Ambulance Trust 17. Mr P has concerns the ambulance Trust caused delays in treatment and handing over his father to the hospital Trust. He also has concerns the ambulance Trust did not carry out the appropriate tests and treatment, specifically an abdominal examination.
18. The ambulance Trust has acknowledged it did not carry out an abdominal examination but says it wouldn’t have changed the outcome.
19. The JRCALC guidelines are applicable here. They set out in an emergency to assess the history of the presenting complaint, details of when the problem started, exacerbating factors and any previous similar episodes. They explain the patient history can provide valuable insight.
20. The JRCALC guidelines also set out after initial observations and an assessment of the patient’s critical status has been made, a secondary assessment should be carried out. This is a more thorough assessment of the patient. The guidelines say it is important to monitor the patient’s vital signs during this assessment.
21. There is guidance within JRCALC which is also applicable depending on the patient’s presenting condition. For example, for gastrointestinal symptoms such as abdominal pain, the guidelines say to auscultate (listen to the sounds from the body e.g. heart or lungs), percuss (press) and palpate (physical examination).
22. The NEWS guidance is also applicable here. NEWS is a tool developed by the RCP, which improves the detection and response to clinical deterioration in adult patients. It is a key element of patient safety and recognising when someone is becoming increasingly unwell.
23. It is a scoring system where a score is given to physiological measurements. There are four trigger points within the NEWS scoring system. A NEWS of one to four is classed as ‘low’ clinical risk. A key trigger threshold would be a score of five to six. The next key trigger is a score of seven or more.
24. The paramedic recorded Mr B had suffered mild abdominal pain and fainted. He was short of breath and clammy. The paramedic carried out baseline observations. This is the initial set of vital signs taken when a patient is first assessed, for example heart rate, blood pressure and temperature. A full set of observations were taken, and Mr B’s NEWS was two.
25. Following this, the paramedic took an electrocardiogram (ECG), a test that records the electrical activity of the heart. This is to show whether the rhythm is steady or irregular. The ECG was sent to the primary percutaneous coronary intervention (PPCI) ward at the hospital. Staff on the PPCI ward at the hospital reviewed the ECG and advised it did not show Mr B would be suitable for the ward and advised to go to ED.
26. The JRCALC guidelines outlined above indicate at least two sets of observations should be taken and documented. The records show only partial observations were taken, with no further blood pressure readings recorded.
27. The Trust says in its complaint response the paramedic could not take further blood pressure readings as Mr B was too restless. This is not recorded in the medical records. Our adviser recognises when using an electronic blood pressure cuff, if blood pressure is very low the cuff may not be able to take a reading. It is also possible Mr B was restless, and his blood pressure could not be taken due to agitation.
28. Our paramedic adviser explains there are other checks a paramedic can do to try to understand if a patient’s blood pressure is very low, for example taking a pulse on the wrist to see if there was a systolic blood pressure of above 90. If a radial pulse (felt on the thumb side of the wrist) could not be taken, a carotid pulse (a pulse felt along the carotid artery located on the neck) could try to be taken.
29. The JRCALC guidelines also explain an abdominal examination should have taken place. The ambulance Trust did not record a manual pulse or carry out an abdominal examination and there is a failing here.
30. We have carefully considered the impact of this. Mr B’s cause of death was a ruptured abdominal aortic aneurysm (AAA). An AAA occurs when a section of the aorta, the main artery that carries blood from the heart to the rest of the body ruptures.
31. Our adviser explains it can be extremely challenging for a paramedic to suspect a patient has a ruptured AAA, especially if a patient has not got a previous diagnosis of suffering with an AAA. This is because a ruptured AAA can only be diagnosed with a scan called a bedside aortic ultrasound.
Paramedics do not have access to these in ambulances. Furthermore, some of the presenting symptoms of a ruptured AAA are nonspecific and can be caused by other conditions. Very few symptoms for an AAA are ‘typical’.
