3. Ms A complains that in April 2021 the Trust refused to take her father to hospital despite the severe pain he was in.
4. Ms A says because of this her father died of sepsis and this could have been prevented if he had been taken to hospital.
5. Ms A would like financial compensation.
6. In early April the ambulance crew arrived, did different observations (tests) and decided Mr A did not need to be taken to hospital (first attendance).
7. The next day (second attendance) the ambulance crew arrived and after doing observations, decided there was no need to take Mr A to hospital.
8. A day later (third attendance) a health care professional asked for an ambulance to take Mr A to hospital.
9. He was taken in and he died of sepsis four days later.
First attendance
13. The Trust says this about the first attendance:
‘the crew assessed your father for back pain following a fall two days earlier…the pain was believed to be muscular in origin…the ambulance crew recorded your father’s heart rate, respiratory rate, blood sugar level, blood pressure, oxygen saturations, pain score, NEWS2 score, temperature & conscious level (Glasgow Coma Score). His stroke assessment using the FAST test was also negative. In addition to these observations, other assessments were also completed including skin assessment, mental capacity assessment, breathing sounds, distal motor/sensory/circulation, consciousness and abdominal assessment. It was documented that there were no urological symptoms (increased urine frequency or abdominal pain). After the assessment it was found that your father did not have a risk of Sepsis, and that he did not need to be transported to hospital’.
14. It adds, ‘following advice from an Out of Hours Doctor to arrange pain relief, and for approval of the crew’s assessment and plan, the crew also provided advice for increased pain relief, contacting the GP if your father was struggling to cope, 111 for advice & 999 in an emergency’.
15. A NEWS2 is the National Early Warning Score. It is a system to help identify very ill patients, including those with sepsis.
16. A Glasgow Coma Scale is a tool medical professionals use to score a person’s level of consciousness. A lower score suggests a more severely affected consciousness, like a coma.
17. A FAST test is used to help recognise the most common signs of a stroke.
18. Our adviser says as Mr A’s medical records suggest the paramedics were newly qualified paramedics (NQP), they used the Trust’s clinical support guidelines. These say NQPs need to practice in a different way in the first 24 months of being a paramedic.
19. NQPs must keep to guidance and must not discharge from the scene without a senior health care professional agreeing with their decision. When considering discharge at scene they need to take advice if:
• the NEWS2 score is four or above • they think they need to take action that is not part of standard guidance • the patient is in a high-risk group.
20. Factors for deciding if the patient is in a high-risk group are if they:
• are aged 75 or more • have more than two long term conditions • have a history of traumatic injury.
21. It is noted in the patient care record that the paramedic did contact an out of hours GP, in line with the Trust’s clinical support guidelines. It is unclear if this was to validate the decision in line with the NQP policy, or to only get pain relief for Mr A’s back pain. If the paramedic called the GP for the first reason, it would have been in line with policy and they could have been able to make the decision that Mr A did not need to be taken to hospital. From the information available, we cannot say if this was the case because there is no record of a conversation.
22. Our adviser says sepsis can be difficult to identify in a pre-hospital environment. The sepsis guideline in JRCALC guidance says that ‘The final diagnosis of sepsis is usually only confirmed at the end of an admission, when all the evidence becomes available’.
23. This guideline also states that sepsis should be suspected:
• in anyone that presents with fever/feeling unwell • and anyone with a NEWS2 score of five or above • and/or anyone who looks unwell with a history of infection.
24. Our adviser said Mr A did not present with any of these at the time of the attendance. Mr A did have back pain which is not mentioned as a specific flag for sepsis. JRCALC guidance also gives lists of alert flags, both red and amber, that are specific markers to suggest sepsis is likely.
25. Within the amber list there are four flags that may be relevant to this case. These are:
• history of a new altered mental state (Mr A had Alzheimer's disease, a form of dementia, but there is no evidence to suggest his mental state was worse than before) • trauma in the past six weeks (Mr A did have trauma two days before) • not passing any urine in the last 12 to18 hours (we cannot tell from the records if the paramedics checked this) • measuring the temperature from the ear and having a temperature of less than 36 degrees ( Mr A had a temperature of 36 degrees).
• 26. Our adviser said it is important to note that Mr A did not have any specific signs of sepsis so these flags, would have been less clear.
27. Our adviser said there is good evidence to suggest primary and secondary surveys (tests) were completed in line with JRCALC guidance.
