14. JRCALC guidance highlights the general considerations for paramedic crews, especially the focus on how to manage patients in the community, if that is what is appropriate.
15. Our paramedic adviser said when someone has had a fall, the two key questions for the crew are ‘were there injuries?’ and ‘what caused the fall?’.
16. We understand heart issues can be a cause of falls and note the crew did not do a 12-lead ECG to explore this. The evidence also shows Mr M’s blood pressure was low when they stood him up and this can be a potential sign something is wrong.
17. Based on this, we consider Trust staff did not do all the checks they should have done and there is a failing here.
18. Our paramedic adviser said the crew appears to have carried out a thorough assessment including muscular skeletal assessment and observations. They considered Mr M’s clinical frailty using the Rockwood clinical frailty scale and scored him an 8. This is a high Rockwood score, meaning the patient is at high risk of dying and susceptible to severe infection.
19. The paramedic on the phone was quite concerned about how long Mr M was on the floor and it was a further two hours before the crew got to him. We would have expected the crew to be aware of those concerns, in line with HCPC standards. They advise paramedics they must share relevant information, where appropriate, with colleagues involved in the care provided to a service user.
20. We can see from the records the paramedic mentioned Mr M had an unwitnessed fall. They said he was complaining of back pain but it was not clear whether this was linked to the fall. They noted he had been laid supine (on his back) for a long period, and had been unable to move for at least two hours.
21. All of this was relevant information and reflects the HCPC standards.
22. The Trust told us information from the paramedic’s phone assessment was passed to the crew via its mobile data terminal. It said this did not include the paramedic’s view Mr M may need to go to hospital for blood tests as they knew the crew would make their own decision.
23. We have considered whether the paramedic was right to be concerned. JRCALC says anyone who has experienced a long lie is at a higher risk of complications, such as rhabdomyolysis (a breakdown of muscle cells that can lead to kidney issues). Our paramedic adviser said it is likely this is why the telephone clinician advised the ambulance to attend under the impression Mr M would require blood (and urine) tests at hospital.
24. JRCALC says a patient who has been immobile over an hour is also at risk of dehydration and hypothermia which the crew seem to have considered. We know Mr G’s main concern is the risk of blood clots. JRCALC uses the Wells Criteria to assess this.
25. Based on Mr M’s history of surgery and immobility alone, our paramedic adviser said he would have been low risk for blood clots as he was not displaying any other obvious signs or symptoms (based on what the crew documented). That said, his history, high frailty score, recent surgery and being mostly bedbound is a significant risk factor for a deep vein thrombosis (DVT, a blood clot in a vein) or PE.
26. This in itself would not have justified taking Mr M to hospital. JRCALC says patients should be assessed on an individual basis. Our paramedic adviser said considering whether to transport Mr M was a more complex decision due to his clinical history and frailty.
27. On one hand, a frail person’s vulnerability can increase during a hospital admission. They can be susceptible to infections, like hospital-acquired pneumonia.
28. However, the decision not to transport him meant Mr M did not undergo a blood test and the Trust did not arrange a referral to follow-up on him either as we would have expected to see. It is not clear from the information documented at the time, whether the crew thought Mr M’s care package and physiotherapy input was sufficient not to justify further action. We consider this a failing.
29. We consider the lack of a 12-lead ECG and the crew’s lack of recognition about the potential impact of the long lie contributed to the decision not to transport him. The Trust assessed him and identified a risk, but then did not act on this when it attended to Mr M.
30. We asked our ED adviser about the impact of these failings. They explained if Mr M had been transported to hospital, it is likely he would have had blood tests for creatine kinase (CK) to identify and measure the breakdown of muscle tissue.
31. He might have had an X-ray of his back due to the tenderness he had there, but it seems unlikely he would have had any investigations that would have identified a PE. This is because it is common for patients who have undergone a hip operation to have a fall, and a PE would not have been suspected given his history and observations.
32. Our ED adviser explained even if the hospital had done a D-dimer test to detect a blood clot, it is likely staff would have considered the elevated result to be because of his recent hip operation. Therefore clinicians would not have identified the PE.
33. Based on the advice we have received, transporting Mr M to hospital would not have prevented him from dying.
34. We know we cannot change Mr G’s experience and he may remain concerned about whether the outcome could have been different. We hope our investigation provides some clarity about the care his uncle received and the likely impact of this.