Patient Story - February 2025

Meeting: Public Board

Date: 12 February 2025

Report Title: Patient Story – Leg Injury EOC Experience

Agenda Item: PUB25/02/1.4

Author: Victoria Boyce, Patient and Public Engagement Manager

Lead Director: Simon Chase, Chief Paramedic and Director of Quality

Purpose: Discussion/review

Link to Strategic Objective:

• Provide outstanding quality of care and performance

Link to CQC domain:

• Caring
• Responsive
• Effective
• Safe

Link to strategic risk(s):

• SR1a: If we do not ensure our people are safe and their wellbeing prioritised, there is a risk that we will be unable to attract, retain and keep all our people safe and well
• SR1b: If we do not ensure our leaders are developed and equipped, there is a risk that we will not be able to change our culture, and value, support, develop and grow our people
• SR4: If we do not resolve long standing organisational inefficiencies, we will be unable to deliver an effective, sustainable, value for money service to our public

Equality impact assessment: No negative impact identified

Previously considered by: The discovery interview has been reviewed by the Chief Paramedic and Director of Quality and has also been considered by the Executive Leadership Team.

Recommendation: To share the experience of a patient attended for a fall at home who was not conveyed to hospital. To update the Board and public on the learning taken from the non-conveyance thematic review under Patient Safety Incident Review Framework (PSIRF).

Purpose: The purpose of this patient story is to highlight the proactive involvement of staff and a family of a patient affected by a non-conveyance incident that will lead to improvements in patient care

Executive Summary:

This patient story depicts a patient’s experience using the ambulance service and has been reviewed as part of the Patient Safety Incident Investigation (PSII) – A thematic review around the non-conveyance of patients.

Introduction / Background:

This is an interview with Jonathan and Julie who called the ambulance service for Jonathan’s mother, Marjorie, when she fell at home hitting her arm and ribs on the arm of a chair. Marjorie had Osteoporosis and Jonathan and Julie were concerned how the fall would have impacted on her.

They called the ambulance service and were advised there would be a 4-hour wait. Julie and Jonathan attempted to take Marjorie to hospital themselves. When it was clear this wouldn’t be possible, they called the ambulance service again. The ambulance crew arrived 30-minutes later. Marjorie was assessed by the Paramedic who concluded that Marjorie had sustained soft tissue damage and advised at the time he didn’t feel she needed to go to hospital. Marjorie was seen by a GP a couple of days later, at the request of the crew. The GP suspected Marjorie had broken her arm and sent the family to the hospital for an x-ray. The hospital confirmed a broken arm. After returning home, Marjorie experienced severe back pain shortly after getting into bed. Jonathan and Julie called for an ambulance who conveyed Marjorie to hospital. Marjorie was further diagnosed with broken ribs and a chest infection and was admitted to hospital. Over the next nine days, Marjorie deteriorated and sadly died in the early hours of 10 June 2023. Following Marjorie’s death, Jonathan contacted the Trust to express the family’s concern that Marjorie wasn’t taken to hospital by the first crew who attended her and that her broken arm and ribs were missed and she did not receive prompt treatment. The concern raised regarding Marjorie’s experience was reviewed as part of the Patient Safety Incident Investigation (PSII) – A thematic review around the non-conveyance of patients. We thank Jonathan and Julie for their participation in assisting the Trust in learning from this patient safety event and wish to again express our condolences on the death of Marjorie.

Key Issues / Risks:

From the PSII – Non-completion of the action plan or failure to implement actions will see further patient safety events and poor clinical outcomes and experiences for future patients.

Key actions have been set under the following headings to address the safety recommendations in the PSII report:

• Audits of the safe discharge care bundle
• Electronic Patient Care Record updates to incorporate the amended safe discharge care bundle
• Promotion of shared decision-making with non-conveyance incidents
• Policy updates to align with changes to the care bundle and shared decision-making recommendations
• Alternate care pathways to be fully embedded in the NHS service finder to better support staff in safety-netting patients
• Continued monitoring of non-conveyance incidents by the Patient Safety team with a post-PSII review in 12-months to evidence improvement
• Sharing of the PSII report with system partners and National Ambulance Service Risk and Safety Forum to promote national learning

Options:

N/A

Summary:

Since adopting PSIRF, the Trust has completed two thematic reviews and has fully embedded the PSIRF approach. The second PSII is a review of the non-conveyance theme, this report has been written with proactive involvement of staff and a family of a patient affected by a non-conveyance incident. The thematic review incorporated 100 incidents of varying harm levels to maximise learning and assist with improving the overall safety of non-conveyance incidents.