15. Mrs O says ERS did not alert her or take any further action when her mother failed to answer the door when they arrived to take her to hospital.
16. ERS says it cannot confirm anybody contacted the hospital when Mrs A failed to answer the door. It says the crew was unaware the appointment was for an urgent blood transfusion or there was a key safe at the property as this was not on the booking form. It says the correct process when a patient does not answer is to try and call them, and in this case, there was no answer, so the journey was aborted. In hindsight, ERS says the control team could have highlighted the no reply to Mrs O’s husband when they called him, which may have prompted the key safe information and alerted them to the possibility of a fall.
17. The booking form shows transport was booked with ERS on 7 December 2021 to take Mrs A to the cancer centre at the hospital on 10 December at 10am. The form stated Mrs A was neutropenic (low number of white blood cells) and she was a palliative cancer patient. It also stated she was traveling alone, used a walking stick and was covid-19 negative. Poor mobility and low immune system are also ticked on the form.
18. The crew arrived at the agreed time and knocked on Mrs A’s door. Mrs A had fallen and was unable to get to the door to answer it. The crew contacted the control team, who called a number on the booking form. They got through to Mrs A’s son in law (Mrs O’s husband) and asked to speak to Mrs A. Mr O informed them they had the incorrect number and provided the correct number to reach Mrs A. The control team then tried to call Mrs A but there was no answer. The control team aborted the journey and the crew left Mrs A’s property.
19. Mrs O went to her mother’s house the following morning, after she was unable to reach her by phone. She found her mother on the floor, having fallen and injured her right arm/shoulder. She called an ambulance and paramedics took her mother to hospital.
20. The ERS crew member provided a statement as part of its investigation. They said they remember getting no reply to knocking so they contacted control. They could not remember exactly what control said but they did advise them to abort the run. The crew member says they were not aware of reason for the hospital visit and they did not see a key safe at Mrs A’s property.
21. As the staff involved were Ambulance Care Assistants, the national guidance that applies to Paramedics and other grades of ambulance staff is not applicable. Ambulance Care assistants have no regulatory body. It would be normal for a company commissioned to provide a transport service, such as ERS, to have a policy that advises what actions to take if no-one responds to the door when a crew arrive for a booked journey. ERS has not been able to provide us with a local policy which would have been in place at the time of events, although it has since introduced a policy which we refer to later in the report.
22. Mrs A was a palliative cancer patient and this information was recorded on the booking form. Our paramedic adviser says the expectation is the crew would act in the patients’ best interests and contact control who would advise them what to do. Whilst the crew did report to control, there appears to be little follow up or an appropriate plan of action, other than to abort the journey. As above ERS contacted Mr O as his number was on the booking form. Mr O provided a contact number for Mrs A but she could not answer the phone when ERS tried to call her because she was on the floor. Mrs O says ERS did not mention on the call to her husband that Mrs A had not answered the door or that there was an issue. There are no notes in the records of this call.
23. Whilst ERS has not been able to provide us with a policy in place at the time, we can see its current policy says ‘every attempt should be made to contact the patient or ascertain why the patient is not answering their door. This could include phoning, calling, and looking through windows and letter boxes. If in any doubt the crew should seek immediate assistance and inform their control. If necessary 999 may need to be called’.
24. ERS could have phoned the ambulance service or the police for assistance/additional knowledge and the crew could have waited at Mrs A’s property until they had means of access. The emergency services could also have potentially passed on the key safe information. Our paramedic adviser says the onus was on ERS to keep trying to make contact with the patient or a relative. Other than the brief call to Mr O, it does not appear the ERS control room made any further attempts to contact Mrs A’s family to advise that there was no response, and that they would be aborting the journey. There is no indication from the notes ERS considered calling 999 for assistance and/or attempted to look through the windows or letterboxes.
25. We consider ERS could have done more to ensure Mrs A had not come to any harm before they decided to abort the journey. When the crew established Mrs A was not answering the door or her phone, they should have taken additional action by either calling Mr O back or seeking support from the control room to gain access or contact the emergency services. ERS acknowledge it could have alerted Mr O to the ‘no reply’ when they spoke to him on the phone, and it did not contact the hospital. Had ERS taken further action, on the balance of probabilities, Mrs O would have been alerted that her mother had fallen sooner, and she likely would not have been on the floor for such an extended period of time. We will further explore the impact below.
Impact:
26. Mrs O says her mother was left on the floor all night following her fall. She says her mother was highly distressed when she found her the following day and she was embarrassed having been incontinent due to being stuck on the floor. She says her mother was admitted to hospital and was there for an extended period and was never the same again. She says her mother’s health never really recovered and this incident set off a chain of events, culminating in her mother’s death.