32. The AAA guidance explains a person can suffer with an AAA for many years, with it going undetected. People are more at risk of having a ruptured AAA if they are over 60 with a history of hypertension and have an existing diagnosis of AAA. We understand Mr B had not previously been diagnosed with an AAA.
33. The JRCALC guidance for abdominal pain for leaking or ruptured AAAs, for the characteristics of pain it refers to sudden severe abdominal pain or back ache, or renal colic type pain. It explains less than 25% of patients present with classic signs and symptoms when they have an AAA, so there is a risk of misdiagnosis.
34. The records explain Mr B presented with mild pain that then eased, and he had no pain when the ambulance crew were with him. As set out above, a leaking or ruptured AAA is characterised as sudden severe pain.
35. This is balanced with that under 25% of patients present with classic signs and symptoms. This highlights it is very challenging for paramedics to diagnose an AAA.
36. If an AAA has ruptured, in some cases a ‘palpable mass’ can be felt. This is a growth or lump in the abdomen that can be felt during a physical examination. As we have set out above, we recognise a physical examination did not take place. We think there was a missed opportunity here. If an abdominal assessment had been carried out, and a mass had been identified, this could have changed the information the ambulance staff had and on handover. There is a chance he may have got into the hospital quicker, but this would also be dependent on the hospital’s actions.
37. We also do not know what the abdominal examination would have shown. Due to the way an AAA presents, Mr B may not have had a mass. We recognise as a result Mr P is left not knowing if a physical examination would have shown anything. We are mindful this is distressing in itself. We recognise there is still a chance a mass would have been identified if this examination took place, so we have gone on to consider what would have happened next to understand if we think the outcome could have been avoided.
38. If a patient has a ruptured AAA, in line with the AAA guidance the only treatment available is surgery. The guidance suggests transfer to unit for this should be 30 minutes.
39. The time from the 999 call to Mr B’s arrival at ED, was a time of one hour and 15 minutes. Our adviser explains the initial response time from by the ambulance Trust was very quick to locate Mr B, assess him, get him into to the ambulance and take observations. Our adviser explains this is reasonable given the context that Mr B collapsed on the pathway next to a lake. The ambulance Trust has explained the journey to hospital was then 31 minutes.
40. As set out above, the only way of definitely diagnosing a ruptured AAA is with a scan in hospital. If Mr B had got to hospital quicker, he would still have needed to be transferred to theatre before cardiac arrest. Our adviser explains there would not have been enough time to diagnose, transport to site for treatment and undergo surgery before the time of collapse and cardiac arrest.
41. The AAA guidance explains regarding a ruptured AAA, there is a very high chance of mortality. Eight out of ten patients sadly die before they reach hospital for surgery.
42. Overall, we think even if a mass had been identified alerting the ambulance Trust to the possibility of an AAA, this would not have changed the sad outcome. Whilst it remains that the Trust made mistakes in how it managed Mr B care, his clinical circumstances and the timeline that followed means that we cannot say Mr B would have had a better outcome. This is because there would not have been enough time to carry out a diagnosis and complete surgery.
43. We recognise the ambulance Trust still got something wrong in not completing full observations and carrying out an abdominal examination. Although we cannot link this to Mr B’s very sad death, this does not detract from the mistakes that were made.
44. We understand it is distressing to learn there were wrong doings. This alongside the worry at the time Mr P experienced when he was worried there was a direct link to the care and his father’s death.
45. We have looked to see if the ambulance Trust has taken any steps to put this right. The ambulance Trust has apologised it did not carry out an abdominal examination. It also says all staff receive regular and refresher training, and the recognition and management of ruptured AAA has been included. We are reassured to see the ambulance Trust has taken some steps. We do not think this goes far enough to recognise the failings we have identified.
