13. Miss H complains the ambulance crew failed to recognise the seriousness of her mother’s condition and did not act fast enough to take her to hospital. She thinks the paramedics thought Ms G was drunk, because she had an alcohol dependency.
14. Miss H says the paramedics spent too long trying to get Ms G to eat a Mars bar to help her blood sugar levels, even though she could not sit up to eat. She says they also saw Ms G had vomited brown coloured liquid, which the paramedics described as ‘coffee ground vomit’ but ignored this and continued trying to feed her.
15. Miss H says the paramedics then put Ms G on a commode to take her to the stair lift because she could not walk. She says Ms G became unconscious at the top of the stairs and a paramedic said she was hypoxic (had low oxygen levels in the blood). They told Miss H to turn her oxygen compressor up to maximum and to get her DNAR document. Miss H says it did not seem right to turn her compressor up and getting the DNAR wasted time because the paramedics did not know how to take Ms G down the stair lift without her help.
16. 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.
17. When the ambulance crew arrived at 10.52am, Ms G was lying in bed on oxygen. It seems that Miss H reconnected Ms G to her home oxygen before the ambulance crew arrived. The crew observed that Ms G was confused.
18. The crew examined her airway, noting this was clear and they helped her breathing using a valve bag mask. This is a self-inflating bag used to give ventilation to a person who is not breathing normally. The crew noted her breathing had a good rise and fall with ventilation. They took her respiratory rate, which was 16, and noted she was making respiratory effort and had a wheeze. They noted Ms G said she had a productive cough and was producing brown/black sputum.
19. The crew documented that Ms G showed no signs of cyanosis (blue/grey skin or lips caused by a lack of oxygen in the blood or poor circulation) and took her oxygen saturations (level of oxygen in the blood). Her saturations were 94% on arrival while on home oxygen, at a rate of four litres per minute.
20. The crew documented that Ms G had low blood pressure, was pale in colour, did not have a high temperature and she said she was cold. The crew raised her legs and her blood pressure increased. The crew attempted to insert an intravenous line (IV) into Ms G’s vein to provide fluid therapy, but this was not successful.
21. The crew also checked her heart rate and documented that she had a fast-resting heart rate at 103bpm. It did an ECG (a test to record the electrical activity of the heart), took her pulse and documented that she was not clammy, not sweating excessively and had no chest pain. The crew then measured her consciousness using the Glasgow Coma Scale (GSC) and placed her at 14. The GCS is used to assess a patient’s level of consciousness. The highest possible GCS score is 15, meaning a patient is fully awake and responsive.
22. The crew found Ms G’s blood sugar levels were low and tried to get her to eat something to increase this, but she did not want to. The crew noted Ms G had reduced mobility, was unable to stand and said she felt dizzy sitting up. She had no headache, no seizure like activity, her eyes were open and reactive, and she was responsive to pain.
23. The crew documented Miss H told them Ms G had been vomiting all morning. It described her vomit in its notes as looking like ground coffee. They checked her abdomen, which was distended (swollen) but soft and tender in the centre and she had no pulsating masses. The crew documented it witnessed her drinking water and she did not seem drunk.
24. After taking these observations and actions, the crew put Ms G on a commode to get her to the stair lift, to take her to the ambulance. Once down the stairs, the crew observed her GCS had fallen to seven and her respiratory rate dropped to three. Ms G went into respiratory arrest and vomited blood. The crew used suction to clear her airway and gave her 15 litres of oxygen per minute and helped her ventilation using a bag-valve mask. Her oxygen saturation returned to 100% on oxygen therapy and Ms G was making some effort breathing herself.
25. In the ambulance, the crew tried to get IV access five more times to give fluids before going to hospital, but this was not successful. The crew took Ms G to hospital with blue lights and continued ventilation and suction on the way.
26. The evidence shows Ms G deteriorated at around 11.20am. The ambulance crew left her home at 11.52am and arrived at the hospital at 11.59am. The hospital assessed Ms G on arrival and made a plan for end-of-life care. Ms G sadly died in hospital at 12.25pm. We give our sincere condolences to Miss H and her daughter for their sudden loss.
27. The Resuscitation Council gives guidance on the primary survey approach emergency responders (paramedics) should take with deteriorating or critically ill patients. A primary survey is a survey that emergency responders use to detect and treat life threating conditions in order of priority. The ABCDE Approach is the most recognised primary survey approach.
28. First, clinicians should look at a patient to see if they seem unwell. Our adviser explains clinicians should form an initial impression of the patient through visual checks like appearance, alertness, position, colour and breathing and try to talk to them to assess their breathing. The severity of the patient’s initial presentation should guide the actions clinicians will take to assess and manage them.
29. The ABCDE Approach says clinicians should first check the patient’s ‘Airway’. They should look for signs of obstruction and if necessary, clear this using simple methods such as airway suction and opening manoeuvres and devices.
