East Midlands Ambulance Service NHS Trust

8. Ms A complains about the care her father, Mr A, received from the Trust on 3 August 2022. In particular, she complains the ambulance crew:

• did not advise Mr A about the risks of not going to hospital when it assessed him • did not check Mr A could stand before leaving him - he could not, so it was not safe for him to be left at home.

9. Ms A says as a result, Mr A was left at home in a chair, unable to move or use the bathroom. He developed pneumonia and sepsis by the time the second ambulance crew arrived on the morning of 4 August. Ms A had to deal with Mr A’s focal aware seizures all night until the second ambulance crew arrived which was distressing for them both.

10. Ms A is seeking an acknowledgment, thorough explanations, service improvements and financial remedy.

11. Mr A was 81 years old. He had a history of restless leg syndrome for around six months prior to the events and was taking anticoagulants (medication that prevents or reduces blood clots).

12. On 3 August 2022 at 3.50pm emergency services were called as Mr A had fallen in the street, near his house earlier that day, due to his legs giving way. He had sustained a head injury. Emergency services told Mr A that the wait for an ambulance would be four hours, so he was taken home in a wheelchair by nurses from his GP practice. He was lifted into the wheelchair by passersby as he was unable to stand.

13. Mr A fell again when he was trying to go to the bathroom. He was lifted back to his chair by a neighbour. He was unable to move his left side and was having seizures.

14. An ambulance crew attended at around 7.55pm and assessed him. The records state Mr A said he did not want to go to hospital, as his restless leg syndrome had been going on for a long time. Ms A disputes the crew talked to her father about going to hospital.

15. The ambulance crew spoke to a doctor from the 111 service because Mr A had declined to go to hospital. 111 is a service providing direction and support for urgent care needs. The 111 doctor said Mr A did not need to go to hospital, taking into account his medical history and observations at the time. They advised Mr A should speak to his GP about a possible referral to a neurology service in the morning.

16. The crew left Mr A that evening with safety netting advice (advice on how to seek further medical help if a patient’s condition worsens, fails to improve or if new symptoms develop). They also provided Mr A with a care advice leaflet which advised him to call 999 if he suspected a stroke or heart attack, if he lost consciousness, had another fall or had symptoms such as chest pain.

17. Emergency services were called again and an ambulance arrived at around 11.14am. He was assessed by the ambulance crew who noted he had a chest infection and was experiencing seizures, and he was transported to the Emergency Department (ED) at another Trust later that day. Clinical staff suspected that Mr A had seizure like activity or jerky movements either caused by the head injury or due to infection.

18. Mr A sadly died from metastatic cancer of the brain six weeks after his fall on 19 September 2022. This was diagnosed during Mr A’s admission to hospital and was not known at the time of the falls.

Assessment in relation to standing

22. Ms A told us the ambulance crew that attended to Mr A on 3 August 2022 did not check he could stand. She said he was unable to stand, so he should not have been left at home as it was not safe.

23. Mr A had fallen, which was the primary reason for the initial 999 call. The electronic patient report form (EPRF), which is a form used by paramedics and clinicians to contemporaneously record patient data at the scene, states Mr A’s shaking legs had caused him to find mobilisation difficult (though not impossible) for the last six months. He had fallen in the street, having been able to walk there. We understand from our paramedic adviser this shows his inability to stand, given that he had fallen in the street, was likely a new presentation or an acute worsening of his current situation. Ms A told us he fell again before the ambulance crew arrived and had to be lifted into a chair by a neighbour. The second fall supports that he was unable to stand. Mr A was sitting upright with his legs raised in a recliner chair when the ambulance crew arrived.

24. Our paramedic adviser told us the assessment of a patient following a fall is complex and multi-faceted, reflecting that there are many reasons a patient might fall. The JRCALC guidance on ‘falls in older adults’ states ‘a thorough and careful physical examination is required along with a high index of suspicion, to exclude common but easily missed injuries’.

25. JRCALC states ‘postural hypotension should be checked for if there is no clear extrinsic cause of the fall, if there are no features to suggest an alternative cause, if symptoms are typical such as light-headedness, dizziness or feeling weak and faint on standing and if the patient is being considered for management at home’. Our paramedic adviser told us that Mr A did not have an extrinsic factor which include external or environmental influences that increase the likelihood of a fall, such as environmental hazards, mobility aid issues or medication-related effects.

26. He therefore should have been assessed for postural hypertension (low blood pressure when you stand up). We have not seen anything in the records to indicate Mr A was asked to stand up. As such, this assessment could not have taken place.

27. JRCALC also indicates that a functional assessment of mobility should be considered. It advises to ‘observe the person getting up from their chair, balancing on standing, walking around their home (including turning) and sitting down again- using their usual walking aid if applicable’. It further states that steadiness, safety and confidence in relation to weight-bearing should be considered and ambulance crews should also consider whether the person can get to the toilet/commode and transfer on and off it safely.

