London Ambulance Service NHS Trust
Recognising stroke symptoms/transporting to HASU/ seeking clinical input:
20. Mr L says the ambulance clinicians did not correctly recognise and assess his mother's stroke symptoms, seek further clinical input or transport her to a hyper acute stroke unit (HASU). He says this meant she did not receive timely treatment.
21. The Ambulance Trust says Mrs L’s FAST test was negative so there was no indication she required immediate conveyance directly to a HASU. In its investigation report, it says the ambulance clinicians should have considered having further discussions with the clinical hub.
22. Joint Royal Colleges Ambulance Liaison (JRCALC) guidelines are used across the UK to guide ambulance clinicians’ decision-making. The section of the JRCALC guidelines about stroke and transient ischaemic attack says ambulance clinicians should assess the patient in the following ways:
• assess the patients Glasgow Coma Scale (level of consciousness) • measure and record the patient’s respiratory rate (number of breaths per minute) • measure and record the patient’s pulse (heart beats per minute) • monitor the patient oxygen saturation (level of oxygen in the blood) • measure and record blood pressure (pressure of blood in the arteries) • measure and record blood glucose (sugar in the blood) • measure and record temperature • calculates NEWS2 (National Early Warning Score) • electrocardiogram (to test and record electrical activity of the heart including rate and rhythm) – JRCALC discourages this in a time-critical suspected stroke patient as it may cause a time delay in transport.
• assess the patient’s pain
23. Paragraph 1.1.1 of NICE Guideline NG128 says, ‘use a validated tool, such as FAST outside hospital to screen people with sudden onset of neurological symptoms for a diagnosis of stroke or transient ischaemic attack’. The JRCALC guidelines say a FAST test should be carried out on all patients with suspected stroke/Transient Ischaemic Attack (TIA). A TIA is a short period of symptoms similar to a stroke that normally resolve within 24 hours.
24. The Ambulance Trust’s stroke guidance says ‘patients will be conveyed to the most appropriate centre for their condition in accordance with its policy on responding to 999 calls’. The conveyance policy in place at this time says the patient should attend the nearest A&E unless there is an exception. JRCALC says if a patient is assessed as FAST positive or is suspected to be experiencing a stroke, they should be transferred to a HASU as per local pathway. The ambulance Trust tells us its agreed practice (pathway) is for FAST positive patient’s to be directly conveyed to a HASU, so long as their symptoms onset within the specified time window for treatment.
25. From the records, we can see the ambulance clinicians assessed and recorded all the above observations set out in the JRCALC guidance for Mrs L, and most were within normal limits. Her blood pressure was slightly high, and her respiratory rate was slightly elevated initially, and it then returned to normal. The notes say Mrs L reported she felt ‘extremely dizzy’, had tingling and pins and needles in her right leg and arm and muscle weakness. The ambulance clinicians noted they completed a FAST test for Mrs L as per the NICE and JRCALC guidelines and it was negative.
26. We know Mrs L was later diagnosed with a posterior circulation stroke in hospital. Posterior circulation strokes occur in the arteries that supply blood to the back of the brain. None of the guidelines specifically mention this type of stroke. The JRCALC guidelines do say there are recognised limitations with using the FAST test in isolation, and not all stroke symptoms can be identified only using the FAST test. We can see the ambulance clinicians did suspect Mrs L’s symptoms may be neurological but given she was FAST negative; they did not have high index suspicion of a stroke and consider transporting her to a stroke unit. The nearest hospital with a stroke unit (hospital B) was also on divert because of capacity issues.
27. In its investigation report, the Ambulance Trust said the ambulance clinicians should have also sought input from a senior clinician when attending to Mrs L. Our paramedic adviser says there is no national guidance about this, and the ambulance Trust’s local policies do not appear to offer any criteria or guidance on when clinicians should seek advice on decision making. The ambulance Trust has since told us as an HCPC registered clinician, the qualified paramedic would be expected to make independent decisions. We cannot see there was any requirement in any national or local guidance for the ambulance clinicians to seek additional clinical support and we are therefore not critical of them not doing so.
28. We recognise that in hindsight Mrs L had had a stroke, and whilst some of her symptoms could be indicative of a posterior stroke, there were also a number of other possible diagnoses at that point. The ambulance clinicians appear to have followed the NICE and JRCALC guidance in place at the time, by performing a comprehensive assessment and a FAST test to assess Mrs L for signs of a stroke. Given the FAST test was negative, we consider the ambulance clinicians acted appropriately by transporting Mrs L to her nearest A&E and we do not consider they got something wrong.