30. Clinicians should then check ‘Breathing’, looking for general signs of respiratory distress such as sweating, central cyanosis, use of the accessory muscles of respiration and abdominal breathing. They should count the respiratory rate, which should be 12 to 20 breaths per minute and assess the depth of each breath, rhythm of breathing, chest expansion and note any chest deformity and signs or sounds of abnormal breathing.
31. The ABCDE Approach says specific treatment of respiratory disorders depends on the cause. But, clinicians should give all critically ill patients oxygen. In patients with COPD, clinicians should give four litres of oxygen per minute at first and then reassess and aim for a target oxygen saturation of 88% to 92%. If their depth or rate of breathing is poor or absent, clinicians should use a bag-mask or pocket mask ventilation to improve oxygen supply and ventilation. In patients with a flare-up of COPD, non-invasive ventilation is often helpful. This involves wearing a mask and prevents the need for more invasive ventilation methods.
32. Clinicians should then check the patient’s ‘Circulation’, by checking their temperature, colour of their hands, appearance of their veins and measure their capillary refill time, pulse, blood pressure and heart sound. Clinicians should look for other signs the heart is not pumping enough blood, such as reduced consciousness.
33. Clinicians should also look for signs of external or concealed haemorrhage (the escape of blood from a blood vessel), insert an IV cannula and take blood for investigations before giving IV fluid. Clinicians should reassess the heart rate and blood pressure regularly.
34. Clinicians should check ‘Disability’, by reviewing the patient’s ABC’s, examining their pupils and making a fast initial assessment of their level of consciousness. This can be done using the GCS. Clinicians can give a patient a painful stimulus by applying pressure into the indentation above the eye, near the nose. Clinicians should also measure the blood glucose (sugar) levels and follow local processes for management of low blood sugar levels.
35. Lastly, ‘E’ in the ABCDE Approach refers to ‘Exposure’. This means a proper examination of a patient may require exposure of their full body. Clinicians should respect their dignity and minimise heat loss.
36. The ABCDE Approach says the ABCDE primary survey must be supplemented by a history of the patient’s presenting complaint and medical history from them, or relatives and friends present. The clinicians should consider which level of care the patient needs going into hospital and make complete entries in the medical records of their findings, assessment and treatment and the patient’s response to the treatment.
37. Our adviser explained in emergencies where a patient deteriorates into respiratory arrest (failure), a clinician may override the ABCDE guidance on how much oxygen to use and provide high flow oxygen, in line with the Oxygen guidance.
38. Oxygen guidance states if a patient’s blood oxygen levels fall below 85%, clinicians should give an initial oxygen dose between ten and 15 litres per minute until a reliable oxygen saturation level and vital signs are normal, then adjust the flow to aim for a target saturation level between 94% and 98%. But, where a patient’s vital signs remain abnormal, clinicians should continue to provide high flow oxygen using a bag-valve-mask until they arrive at hospital.
39. Glycaemic guidance also sets out what clinicians should do to manage low blood sugar levels. These state if a patient is capable, cooperative and safe to swallow, clinicians should first give them oral quick-acting carbohydrates. The guidance states chocolate should not be provided as this is slow acting. But, our adviser explained a Mars bar is a reasonable option to consider due to its added high-sugar content.
40. If clinicians cannot give oral sugars or these are not effective after three treatments, they can attempt to give IV glucose. But, our adviser explains it can be difficult to access a vein to give this in confused or agitated patients. Glycaemic guidance says glucagon can also be given into the muscle if oral or IV glucose is not possible. Glucagon is a treatment for severe low blood pressure. This may not be effective in patients who are not diabetic.
41. Our adviser says the most appropriate method to use for each patient depends on how low their blood sugar is, their overall presentation because of this and whether they can eat and swallow safely. If none of these treatment options are possible or effective, the patient should be taken to an emergency department for further attempts at IV access and to provide some type of sugar.
42. There is no formal guidance saying what an appropriate amount of time for ambulance crews to spend on scene with patients. The amount of time depends on each individual patient, their presenting condition and environment and the abilities of the clinicians who attend. Our adviser explains that in some cases it may be appropriate to delay travelling to hospital to provide critical interventions (treatment) because it is not usually safe to attempt these in a moving vehicle.
43. Our adviser added that coffee-ground-like vomit suggests potential bleeding within the gastrointestinal tract. They say this should alert clinicians to do a focussed abdominal assessment to find other features that may support this diagnosis, followed by going to hospital for further investigation and management.
44. On arrival at the scene the ambulance crew observed Ms G was confused in bed. Our adviser says her initial presentation of confusion suggested she was potentially seriously unwell. The crew took the correct action in doing a primary survey using the ABCDE Approach. It first checked her ‘Airway’ to make sure this was clear and helped her with ventilation.