28. The EPRF states ‘pt is not able to weight-bear just to having a fear of falling and the recurring shaking legs’ which shows Mr A was able to move his legs normally when sat down, but this is not a sufficient alternative assessment to determine if his legs were strong enough to support his body weight i.e. that he had enough strength to stand.

29. As the records do not show Mr A’s walking and ability to stand was assessed in line with the above guidance, our current thinking is the Trust did not act in line with applicable standards.

30. In relation to Mr A’s head injury due to the fall, the JRCALC head injury guideline says assessment of a head injury should include assessment of focal neurological deficit including ‘loss of balance’, ‘general weakness’ and ‘problems walking’. From what we have seen, none of these factors were assessed.

31. Our paramedic adviser commented that the EPRF states ‘no abnormal gait’ and says this cannot have been established if Mr A had not been asked to stand. As a result, our current thinking is the documented neurological assessment is not reflective of the assessment carried out on scene.

32. With this in mind, and as we have no evidence showing the details of what exactly was said in the call to the 111 doctor, we cannot give any view as to whether the decision to agree Mr A could stay at home was safe.

33. The Trust’s complaint response of 22 September 2023 acknowledges Mr A’s legs were weaker than usual and this was not taken into consideration when completing the clinical assessments, which impacted the ambulance crew’s decision making. However, its complaint response dated 12 February 2024 states adequate assessments were carried out in relation to Mr A’s ability to stand, indicating it does not consider there were any failings in relation to the assessments of Mr A’s ability to stand. We cannot see the evidence available supports the view that adequate assessments of Mr A’s ability to stand were carried out.

34. The evidence suggests the above assessments were not carried out, so the true clinical picture in relation to Mr A’s ability to stand was not clear. We consider this fell below the standards expected. We have considered the impact of this failing below.

Risks of not attending hospital

35. Ms A is concerned the Trust did not advise Mr A about the risks of not going not going to hospital when it assessed him.

36. Ms A said by the time she arrived at his home at 10.15pm, he was unable to sit up, meaning he was unable to use the bathroom or even a bottle to relieve himself. She said he was having focal aware seizures (brief seizures where the person remains conscious and alert) and developed sepsis (a life-threatening response to infection) and pneumonia (lung infection) by the time the second ambulance crew arrived the following morning.

37. We have seen no evidence of what risks were explained to Mr A of not attending hospital either for the fall or for the head injury. The EPRF indicates Mr A refused to go. As he did not want to go, the ambulance crew had a discussion with the 111 doctor and the agreement was for him to stay at home with safety netting advice and a recommendation to contact his GP the next day about his legs.

38. Our paramedic adviser explained that for Mr A to make a decision to refuse transportation to hospital, he must be appropriately informed of the risks so he can weigh up the information. This is described as the ‘Montogomery Principle’. The responsibility is on the health provider, in this case the Trust, to disclose material risks to the patient so that they can make an informed decision about their treatment. Whilst Mr A should be involved and asked for his decision on what he wanted to do, he needed the information to make that decision in his own best interests.

39. Lots of patients will express a preference not to attend hospital, but that is not the same as refusing to attend hospital if they are advised to do so. The EPRF states Mr A ‘does not want to go to ED’, but we do not know if his decision would have been different had he been provided with and understood the full risk of not attending. We have not seen clear evidence in the records that the risks of remaining at home were explained to Mr A. The EPRF states he was given ‘worsening advice revolving around hitting head on blood thinners’ rather than specifically stating why he should attend hospital and the risks of not doing so.

40. We consider the lack of clear evidence explaining the risks of not attending the emergency department is a failing and a missed opportunity for Mr A to make an informed decision about whether or not to go to hospital.

Impact

41. Our paramedic adviser told us that, had an adequate assessment of Mr A’s mobility been carried out, the ambulance crew may have identified that Mr A was unable to function safely within his own home. The lack of an adequate assessment therefore led to a missed opportunity for Mr A to make a different decision about transfer to hospital. We consider the impact of this is the uncertainty of not knowing if he would have made a different decision about whether or not to go to hospital and the distress this will cause to Ms A as a result.

42. Whilst it is unclear whether Mr A did not want to go or refused to go to hospital, we consider that on balance, he missed the opportunity to make a different decision about transfer to hospital due to not being properly informed of the risks of not going. As above, we consider the impact of this is the uncertainty of not knowing whether Mr A would have made a different decision and the distress this will cause Ms A.

43. As we cannot give any view on the balance of probabilities that Mr A would have decided to accept transfer to hospital on 3 August if a full and comprehensive discussion about risks had taken place, we also cannot give any view that Mr A’s deterioration and Ms A’s clearly very stressful experience in caring for her father that evening were avoidable.

44. However, for reassurance, we discussed with our emergency department adviser whether Mr A was showing signs on 3 August of the illnesses he would go on to receive care for when he attended hospital the next day. This is because we know Ms A is very worried that her father needed treatment for sepsis and pneumonia on the evening of 3 August.

