10. Miss A says the Trust paramedics failed to identify the cause of her mother’s condition and provide appropriate treatment when they attended. In its response to this complaint the Trust said the paramedics assessed Mrs B and found she was suffering with low blood sugar. The Trust said providing treatment for low blood sugar was a reasonable course of action to take given the initial assessment of Mrs B’s condition.
11. The GMC guidance says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values
• promptly provide or arrange suitable advice, investigations or treatment where necessary.
In providing clinical care you must:
• prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs
• provide effective treatments based on the best available evidence.’
12. The JRCALC guidance says paramedics should gain knowledge of the patient’s history. The evidence in the records indicates the paramedics did this as there is information about Mrs B’s history of COPD, emphysema, her previous heart attacks and stent surgery included in the notes of the initial assessment.
13. The JRCALC guidance says initial assessments should focus on the patient’s airway, breathing, circulation and disability (the ABCD approach) to identify potential life-threatening conditions or symptoms. Our paramedic adviser said the records indicate the paramedics who attended to Mrs B followed the ABCD approach and found that her airway was clear, she had difficulty breathing and an increased respiratory rate and her pulse indicated a slightly elevated rate of circulation.
14. It is when assessing disability that paramedics would consider the patient’s level of response, pupil size, limb movement, sensory function and blood sugar levels. Our paramedic adviser said the records indicate the paramedics checked all of aspects of Mrs B’s condition during the initial assessment and identified her low blood sugar level.
15. The records show as the initial assessment identified Mrs B’s breathing difficulties and low blood sugar the initial treatment from the paramedics was to sit her up from her lying position and administer oxygen. Our paramedic adviser said this is appropriate treatment when a patient is having difficulty breathing and consistent with the JRCALC guidance.
16. Our paramedic adviser said the finding of low blood sugar is particularly relevant in this instance. In relation to treating low blood sugar, the JRCALC guidance says:
‘Correction of low blood sugar is a medical emergency which, if left untreated may lead to a patient suffering permanent brain damage and may even prove fatal. Occasionally, low blood sugar will be experienced by patients who do not have a diagnosis of diabetes.’
17. The appropriate treatment for low blood sugar in patients who are conscious, oriented and able to swallow, as Mrs B was at this time, is eating and drinking quick-acting carbohydrates such as glucose gel, fruit juice, sugar dissolved in water. The JRCALC guidance says if the patient shows no improvement the paramedic should repeat oral treatment up to three times and if there is no improvement after 30–45 minutes, treat with intravenous glucose.
18. Our paramedic adviser said the evidence in the records of Mrs B’s condition, observations and symptoms at this time, and the risk posed by her low blood sugar, indicate it was appropriate and in line with the JRCALC for the paramedics to focus treatment on increasing her blood sugar level. Her low blood sugar was a clinical emergency and the JRCALC guidelines state that when identified it must be corrected, which the records indicate the paramedics tried to do.
19. The JRCALC guidance says ‘if required, monitor and record 12-lead ECG and assess for abnormality’. Miss A says the paramedics should have done an ECG and taken her mother to hospital immediately rather than treating her for low blood sugar at her home. Miss A says an ECG would have led to care being provided that would have prevented her mother from suffering a cardiac arrest and saved her life.
20. In its response to Miss A the Trust acknowledged there was adequate opportunity for the paramedics to perform an ECG but failed to do so and it has upheld this point of complaint. The Trust said although an ECG may have led to a better understanding of Mrs B’s condition it would not have changed the treatment provided by the paramedics or the plan to transport her to hospital once her blood sugar level had improved. The Trust said Mrs B’s cardiac arrest was sudden and could not have been predicted.
21. Our principles say good practice with regard to remedies means:
• Getting it right • Being customer focused • Being open and accountable • Acting fairly and proportionately • Putting things right • Seeking continuous improvement.
22. As a result of Miss A’s complaint, and to address this failing, the Trust has produced an action plan with the aim of improving this area of care for the benefit of future patients. The Trust said the action plan will provide feedback to the paramedics with a focus on how there was time for an ECG to be completed during this attendance, and how in future this could impact a working diagnosis. We think the action taken by the Trust is appropriate to address this failing and consistent with our principles.
