Care and treatment
13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
14. Mrs F says the paramedics did not take her to hospital for further investigations on 13 July 2024. As a result, she says she was left in pain and unable to go to the toilet for three days. After three days, Mrs F contacted her GP, who referred her to the local surgical assessment unit. Mrs F told us her appendix had perforated and caused three abscesses which required surgery.
15. We were sorry to hear Mrs F spent time in pain. It must have been very distressing for her during this time. We understand she has since required further care and treatment regarding her appendix up to December 2024. To address Mrs F’s concerns, we reviewed her relevant medical records from the Trust and sought clinical advice. Our adviser told us the JRCALC guidelines are the most relevant.
16. Section 5.1 of the JRCALC guidelines says ‘where the working diagnosis is of a minor illness, e.g. gastroenteritis or a single episode of self-limiting abdominal pain, discharge in the community may be appropriate. These patients do not routinely require discussion with a senior healthcare professional unless the clinician needs further advice.’ It also says, should the patient be discharged on scene, paramedics should provide the following advice:
• ‘reassure the patient and encourage them to rest • if they are not vomiting, advise regular paracetamol for pain relief • encourage the patient to drink plenty of clear fluids • do not push the patient to eat if they feel unwell • if the patient is hungry, encourage them to eat bland food • many patients with abdominal pain get better without intervention over a few hours or days. However, if problems persist, encourage them to seek further medical advice.’
17. The Trust also provided us with copies of its discharge procedure and its referral discharge and conveyance policy. We consider both are relevant to the complaint.
18. Section 2.1.1 of the discharge procedure and sections 2.3.3 and 3.2 of the conveyance policy say discharging a patient means their health problem has been resolved or is deemed to be self-limiting and requires no follow up. It says the Trust recognises diagnosis uncertainty is limited. Patients being discharged must have specific worsening care advice and safety netting in place should they deteriorate. This information should be shared with the patient and/or their family or carers.
19. At 10.37pm on 13 July 2024, Mrs F contacted 999. She was categorised as Cat2 and her reported symptoms are: feeling her coil may be coming out, lower abdominal and groin pain, and pain in the chest, upper back and abdomen. At 10.54pm, Mrs F reported further pelvic pain symptoms.
20. According to the patient care record, paramedics arrived at the scene at 11.16pm. They noted the presenting complaint as ‘abdominal pain’. They documented Mrs F’s husband had been unwell with diarrhoea and vomiting for the past four days. Mrs F had also experienced these symptoms but had developed lower abdominal pain that evening.
21. The paramedics took observations at 11.27pm and 11.58pm. They document a National Early Waring Score (NEWS) of 1 and 0, respectively. Mrs F’s neurological, cardiac, and respiratory observations appear normal. The notes document Mrs F had several episodes of diarrhoea and vomiting which was not bloody.
22. Mrs F reported new lower abdominal pain which was constant but had ‘waves of intensity’ and felt like a band across her abdomen. The paramedics performed an examination. They noted ‘bowel sounds heard. No swelling. Generally, tender all over, no masses felt.’ They noted Mrs F’s suspicion her coil had become dislodged as she had ‘never experienced this lower abdo pain before.’
23. The paramedics recorded working diagnoses of abdominal pain, norovirus and gastroenteritis. At 11.31pm, they offered paracetamol for pain relief, but Mrs F vomited around 20 minutes later. In their clinical notes, the paramedics documented they had advised Mrs F her pain could be related to excessive strain. They documented her husband was on scene to monitor Mrs F and she was ‘happy with plan and wca (worsening care advice) given.’
24. The paramedics’ advice sheet given to Mrs F contained copies of her observations, a clinical impression of norovirus or gastroenteritis, advice on managing the condition and signposting and red flag symptoms. On review of the advice sheet, we consider the information provided is in line with the JRCALC guidelines and the Trust’s policies.
25. In addition to the advice sheet, the paramedics offered reassurance of normal observations. Regarding their decision making on discharge, the paramedics documented they had advised ‘pt likely to get more rest and be more comfortable here if she feels able to cope as opposed to a busy A&E with a ?very contagious illness.’ We consider this decision to be in line with the JRCALC guidelines and the Trust’s policies. This is because the paramedics had a working diagnosis of gastroenteritis, which is a self-limiting illness.
26. We discussed the patient care records with our adviser. They told us the assessment of abdominal pain can be difficult. No part of the JRCALC guidelines say explicitly which patient with abdominal pain should go to hospital should and which ones should not. For this reason, it was difficult for them to say the guidelines had been breached by the decision not to take Mrs F to hospital. They told us this is because the decision making depends on the assessment of the patient. We note Mrs F’s observations and examination were normal.
27. Our adviser told us there is a good assessment articulated in the patient care record. The paramedics identified someone in the house had been experiencing similar symptoms. Our adviser stated this would be an influencing factor in thinking both occupants had an infection making them sick. It is understandable why the paramedics thought Mrs F was experiencing GI upset. Our adviser stated the paramedics provided accurate worsening care advice for gastroenteritis causing abdominal pain, which Mrs F followed.