46. Our complaints standards say organisations should take action to make sure any learning is identified and used to improve services. We are yet to see action has been taken to sufficiently remedy the impact we have identified. We therefore are likely to recommend the ambulance Trust take action to put this right
47. We understand Mr P also has concerns about when his father got to hospital and the time it took for the ambulance Trust’s handover. The NHSE guidance explains the hospital is responsible for the patient upon arrival, not after handover. The ambulance arrived at the hospital Trust at 11.11am. The guidance sets out this is the time the hospital became responsible for Mr B, and we will go on to consider the hospital Trust’s involvement in detail below.
Hospital Trust 48. Mr P has concerns about the timeline of his father arriving at hospital, and if he was treated and seen as urgently as he should have been. The Trust says his father was given all the appropriate treatment.
49. Mr B was taken to the hospital Trust via ambulance following collapse. The records show he arrived at the hospital Trust at 11.11am. The RCEM guidance sets out the standard for triage is within 15 minutes of patient arrival. He was triaged by the hospital Trust at 11.14am, in line with this.
50. The offload time for ambulance is 15 minutes, with 30 minutes still being good practice.
51. The time of arrival to arrest was 17 minutes. Mr B went into arrest at 11.28am. He had been triaged and was awaiting transfer, in line with the above guidance. Mr B arrested shortly after this. There did not appear to be any initial clinical concern he was peri-arrest. As set out above, Mr B did not have a typical presentation of an AAA, or present with extreme pain in his abdomen.
52. As Mr B went into cardiac arrest in the ambulance CPR was started in the ambulance in line with advance life support guidance. Blood gas tests were taken at 11.40am and 11.51am, and an ultrasound diagnosing AAA.
53. Our ED adviser explains there was not an unreasonable delay between the ambulance arriving at the hospital, triage, identifying cardiac arrest and commence and continuation of CPR in ED.
54. Our ED adviser explains there is a high mortality rate of for a ruptured abdominal aortic aneurysm, some studies going up to 80%. Very sadly, a substantial number of patients with AAA die outside hospital. The hospital Trust carried out its triage, assessment and treatment in line with guidance.
55. We are mindful of what happened, and Mr B tragically died shortly after he arrived at hospital. We can understand why Mr P has serious concerns the outcome could have been avoided. We have seen the Trust acted in line with guidance, taking into account Mr Bs clinical presentation. We hope this can provide some reassurance the Trust was taking the appropriate steps at the time.
56. We understand Mr P complains he was not contacted until hours after his father had died. The Trust has recognised this.
57. GMC guidance says clinicians must give patients the information they want or need to know in a way they can understand. It also says a clinician must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
58. Our adviser explains when a patient rapidly deteriorates, as Mr B did, the clinical priority is treating the patient. Mr B deteriorated quickly after getting to hospital, so there was a small window in contacting the family at this time where the focus needed to be clinical care. We recognise the family were then not contacted until two and a half hours after Mr B died. We acknowledge given this length of time, there may have been an opportunity to contact the family sooner. There is a failing here.
59. We have carefully considered the impact of this. Our adviser explains Mr B deteriorated suddenly and rapidly. Mr B then sadly died a few minutes after CPR was stopped. Based on this, we think it is highly unlikely the family would have been able to get to the hospital in time. We acknowledge they may have had the opportunity to have known slightly sooner, but very sadly would not have been able to be with him.
60. Recognising the time the Trust took to make contact, we have carefully considered what it has done so far to put this right. We are reassured the Trust has acknowledged it should have contacted the family sooner. It has apologised that this did not happen. The Trust has set out it has reiterated to staff via a three-point learning communication that communication with loved ones is paramount, particularly when a patient is deteriorating. We are pleased to see the Trust has taken steps to resolve this in line with our complaints standards.
61. To summarise, we have found the ambulance Trust should have carried an abdominal examination and further observations. We do not think this would have changed the outcome. We think the hospital Trust acted in line with guidance when Mr B arrived at hospital. We think there may have been an earlier opportunity for the hospital Trust to contact the family but cannot say they would have been able to be with Mr B.