45. The crew checked Ms G’s ‘Breathing’, the rhythm and sound of this, noting she was making some respiratory effort and had an audible wheeze. It looked for signs of respiratory distress such as cyanosis, took her respiratory rate and oxygen saturations and maintained her home oxygen, all in line with the ABCDE Approach. The crew also used a bag-valve mask to assist ventilation on arrival, which is appropriate for COPD patients experiencing flare-ups, and maintained her oxygen in line with the Oxygen Guidance.
46. The crew checked Ms G’s ‘Circulation’ by checking her colour, temperature, pulse, heart rate and blood pressure in line with guidance. It found she had low blood pressure and raised her legs to increase this. It found she was not sweating or clammy, had no chest pain and did an ECG. The crew could not insert an IV cannula but attempted this at the scene and again in the ambulance. The crew took appropriate action in line with the ABCDE Approach.
47. The crew checked for ‘Disability’, by examining her eyes and making sure she was responsive to pain. It assessed her consciousness using the GCS in line with guidance and documented she felt dizzy. It then took her blood sugar and found this was low. The crew completed the ‘Exposure’ stage by physically examining her abdomen. These actions are in line with the ABCDE Approach.
48. The crew’s medical notes show it took information from Ms G and Miss H about Ms G’s presenting complaint and medical history. The crew took Ms G to hospital and made complete entries in her medical records of its findings, assessment and her response to the treatment it provided. The crew acted in line with the ABCDE approach in gathering and documenting information and responding to it.
49. The primary survey suggested there were no immediate airway or breathing problems, a high heart rate, low blood sugars and confusion. Although it is not possible to know the definite cause of Ms G’s presentation, our adviser says based on these clinical features her main presenting problem seemed to be low blood sugar. This can cause high heart rate and confusion. The crew documented she did not look drunk, showing it did not think this was the reason for her condition.
50. The aim of initial treatment would have been to increase Ms G’s blood sugar levels. Although Ms G was confused, she was maintaining her own airway, was able to speak and was observed drinking water. So, initially encouraging her to eat a high sugar food is reasonable and in line with Glycaemic guidance which lists this as the first action to take.
51. The guidance says chocolate is not an effective option. But, the added high-sugar content of a Mars bar makes this a reasonable option in the circumstances, because the crew could not get IV access to give IV glucose. It seems this was difficult for the crew because Ms G was confused and agitated. Even when she deteriorated and was less responsive, the crew attempted IV access five times in the ambulance and this was not successful. This shows it would have been even more difficult when Ms G was more alert and confused.
52. The crew acted in line with Glycaemic guidance by trying to increase Ms G’s blood sugar first and this seemed to be the most appropriate method in the circumstances. When this did not work, the crew took Ms G to hospital for further treatment. We can see the crew were trying to take Ms G to hospital before she deteriorated.
53. When Ms G deteriorated, Ms H says the crew told her to turn Ms G’s oxygen compressor to maximum. It was appropriate to increase Ms G’s home oxygen to maximum, until the crew could ventilate her using a bag-valve-mask and high-flow oxygen because most home compressors only reach six to eight litres of oxygen per minute.
54. The crew then gave 15 litres of high flow oxygen per minute until her saturations returned to a reliable measurement at 100%. This is in line with the Oxygen guidance which states ten to 15 litres of oxygen per minute until a target saturation level between 94% and 98% is achieved.
55. The records show the crew spent one hour overall at the scene. The crew assessed Ms G on arrival, attempted to improve her blood sugars in line with guidance and tried to move her down the stairs. Ms G’s confusion and inability to stand and move independently will have caused some delay in moving her to the ambulance.
56. When Ms G deteriorated, the crew needed to take further action before taking her to hospital. Our adviser says if Ms G did not deteriorate during the movement to the ambulance, she would likely have been in the vehicle within 40 minutes of the crew’s arrival. Our adviser says this is not an unreasonable time to spend on scene given the actions the crew took before deciding to move Ms G.
57. Our adviser said the crew could have saved some time if it did not attempt to gain IV access five more times before driving to hospital. There is no formal guidance on how many attempts to make. This is guided by the severity of a patient’s presentation, the importance of the medication to be given and how close the hospital is. The crew used their clinical judgement.
58. Our adviser said the time the crew spent on scene overall was appropriate and although fewer IV attempts could have reduced this time, this almost certainly would not have changed Ms G’s sad outcome.
59. Overall, the crew visually assessed Ms G and took appropriate action by going on to complete a primary survey. It followed the ABCDE Approach to assess and treat her and provided appropriate glucose and oxygen treatment to manage her presenting problems. It then took action to take her to hospital within reasonable timescales.
60. The crew did not fail to recognise the severity of Ms G’s condition and to take her to hospital soon enough. There are no signs the Trust got anything wrong. For this reason, we will take no further action.
61. We are terribly sorry to hear about Ms G’s death and the distressing events that led up to this We hope our decision gives Miss H some reassurance that the Trust took appropriate action in line with guidance, when caring for and treating her mother.