difference between the family’s account of Mrs A’s condition and the clinical observations.
18. We asked our adviser if the family’s account and the first 999 call match the GCS recorded on the PRF.
19. They explained that GCS is calculated by a trained clinician assessing the patient’s eyes, verbal, and motor responses to different stimulation.
20. The GCS measures physical, eye and motor stimulation and the overall score is based on those responses. Mrs A was clearly very unwell when her family phoned 999 and we appreciate why the family were surprised that her GCS was high.
The GCS at the time of attendance was supported by clinical observations and it is likely that the GCS score was accurate.
21. Our adviser confirmed the altered level of consciousness guideline in the JRCALC guidance says, ‘only patients with a GCS 15, with normal blood glucose and responsible adult supervision’ may be left at the scene, which is what happened in this case.
22. We have seen no sign of failings with the crew’s GCS assessment.
NEWS2 and hospital admission
23. Mrs A and her family complain the first ambulance crew did not properly assess her using NEWS2. The family point to the fact the NEWS2 box on the PRF was left blank with no score calculated, so they feel the NEWS2 assessment was not done.
24. The Trust recognised the box should not have been left blank. It apologised and said it fed this back to the crew. The Trust says the correct assessments were completed and a NEWS2 score of two was calculated from the first observations (8.01am) and a score of one after the second observations (8.25am).
25. Our adviser explained that a NEWS2 score comes from these clinical observations, which are noted on the PRF: • respiratory rate (breathing rate) • oxygen saturations (the balance of oxygen levels in the blood) • pulse • temperature • blood pressure • conscious alert level • whether or not supplementary oxygen was given.
26. A score of zero to three is given to each. Zero is within the healthy range and three suggests urgent intervention is needed. The values are added together to give the overall NEWS2 score. The overall NEWS2 score alerts clinicians of how serious a patient’s condition is and helps them decide what to do.
27. As the medical records detail all the necessary observations, this is how the Trust could be sure of the NEWS2 score without the box being filled out. The clinical observations were recorded on the PRF.
28. The first ambulance crew did two sets of observations. What we have seen in the medical records matches with the NEWS2 score the Trust stated. Information from the JRCALC guidelines and the clinical observations recorded on the PRF show the NEWS2 score calculated by the first ambulance crew was correct. Even if the NEWS2 box on the PRF was filled out as it should have been, the conclusion would have been no different.
The second ambulance crew performed multiple sets of observations. The first set resulted in sepsis diagnosis and hospital admission. The overall score was 12.
29. JRCALC guidelines say NEWS2 is a tool for clinical assessment, to be used with other tools and good clinical judgement. It is designed to identify seriously ill patients and how urgently their care needs to be escalated (a higher score denotes more urgency to be seen by a doctor). It does not diagnose the cause of an illness.
30. At the time of the first assessment, Mrs A was categorised as having a low risk of being critically unwell.
31. We can see that there was a mistake in that the ambulance crew did not complete a box on their documentation. But, the crew did take the right actions and the results were that Mrs A did not need to go to hospital.
Sepsis red flags
32. We asked our adviser if there was any sign of sepsis (red flags) when the first ambulance crew attended and what the signs of suspected sepsis are.
33. JRCALC states:
‘Suspect sepsis in: • anyone that presents with fever/feeling unwell and • NEWS2 greater than or equal to 5 and/or • looks unwell with history of infection’.
34. Our adviser said Mrs A met the first point because she had a fever and clearly felt unwell. She did not have a NEWS2 of five or more, so did not meet that point. She did have a history of infection because she had an ear infection and had begun treatment the night before. Our adviser could not comment on how Mrs A looked at the time.
35. The paramedic’s statement says:
‘On first impressions of [Mrs] A she appeared to be of good colour, able to communicate effectively, no evidence of “gobbledygook”. She was breathing as normal, able to talk in full sentences with no evidence of increased work of breathing.’
36. Our adviser said this information does not suggest she looked obviously unwell. This means that Mrs A did not fully meet the ‘looks unwell with history of infection’ part of the criteria. Because of this we cannot say the crew should have suspected sepsis or that its decision not to take her to hospital was wrong.
37. Sepsis can come on quickly with little warning. While there was not a clear sign to suspect sepsis this does not rule out that it could develop later.
38. Our adviser said although the Trust decided not to take Mrs A to hospital, the first ambulance crew correctly ‘safety netted’ her. Safety netting is the practice of giving advice on what to do if a patient’s condition gets worse. The PRF said the crew advised Mrs A she should continue her ear infection medication, take paracetamol for the fever and importantly call 999 if there were any concerns.
39. The PCR from the second ambulance crew shows Mrs A’s condition had deteriorated since the first ambulance crew had left. The second crew did four sets of clinical observations showing NEWS2 scores between 11 and 12 and a GCS score between seven and eight. As well as this, Mrs A had started vomiting.
40. These NEWS2 scores with the history of infection would have been enough to suspect sepsis using the JRCALC advice above, so Mrs A needed to go to hospital. The second PCR shows the crew suspected Mrs A had sepsis.
41. The first crew’s safety netting advice worked because when Mrs A’s condition worsened and the family were concerned, they phoned 999 and a second ambulance crew came and admitted her to hospital.
42. Our adviser highlighted JRCALC guidelines that say pre-hospital screening tools are used to advise on outcomes, but specific tools are agreed locally by individual organisations, or across regions. We got the sepsis recognition tool used by the Trust to help our investigation.
43. The sepsis recognition tool is a flow chart with a statement followed by a ‘yes’ or ‘no’ option, which then leads to another statement. The first step states screen patients where infection is suspected and they have a NEWS2 score over four, or three in a single category.
44. As explained before, Mrs A did have an infection but did not have a NEWS2 score as high as four during the first ambulance visit. The next relevant step of the tool is to follow ‘standard treatment and management pathway’ which is what the ambulance crew did with their safety netting advice.
Lies in the complaint response
45. Mrs A and her family believe the Trust’s investigation contained lies to cover up the mistakes of the paramedics.
46. As discussed above, although the NEWS2 box of the PRF was not filled out as it should have been, the observations needed to calculate the NEWS2 score were recorded. We have not seen evidence the investigation lied to cover up mistakes.
47. While we appreciate it would have caused some concerns, failing to fill in a box on the relevant form is not evidence of not doing the relevant clinical observations. As the Trust responses are consistent with what we are seeing we have found no sign of lies or a cover up in the Trust’s complaint handling.
48. We understand this may not be the outcome Mrs A and her family wanted but we hope we have clearly explained our decision.
49. We hope our findings give some assurance to Mrs A and her family that paramedics did not fail to properly assess her or to give her the right treatment at the right time.