23. Our paramedic adviser said there is no evidence in the records that would indicate an ECG would have resulted in a different plan of treatment or prevented Mrs B’s sudden deterioration. It is possible an ECG may have identified an arrhythmia (an abnormality of the heart’s electrical rhythm) but it also possible it may not have.
24. The JRCALC guidance says ‘in the pre-hospital environment, safe care consists of high-risk arrhythmia identification, treatment (if indicated) and conveyance to appropriate care. For lower risk arrhythmias, signposting or referring for follow-up, with safety netting, may be sufficient.’
25. It is not possible for us to say an ECG would have led to different treatment or a change in the plan of care as it would depend on the presence of an arrhythmia, whether it was high-risk or low-risk and whether treatment was indicated.
26. Our paramedic adviser said when considering the likelihood of an ECG identifying an arrhythmia, the JRCALC guidance says slow arrythmias are usually heart rates of less than 60 beats per minute, and fast arrythmias are usually heart rates higher than 100 beats per minute. The records indicate Mrs B’s heart rate was recorded as 94 beats per minute prior to her cardiac arrest and therefore would have been unlikely to fall into either of these categories.
27. The JRCALC guidance does not provide specific information on predicting a cardiac arrest as they are often sudden, unexpected events. However our paramedic adviser said there are often additional signs and symptoms prior to a cardiac arrest such as chest pain, a change in colour, breathlessness, palpitations or abnormal heart rhythm. The records indicate Mrs B’s symptoms were not indicative of an impending cardiac arrest.
28. Our paramedic adviser said the records indicate, other than her low blood sugar level, the clinical observations during Mrs B’s assessment that would be considered abnormal were her slightly increased respiratory rate, slightly increased heart rate and her oxygen saturation level (the level of oxygen in the blood). Our paramedic adviser said these abnormal findings can be associated with many clinical conditions, including COPD and emphysema, which Mrs B was noted to have.
29. Miss A says she informed the paramedics that her mother was not diabetic and that she felt she needed to go to straight to hospital rather than be treated for low blood sugar at her home. The JRCALC guidance says non-diabetic patients can develop low blood sugar and attempts should be made to correct it due to the impact it could have if left untreated.
30. The JRCALC guidance says ‘transfer to the nearest suitable receiving hospital if the patient requires further treatment, otherwise the patient can usually be safely left at home once blood glucose is >4mmol/L’. Our paramedic adviser said there is no indication in the records that the paramedics had any thoughts about leaving Mrs B at home after treatment for her low blood sugar. There is no evidence in the records that would cast doubt on the Trust’s explanation that it was the intention of the paramedics to take Mrs B to hospital for further tests and treatment.
31. We carefully considered Miss A’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge Miss A’s view that her mother should have been taken to hospital immediately rather than treated at her home.
32. We found the Trust acted in line with the JRCALC guidance which states low blood sugar is a clinical emergency which requires immediate treatment. We found Mrs B suffered a sudden, unexpected cardiac arrest whilst the paramedics were providing this treatment.
33. Our cardiologist adviser said the records indicate Mrs B was at high risk of sudden cardiac arrest due to her history of cardiac problems including previous heart attacks, cardiac enlargement and large areas of scarring in the wall of the heart. She also had narrowing in both her left and right coronary arteries.
34. Our cardiologist adviser said low blood sugar is related to causing cardiac arrest, particularly in patients with pre-existing cardiovascular conditions and immediate treatment to stabilise it is recommended. Our cardiologist adviser said there is no established link between administration of glucose to treat low blood sugar and cardiac arrest.
35. The RCUK guidance says:
‘Treatment of low blood sugar, even if some inaccuracies in measurement are present, generally outweigh the dangers presented by these inaccuracies. Therefore, do not delay the treatment of ‘suspected’ low blood sugar whilst awaiting a formal laboratory venous or arterial blood sample result.’
36. Our cardiologist adviser said the records indicate the paramedics provided appropriate treatment to try to improve Mrs B’s low blood sugar and after she suffered her cardiac arrest, made significant efforts to resuscitate her. Our cardiologist adviser said the records support the view that despite these efforts, Mrs B’s heart condition was so advanced that her death could not have been prevented following her cardiac arrest.
37. We carefully considered Miss A’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate her death was due to failings in care and treatment from the Trust. Her cardiac arrest was sudden and unexpected and we have found no evidence to indicate it could have been predicted.