45. We understand from our emergency medicine adviser there is nothing in the records that shows Mr A had sepsis or pneumonia when the ambulance crew attended to him on 3 August. The EPRF states Mr A’s NEWS score was 1 on 3 August at 8.32pm. NEWS (National Early Warning Score) determines the degree if illness of a patient using a 0-20 points system where 1 would indicate low-risk mild physical deviation from normal. As there are no indications he had pneumonia or sepsis or that these conditions should have been diagnosed when the ambulance crew attended to him on 3 August, we cannot say he needed to be taken to hospital for treatment of these conditions at that time. We hope this provides reassurance to Ms A.

1. Ms A complains about the care and treatment East Midlands Ambulance Service NHS Trust provided to her dad, Mr A on 3 August 2022.

2. We have found failings in that the Trust did not adequately assess Mr A’s ability to stand before leaving him at home, nor adequately explain the risks of not attending hospital, given his condition.

3. We consider that, if the Trust had carried out an adequate assessment of Mr A’s ability to stand, it may have identified it was unsafe for him to be left at home. As the risks of not attending hospital were not adequately explained, Mr A was not given the opportunity to make an informed decision about whether he should attend hospital.

4. We consider these errors led to a missed opportunity for Mr A to make a different decision about whether he should attend hospital. We consider the impact of this is the uncertainty of not knowing if he would have made a different decision and the distress this will cause Ms A as a result.

5. The Trust has recognised Mr A’s legs were weaker than usual and this was not taken into consideration when completing the clinical assessments, which impacted the ambulance crew’s decision making. It has explained it is now reviewing processes for assessing and treating patients and how to communicate better with patients and families who do not want to go to hospital.

6. However, it has not yet fully recognised the failings we have identified and the impact caused to Ms A. As these issues have not been remedied, we partly uphold Ms A’s complaint and recommend the Trust acknowledges and apologises for the failings and takes action to show how it has learnt and reflected on them.

7. We acknowledge the ongoing distress the events have caused Ms A and hope she finds our final report helpful.

46. As we have partly upheld the complaint. We have made recommendations to the Trust, as detailed below. We make recommendations in line with our ‘Principles for Remedy’ (Our Principles) which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. Our Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

47. Our Principles are 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.

48. In line with this, we have found:

• Mr A’s ability to stand was not adequately assessed. An adequate assessment may have shown it was unsafe for him to be left at home.

• the risks of not attending hospital were not adequately explained to Mr A, meaning he was not in a position to make an informed decision about whether or not he should attend hospital.

• The failings led to a missed opportunity for Mr A to make a different decision about transfer to hospital. We consider the impact of both the above failings is the uncertainty of not knowing if he would have made a different decision and the distress this will cause Ms A as a result.

49. Ms A requested financial remedy as an outcome of her complaint. To assess whether financial remedy is appropriate and if so, the level of financial remedy we should recommend, we use our ‘Severity of Injustice Scale’ – full details are available on our website. In Ms A’s case, we think the injustice caused by the Trust’s failings sits at level 1 of our scale which does not attract a financial remedy:

• Level 1: Low level injustice such as annoyance, frustration or worry arising from a single incident of maladministration where the effect is of a short duration.

50. This is because the injustice of Ms A having to look after Mr A and the associated distress, occurred over a short period of time (overnight) and Mr A did go to hospital the following day, on 4 August, after the second ambulance crew attended to him. The records show the second call for an ambulance was made at around 2.48am on 4 August. The first ambulance crew gave safety netting advice before it left. Whilst we understand Ms A will have been distressed at the time, she could have called sooner if she was concerned about Mr A’s condition/deterioration.

51. Additionally, we think the apology and service improvements are enough to remedy the failings we have found in relation to not adequately assessing Mr A’s ability to stand and not adequately explaining to risks of not attending hospital and the impact of uncertainty and distress this caused to Ms A. Ms A has highlighted to us that the second fall happened whilst waiting for the first ambulance to arrive, not after the first ambulance left. This means the second fall did not happen as a result of the first ambulance crew leaving Mr A at home as we initially thought was the case, which lessens the injustice overall.

What the organisation should do

52. Our Principles say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

53. We therefore recommend the Trust writes to Ms A to:

• acknowledge and apologise for not adequately assessing Mr A’s ability to stand and not adequately explaining the risks of not attending hospital, and the impact of uncertainty and distress this caused to Ms A. We will likely ask the Trust to do this within one month of our final report and send a copy to us.

54. Our Principles also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.

55. We therefore recommend the Trust produces an action plan to ensure that in similar circumstances in the future, staff carry out the necessary assessments to check an individual’s ability to stand and explain the risks of not going to hospital, so that individuals can make an informed decision about whether or not to go. The plan should:

• identify the reason(s) for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will be/was monitored • be shared with us and Ms A within three months of our final report.

56. We recognise the ongoing impact and distress that the events have on Ms A. We thank her for bringing her concerns to us and acknowledge how important her complaint is to her.