You said, we did

 1

A non-mobile patient was transported to hospital but due to severe hospital pressures, the patient had to wait in the back of the ambulance for a considerable length of time. Due to the long wait in the back of the ambulance the patient had soiled themselves and developed pressure sores.

The investigation highlighted the crew had informed the hospital staff that they had a non-mobile patient who had soiled themselves although they were not aware of the extent of the situation. Following a reflection of this situation the crews have recognised that they could have communicated better with the hospital staff and asked for an area to be provided for patient personal care even when they hospital is under extreme pressures. By the hospital providing ambulance staff a suitable area to clean patients, this would prevent unnecessary skin sores and improve skin integrity for patients who are lying on stretchers for long periods of time 

Promoting better communication between crews and hospitals for patients personal care. Information on pressure skin sores and skin integrity has been sent out to all staff to promote learning and to prevent pressure sores and skin integrity for our patients. The crews have reflected on this incident and have learnt they can request an area at the hospital to provide personal care for non-mobile patients whilst waiting to be handed over to the hospital. Article to be featured in October’s Safety Matters newsletter highlighting patient safety with delayed hospital handovers.

 2

A complaint was received regarding a 90 minute response for an ambulance attendance to a serious fall outside. Five further calls were made by members of the public. The patient was taken to hospital where they were diagnosed with multiple fractures and a punctured lung. During treatment in hospital, the patient developed sepsis, causing her oxygen and pulse levels fell to a critical level. This complaint was also reviewed by the Parliamentary and Health Service Ombudsman.

The investigation highlighted that there were four calls received in relation to the incident. An error was identified on the second call where the incorrect protocol was selected, however following auditing, it was identified that this did not affect the categorisation (outcome) of the call. During the Parliamentary and Health Service Ombudsman investigation it was established that there was an error with the international 999 Advanced Medical Priority Dispatch System (AMPDS) triage system. Protocol 17 (used for falls) should have prompted the call handler to ask which part of the body was injured and if the patient was having any trouble breathing. This investigation highlighted a national system wide issue and concluded that, had the correct question been prompted under the falls protocols then the calls would have resulted in a faster response to the patient.

Although there were no specific failings for us, this complaint identified learning on a worldwide scale regarding AMPDS. The Parliamentary and Health Service Ombudsman have raised this issue with the International Academy of Emergency Medical Dispatch, the company that created and manages the system worldwide. This was addressed in a global update of the system. The Ombudsman also raised this with NHS England and Improvement to cascade the issue to all the ambulance services in England.