29. The ambulance Trust has confirmed it has since undertaken some work with the Stroke Operational Delivery Network (ODN). It says it has an agreement on inclusion / exclusion criteria for any patient with new neurological symptoms, which may be associated with a stroke, and it is not limited to FAST positive patients. Whilst we consider the clinicians in this case acted in line with established guidelines, we are pleased to hear the Trust has carefully considered Mr L’s complaint and thought about ways to improve it can expand the criteria.
Assessment of speech:
30. Mr L says his mother was able to speak English, but she could not speak at the time because of her condition. He says the ambulance clinicians just assumed his mother could not speak English and therefore did not assess her speech properly.
31. The ambulance Trust says the clinicians recorded on the electronic Patient Care Record (ePCR) Mrs L required some translation. It says the clinicians did not assume Mrs L was unable to speak English.
32. Our paramedic adviser confirms there are no specific national guidelines about this. The British paramedic journal article on strokes recommends asking the patients family if their speech is normal for them. The ambulance clinician recorded in the notes, Mrs L was ‘able to communicate with small English when asked questions and appears to understand but does require some translation’.
33. In statements provided as part of the organisations’ investigation process, the ambulance clinicians’ say a friend who was present at the time, advised Mrs L could understand minimal English and offered to translate. The clinician says they asked the friend if Mrs L’s speech was abnormal or slurred, and they said she was able to communicate well.
34. Our paramedic adviser says the ambulance clinicians’ statements demonstrate they considered Mrs L’s speech. They obtained assistance from a family friend who was present, as recommended by the paramedic journal article. The family friend was able to translate to confirm if Mrs L’s speech seemed normal for her, and this was appropriate.
35. We cannot see any evidence to suggest the ambulance clinicians assumed Mrs L could not speak English. We recognise Mr L says his mother did speak English, and that this has caused him distress. We consider it was appropriate for the ambulance clinician to act on the information they were provided with by those who were present at the time, and we cannot see any evidence a failing has occurred.
Transportation to ambulance:
36. Mr L says the ambulance clinicians refused to carry his mother to the ambulance when she could not walk, and said she was being lazy and stubborn, and they used a wheelchair already at the property.
37. The ambulance Trust say the clinicians could not recall stating Mrs L was 'lazy, stubborn and does not want to walk,' but do remember trying to encourage her to walk independently. This was so they could undertake a mobility assessment. On reflection the ambulance clinicians apologise for any distress they may have caused and reflect they could have used a chair earlier.
38. In their statements, the ambulance clinicians say a friend/ family member offered for them to use a wheelchair to transport Mrs L to the ambulance when they were discussing using the carry chair. They say the wheelchair was in good working order and safe to use.
39. Our paramedic adviser tells us there are no guidelines to specifically state how someone should be transported to an ambulance. The suggestion to use the family wheelchair is not an unusual one. The ambulance clinicians stated they felt it was serviceable for the extrication required. We therefore consider it was appropriate to transport Mrs L to the ambulance in the wheelchair and there is no failing here.
40. Mr L also says the ambulance clinician said his mother was being ‘lazy and stubborn’. We recognise how things are said are open to interpretation and each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception.
41. Whilst we do not dispute Mrs L’s families’ recollection, unfortunately, we were not present at the time to independently know what, and how, things were said. We are left without independent supporting evidence that would indicate to us a service failure took place.
London Northwest University Healthcare NHS Trust
Delays in A&E/ transfer:
42. Mr L says there was a delay in a doctor fully assessing his mother in A&E and prescribing necessary medications. He says there was then a delay in transferring his mother to the stroke unit at hospital B.
43. The Hospital Trust says a doctor assessed Mrs L in the rapid assessment treatment (RAT) area when she arrived in A&E. It says this is a quick pathway and does not involve prolonged and detailed history. It identified that due to a language barrier and the reliance on information from the ambulance crew, there was a missed opportunity to recognise and treat stroke symptoms. The hospital Trust also says Mrs L was not an emergency transfer and there was no hospital transport available when it was requested.
44. GMC Good medical Practice guidance says:
20. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
22. Clinical records should include: a. relevant clinical findings b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions c. the information given to patients d. any drugs prescribed or other investigation or treatment e. who is making the record and when.
45. NHS England guidelines say patients attending an Emergency Department should receive a clinical assessment within 15 minutes of their arrival. The intention of this assessment is to identify patients with life threatening conditions to ensure they are prioritised.