28. We think the ambulance crew did assess Mr A in line with guidance. The only thing we think the paramedics missed was checking if Mr A had passed urine in the last 12 to 18 hours. But, we do not think this would definitely have led to another outcome. And, we cannot confirm if the paramedics got agreement from a senior professional before deciding not to take Mr A to hospital. But, we do not think there are serious failings or signs that they should have done anything differently.
29. We understand it would have been an extremely distressing time for Ms A. We hope what we have found gives her some reassurance.
Second attendance
30. The Trust says, ‘a full set of observations including heart rate, respiratory rate, oxygen saturations, blood pressure, pain score, temperature, Glasgow Coma Score, skin assessment, pain score, pupillary assessment were carried out…there was no indication for transport to hospital or possible Sepsis at the time.’
31. The Trust’s records seem to suggest there were two NQPs in attendance.
32. 999 gave the paramedics extra information so they knew Mr A had been given co-codamol (a type of painkiller), had not opened his bowels for two days and was sleeping more than usual. Constipation and drowsiness are possible side effects of co-codamol.
33. The patient care records suggest these factors do not seem to have been considered by the paramedics.
34. Our adviser says there is evidence of a primary survey being completed, but less evidence of the detail of any secondary survey. There is also less evidence of any focussed examinations being done. The paramedics do not seem to have done a physical examination of Mr A’s back.
35. The patient care records show only one set of observations and it would normally be good practice to do more as part of JRCALC guidance to monitor patient’s vital signs.
36. There are parts missing from the assessment notes that were made. We think this attendance was not as in keeping with the guidelines as it should have been.
37. Our adviser referred to the Trust’s clinical guidelines for NQPs and says Mr A had more than two long term conditions, a history of traumatic injury and contact with a healthcare professional within the last 24 hours (these factors, in addition to his age, made him high risk).
38. It should be considered if the paramedics who attended checked their decision to discharge Mr A with another healthcare professional, as per the Trust’s policy. The patient care records show the referral to a GP box has been ticked, but our adviser notes there is no record of any conversation with a GP having taken place.
39. We are also unsure if any questions were asked about Mr A passing urine. This is important as if Mr A had not passed urine, it may be a sign of infection.
40. We feel less comfortable that the paramedics in the second attendance followed policy and checked their decision with another health care professional.
41. But, our adviser said that diagnosing sepsis would still be very difficult at that point in time.
42. The checks on the second attendance were not strong as the paramedics did not consider the side-effects of co-codamol and there is lack of evidence of a physical examination of Mr A’s back.
43. We noted there are no obvious signs to suggest that Mr A had sepsis in line with the JRCALC guidance we considered above.
44. JRCALC says that NEWS scoring tools are the best physiological scoring systems for assessing sepsis, but that it does not diagnose sepsis. Mr A had a NEWS2 score of one which means he was categorised as low clinical risk.
45. But, checking their decision with another health care professional not to take Mr A to hospital does not seem to have happened and this means we cannot say the paramedics followed the Trust’s NQP policy.
46. Although the policy was not followed, we find we cannot link the Trust’s actions to the sad outcome that followed. Sepsis is difficult to diagnose and Mr A did not show any obvious symptoms to suggest it at the time.
47. Based on the evidence, we do not uphold this complaint as we have seen no evidence of failings during the first attendance and we cannot link the impact Ms A is claiming with the failings identified in the second attendance.
48. The failings identified at the second attendance cannot be linked to the impact of Mr A getting sepsis and then dying. This is because even if the relevant checks were completed and the paramedics decision was validated, sepsis is extremely difficult to identify. And, we cannot say that if all the checks had been done, this would have ended in a decision being made to take Mr A to hospital.
49. We understand how challenging and difficult it is when a loved one deteriorates quickly and sadly dies. We also appreciate how distressing it has been for Ms A to progress her complaint during such a difficult time.
1. Ms A complains that in April 2021 East of England Ambulance Service NHS Trust (the Trust) refused to take her father, Mr A, to hospital despite the severe pain he was in. Ms A says because of this Mr A died of sepsis. Sepsis is a life-threatening reaction to an infection. It happens when the immune system overreacts to an infection and starts to damage the body’s own tissues and organs. She says if he had been taken to hospital, he could have been saved.
2. We have carefully reviewed the evidence and we did not find evidence of failings in the Trust’s actions. We are sorry to hear about Ms A’s sad loss. It is clear how important the complaint is to her and we appreciate that making a complaint at an already difficult time adds to the distress.