28. Based on what we have reviewed, we can see the JRCALC guidelines support leaving a patient with abdominal at home and managing within the community if the working diagnosis is something minor. In this case, the paramedics had a working diagnosis of gastroenteritis. The JRCALC guidelines list gastroenteritis as an example of something manageable within the community. It does not require further discussion with senior healthcare professionals.
29. We consider the Trust’s discharge procedure and conveyance policy recognise diagnosis uncertainty is limited. For this reason, patients must have specific worsening care advice and safety netting in place. Our review of the patient care records indicates this advice and safety netting was provided both verbally and in writing to Mrs F. The notes indicate Mrs F was happy with the plan and was left in the care of her husband.
30. Overall, we consider there are no indications the Trust did anything wrong by discharging Mrs F. It has acted in line with the JRCALC guidelines and its own policies in doing so. Our adviser told us the working diagnosis of gastroenteritis was reasonable in the circumstances. As this is a self-limiting illness, it was in line with both guidelines and policies to discharge Mrs F with safety netting advice. We hope Mrs F is reassured by our explanation.
Communication
31. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
32. Mrs F says the paramedics communicated poorly towards her on 13 July 2024. Specifically, she told us the paramedic stated she wouldn’t want to go to A&E as it was Saturday night and would be full of drunk people. Mrs F told us the paramedic stated she would be sat in A&E for hours and be uncomfortable. This account to us is reflective of Mrs F’s complaint to the Trust dated 26 November 2024.
33. As a result, Mrs F told us she was unhappy with these comments. She stated she felt unheard and dismissed by the paramedics. We recognise Mrs F was in considerable pain at the time of the events. It must have been distressing for her to feel her pain was dismissed.
34. To address Mrs F’s concerns, we reviewed her medical records and the complaint file and noted any references to the paramedics’ communication.
35. We note it is difficult to comment retrospectively about whether verbal communication is in line with relevant guidelines. This is because we were not present at the time of the events. We can therefore only consider what Mrs F has told us and what is documented within the records and complaint file. Further, our adviser told us there is no guidance relevant to verbal communication for us to consider what should have happened.
36. On review of the records, we can see the written communication is full and detailed. Our adviser told us it is documented to a good standard. They told us it does not feel like the paramedics have been lacking in their written communication. Specifically, there is a level of detail in the safety netting advice which would have taken time to write.
37. Based on the written communication, we can assume the verbal communication was the same or similar. However, this is only an assumption. We note the paramedics’ statements, collected as part of the complaint response, differ slightly to Mrs F’s account:
• Mrs F agreed to the plan to remain at home • Mrs F was agreeable to take oral paracetamol and did so • the paramedics provided written worsening care advice and verbally spoke through the advice, which Mrs F followed by contacting her GP.
38. There is also a character reference enclosed with the complaint review. This notes the paramedics had been known to be ‘polite, courteous, and professional.’
39. Based on the recounts of both the paramedics and Mrs F, it would be difficult to reach a decision on what happened and, in the absence of guidelines, whether this was what should have happened. In its complaint response, we can see the Trust apologised for leaving Mrs F upset following the paramedics’ attendance. It advised the operational team leader would discuss the behaviour of the staff member with them and explain how this can lead to intention misinterpretation. The team leader documented they would encourage the staff member to be mindful of this moving forward.
40. Our NHS complaint standards say when something has gone wrong, organisations should identify suitable and appropriate ways to put things right for people. This should include meaningful apologies and explanations that openly reflect the impact on the people concerned. Organisations should see complaints as an opportunity to improve services. Any actions taken to remedy a complaint should be fair, reasonable, and proportionate.
41. The Trust has apologised for leaving Mrs F upset. It has spoken to the staff member about being mindful of intentional misinterpretation. We consider this to be an acknowledgement the verbal communication could have been better.
42. Mrs F told us her desired outcomes would be an apology, acknowledgement, and service improvements. As the Trust has already offered this, we consider it has taken the appropriate actions to put things right. We would not ask an organisation to repeat actions it has already taken.
43. Mrs F also told us one of her desired outcome would be a financial remedy. We use our SOI scale to make consistent, fair and transparent recommendations. The scale has six bands ranging from level one injustices, including worry, pain and annoyance of relatively short durations, up to level six, which are life changing events often with profound consequences.
44. Our SOI scale puts Mrs F’s injustice at level one. A level one injustice typically arises from a single incidence of maladministration or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or wider ongoing impact. This is the case for Mrs F. We would not recommend a financial remedy for a level one injustice and generally consider an apology to be an appropriate remedy.
45. We are satisfied the Trust has taken appropriate steps to put things right. This is especially so when we consider there is limited evidence to support a wider impact. We do not consider there are any indications it needs to do more to remedy this part of the complaint.