46. The national stroke guidelines say patients with suspected acute ischaemic stroke should be admitted under the care of an acute stroke team without delay. It recognises good practice is to admit directly into a stroke unit from the emergency department within four hours, although this is nationally only achieved in around half of all stroke patients in England. This guidance also says patients with ischaemic stroke should receive a dose of aspirin within 24 hours of onset.
47. The RCP guidelines say patients with suspected stroke should receive a CT scan of their brain within one hour of hospital attendance. Our A&E adviser explains this recommendation is aspirational and is not always possible due to issues with patient flow in hospitals which often leads to crowding in Emergency Departments and associated delays in patient care.
48. The notes show a doctor assessed Mrs L in the RAT area within 15 minutes of her arrival which in line with the NHS England standard. The triage note says Mrs L was ‘brought in by ambulance due to dizziness… tingling in right side of the body’. There is a page titled ‘rapid assessment’ in Mrs L’s notes which lists her symptoms and observations. However, the assessment, clinical impression and plan sections of this sheet have not been completed. There is a handwritten note on the triage page stating, ‘CT scan’, but it is not clear who has written this or when. The Trust has acknowledged the treating doctor did not transfer any notes onto the electronic system. The notes show the doctor prescribed Mrs L with an anti-sickness medicine and intravenous fluid at 5:53pm. There is no mention in the records of any referrals, investigations or other treatments being ordered at that point.
49. An A&E doctor assessed Mrs L at 9:35pm and found she had cerebellar signs so consulted with a stroke registrar at hospital B. The cerebellum is the area of the brain that controls balance and coordination. Mrs L’s head CT scan did not show she had a stroke but because of her symptoms, hospital B (which has a specialist stroke unit) agreed for her to transferred there for further assessment. Clinicians also prescribed and administered aspirin for Mrs L over one hour after she had been referred to the acute stroke team, which is within the 24-hour recommended timescale set out in the national stroke guidelines.
50. We appreciate the RAT process is a pathway designed to triage patients quickly but there is a section for ‘assessment’ and ‘clinical impression’ that has not been completed, which is not in line with GMC guidance above. There is a lack of evidence in the notes that the clinician who triaged Mrs L assessed her appropriately and considered her neurological symptoms. The Trust acknowledged there may have been an overreliance on information from the ambulance crew on handover and difficulty due to a language barrier.
51. The notes show the stroke team at hospital B accepted the referral for Mrs L at 11:05pm. The Trust says nursing staff at hospital A tried to book hospital transport, but none was available. Staff requested an ambulance service to transfer Mrs L at 6:18am the following morning. The Hospital Trust acknowledges there was a delay in transporting Mrs L to hospital B. We can see Mrs L experienced a delay of approximately eight hours between when hospital B agreed to her transfer and when she was eventually admitted to the stroke unit. This is not in line with the national stroke guidelines set out above which say patients with suspected acute ischaemic stroke should be admitted under the care of an acute stroke team without delay. We appreciate there was no hospital transport available at that time, but there is no explanation as to why staff did not contact the ambulance service sooner.
52. We consider there was a possible missed opportunity for the A&E clinician to have identified Mrs L’s neurological symptoms sooner and there was a lengthy delay before she was transferred to the stroke unit at hospital B.
Impact:
53. We have considered the impact of these delays on Mrs L, and if it is likely they affected her treatment and clinical outcome.
54. The main treatment for patients who have had a stroke are thrombolysis (medicine to dissolve a blood clot) and thrombectomy (surgical removal of a blood clot). The RCP guidelines state the optimal time window for thrombolysis is three hours, but there is an accepted overall window of 4 and a half hours.
55. The National Institutes of Health Stoke Scale (NIHSS) is a tool used to measure the severity of a stroke. Using a numerical scale, health care providers record the patient’s performance in 11 categories, including sensory and motor ability. Clinicians completed an NIHSS assessment for Mrs L when she first arrived at hospital B and her score was three (out of 42).
56. When clinicians assessed Mrs L at hospital A she was found to have normal tone, power, coordination and sensation in all four limbs. Clinicians noted she had dysarthria (slurred speech) and a subtle right upper motor neurone nerve palsy (muscle weakness). Her visual fields and eye movements were normal. Her presenting symptoms of dizziness and altered sensation on her right side were not demonstrable on examination. From the evidence in the notes, our stroke adviser says Mrs L would have had an NIHSS of two if clinicians had calculated this when she first presented at hospital A. If we add in the unsteady symptoms as possible ataxia (poor muscle control) this could push it up to a three, although there was no sign of incoordination on assessment. This is very consistent with the examination findings and fully documented NIHSS done at hospital B where she scored three for facial palsy, limb ataxia and dysarthria. There is no evidence to suggest Mrs L’s NIHSS score was substantially higher when she was at hospital A than when she arrived at hospital B the following day.