27. On 11 December 2021, the Paramedics took Mrs A to Hospital A. She complained of pain in her right arm/ shoulder. Mrs A was admitted to hospital and the notes show treating clinicians diagnosed her with neutropenic sepsis. An X-ray showed Mrs A did not have a fracture to her arm/shoulder.
28. On 28 January 2021, Mrs A’s care was transferred to Hospital B for further rehabilitation. On 6 February 2021, Mrs A was transferred back to Hospital A with possible sepsis.
29. On 29 March 2022, Hospital A discharged Mrs A home, but she was readmitted again on 5 April 2022. The treating clinicians decided Mrs A was sadly for end-of-life care and prescribed anticipatory medicines. Mrs A very sadly died on 27 April 2022
30. On admission to hospital, clinicians diagnosed Mrs A with acute conditions including infection and a right shoulder injury. The exact circumstances of Mrs A’s fall are uncertain as she was unable to recall the incident and provide details of events surrounding her being found.
31. As the fall was not witnessed and Mrs A could not recall what happened, it is not possible to say when or in what circumstances it occurred or exactly how long she spent on the floor before Mrs O found her. The clinical presumption was she had fallen and lain for some time on the floor. Our physician adviser says this presumption is supported by evidence of trauma from a fall as Mrs A had a soft tissue injury to her right shoulder. Mrs A’s creatine kinase blood test was also high which is an indication of muscle damage and evidence of a prolonged time lying on the floor.
32. The treating clinicians at Hospital A initially treated Mrs A for an infection. Our physician adviser explains infection could be a cause or consequence of a fall, and both are plausible here. Whilst it is possible for infection to develop as a result of lying on the floor, Mrs A’s blood disorder and frailty also put her at increased risk of development of a community acquired pneumonia at any time which could also lead to an increased risk of a fall. Mrs A also had a PICC line (a long tube fitted in a vein to give intravenous treatments such as blood transfusions) in place which is a potential source of infection.
33. The recognised complications of a long lie include dehydration, pneumonia, pressure sores, hypothermia and muscle breakdown (rhabdomyolysis) leading to kidney damage. As discussed above, the treating clinicians treated Mrs A for an infection but there was no evidence she experienced any of the other recognised complications of a long lie. She did not appear to have significant dehydration and her kidney blood tests were not impaired. Clinicians did not document any significant pressure damage, she had a normal body temperature on admission, and there was no deterioration in her kidney function over the following days that may be seen with rhabdomyolysis.
34. Mrs A sadly died just under four months after the fall and long lie. The most prominent clinical complications Mrs A experienced from the episode were related to infection. Mrs A clearly was very frail alongside having significant medical comorbidities (including her blood cancer, liver cirrhosis, pulmonary fibrosis and aortic valve stenosis) that put her at high risk of deterioration. There is no indication the fall and the long lie were contributing factors to Mrs A’s deterioration and sad death. Mrs A experienced recurrent infections and anaemia related to her blood cancer, for which a purely palliative approach was taken in the days leading up to her death.
35. We are very sorry to hear what happened and appreciate it was an extremely upsetting and stressful experience for Mrs O and her mother. We cannot say whether the infection Mrs A had when she was admitted to hospital was a cause or consequence of the fall. We consider it is unlikely these events had an impact on Mrs A’s overall clinical deterioration in the lead up to her sad death. We recognise these events understandably caused distress to Mrs O and her mother at the time.
36. In its complaint responses, ERS apologised for the distress caused by this incident. It says the control team management have highlighted this incident as a point of learning and there has been a working action to improve communication and the audit trail of escalations that have taken place. It says all control team members have received coaching regarding the communication process and it remains a monitored area of focus for the management team, and it has now raised the process of attempting contact with neighbours for review by the Senior Operational Management team. As set out above, the current policy now clearly sets out what should happen when there is no response to a booked journey.
37. NHS complaints standards say ‘wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned and ‘organisations should take action to make sure any learning is identified and used to improve services’.
38. Although we have not found what happened had an impact on Mrs A’s clinical deterioration, we recognise this caused distress to Mrs O and her mother. ERS have acknowledged it could have done better and has apologised to Mrs O for the distress this caused. We are also pleased to see ERS has taken learning from Mrs O’s complaint, and it has taken actions to improve its services. As the failings we identified did not have a wider clinical impact, we consider the action ERS has already taken is in line with the NHS standards and enough to remedy what went wrong.
39. Whilst we do not uphold the complaint overall, we recognise how important this complaint is to Mrs O. We thank her for bringing her complaint to us for consideration.