57. Our stroke physician adviser explains Mrs L’s NIHSS score of three would have put her outside many standard thrombolysis guidelines at that time (including the RCP guidelines) which recommends thrombolysis in patient’s scoring four or more. It also put her below the level for consideration of referral for thrombectomy. It is therefore unlikely Mrs L would have been eligible for thrombolysis or thrombectomy based on her NIHSS, score even if clinicians had identified her neurological symptoms earlier and within the four-and-a-half-hour window.
58. Following Mrs L’s transfer to the stroke unit at hospital B, her condition suddenly deteriorated, and she went into cardiac arrest at around 6:30pm. Resuscitation attempts were successful, and Mrs L was admitted to the intensive treatment unit (ITU) for further observation. A CT scan showed Mrs L had had a further stroke and she had significant damage to the right side of her brain. A heart scan performed after the cardiac arrest did not identify any cause. Our stroke adviser explains it is difficult to say what caused Mrs L to go into cardiac arrest. It could have related to her deteriorating/progressive posterior circulation stroke but could also have been triggered by vomiting causing choking. It would not be possible for us to say with any certainty what the cause was.
59. Given Mr L was not eligible for thrombolysis or thrombectomy when she first presented to hospital based on her NIHSS score, we consider it is unlikely the delay in identifying her stroke symptoms had a significant detrimental impact on her clinical outcome. Our stroke physician tells us there is no clear evidence from the notes Mrs L experienced any harm as a result. We are incredibly sorry to hear about Mrs L’s very sad death and appreciate the delays caused additional worry and distress to Mr L and his family at an already very difficult time.
60. In its investigation report, the Trust outlined an action plan to improve its services:
• Electronic patient notes to be kept updated as patients are reviewed at RAT assessment • Education for staff of stroke symptoms • Case to be presented and discussed at the ED Clinical Governance Meeting • Electronic patient notes to be kept updated as patients are reviewed at RAT assessment • Education for staff of stroke symptoms • Review of the stroke policy • Case to be presented and discussed at the ED Clinical Governance Meeting • Department to research options regarding electronic translation systems for the rapid assessment area
61. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. They are also reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services. We are pleased to see the Trust has already taken learning from this complaint and put actions in place to improve its services. We consider this is in line with NHS complaints standards and is enough to remedy the impact of the failings we have seen.
Swallow test:
62. Mr L says when his mother was on the stroke ward, a clinician gave her a tablet, which she choked on, and she subsequently went into cardiac arrest. The Hospital Trust says a clinician at hospital B carried out a swallow test and Mrs L passed it.
63. The RCP stroke guideline says, ‘patients with acute stroke should have their swallowing screened, using a validated screening tool, by a trained healthcare professional within four hours of arrival at hospital and before being given any oral food, fluid or medication’.
64. The notes show a clinician performed a swallow screen for Mrs L at 8:49am on 14 February, shortly after she arrived at hospital B. The clinician recorded this on a proforma tool and found her swallow was safe and ‘no difficulties were observed’.
65. According to the medication chart, Mrs L was given 25mg of losartan at 6pm. Losartan is a medication to treat high blood pressure. A clinician documented Mrs L reportedly vomited and went into cardiac arrest at 6:30pm. There was no documented medication given at 6:30pm, but our stroke physician adviser explains it is possible there was a delay in her being given or taking the 6pm losartan tablet.
66. We can see clinicians at hospital B completed a swallow screen in line with RCP guidelines. Our stroke physician adviser says because the test showed Mrs L’s swallow was safe, it was appropriate for her to be given her blood pressure medications to keep her blood pressure stable at this time. We therefore cannot see there was a failing here.
67. We appreciate seeing his mother go into cardiac arrest was an incredibly distressing and traumatic experience for Mr L and his family and we are truly sorry they had to go through this.
68. Overall, we have decided not to uphold this complaint. We have seen there were some avoidable delays in Mrs L’s care when she arrived at hospital. We have not seen this had an impact on her clinical outcome. We are very sorry to hear about the additional distress this caused. We consider the hospital Trust has done enough to put this right, in line with our principles and we will not recommend any further action. We hope our decision provides Mr L with some reassurance.