GOVERNING BODY PAPER Meeting Date: 17 December 2013 Title of Paper: Patient Story Sponsor: Dr Cheryl Crocker, Director of Quality & Patient Safety Agenda Item No: GB 13/153 Allocated Time: 5 mins (Please tick relevance) Acknowledge Approve Consider Review Support Purpose of the report/document The Governing Body is asked to NOTE the story and ENDORSE the recommendations Key Points (Provide full context of agenda item) This story focuses on a patient who required an ambulance following a fall. The ambulance arrived nearly three hours later. The patient was told she could not be moved and so lay on the floor. The lady had a deep laceration to her leg and has subsequently suffered from a chest infection. The emotional trauma was significant. Delays in treatment can result in further injury and increased frailty Document links See full document attached. Implications: (please tick where relevant) Commissioning (Inc. Integration & Patient & Public Involvement Reducing inequality) Constitution Quality of Services Governance Innovation QIPP Research Learning and Development Sustainability Patient Choice Version 1.0 April 2013 Page 1 of 6
Patient Story Subject: Significant delay in provision of ambulance placing patient at risk. Date of meeting: 17 December 2013 Presented by: Dr Cheryl Crocker Report prepared by: Hilary Cole Mrs B.I. a 95 year patient in residential care home sustained a fall resulting in a serious leg injury which subsequently required stitches. An ambulance took 2 hours 37 minutes to arrive during which time due to possibility of the patient having a hip fracture she was required to lie on the wooden floor (where she fell) covered in blankets to keep warm. Summary: In spite of good care from care staff the patient subsequently developed a serious chest infection. The patient also developed a significant infection in her leg which so far has not healed and continues to give cause for concern. Whilst waiting for the ambulance the patient s daughter (Ms M.I.) and care staff rang the ambulance service 5 times. The daughter found the experience traumatic and continues to be extremely anxious about her mother s health and welfare. Mrs M.I. experienced similar problems at the beginning of 2012 causing her to make her first formal complaint about EMAS. Her mother s subsequent experience has left her exceptionally disillusioned about the quality of emergency patient transport provision for older, frail patients. Recommendation: The Governing Body notes the content of this complaint, and understands the human suffering experienced by both patient and her family as a result of significantly delayed emergency transportation. The Governing Body is also asked to endorse the recommendations made for service improvement. NICE clinical guidelines: 2012, Patient Experience in Adult NHS Services: improving the experience of people who use adult NHS services.
No. Quality Standard Application 1 Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty. No: the patient s frailty and injuries were not taken into consideration by the provider until the end of the process. Patients dignity was compromised by the inadequate response by the provider, and generally the patients (non clinical) treatment lacked an appropriate level of 2 Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills. 3 Patients are introduced to all healthcare professionals involved in their care, and are made aware of the roles and responsibilities of the members of the healthcare team. 4 Patients have opportunities to discuss their health beliefs, concerns and preferences to inform their individualised care. 5 Patients are supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences. 6 Patients are actively involved in shared decision making and supported by healthcare professionals to make fully informed choices about s, treatment and care that reflect what is important to them. 7 Patients are made aware that they have the right to choose, accept or decline treatment and these decisions are respected and supported. 8 Patients are made aware that they can ask for a second opinion. 9 Patients experience care that is tailored to their needs and personal preferences, taking into account their circumstances, their ability to access services and their coexisting conditions. compassion No: Patient and her daughter were not kept updated regarding the ambulance arrival time causing unnecessary anxiety. Provider failed to be proactive in communication with the patient, her daughter or care staff at the home. No: Provider failed to be proactive in communication with the patient, her daughter or care staff at the home regarding delays. Also provider failed to facilitate effective information from the patient s daughter or care staff which could have ensured patient was offered timely provision of ambulance. No: See above. Not wholly applicable to complaint scenario No: See 1 above. Had provider ensured awareness of full extent of patients frailty and significant injury and then taken this into account ambulance may have been dispatched more swiftly reducing the amount of time the patient was lying on a wooden
10 Patients have their physical and psychological needs regularly assessed and addressed, including nutrition, hydration, pain relief, personal hygiene and anxiety. 11 Patients experience continuity of care delivered, whenever possible, by the same healthcare professional or team throughout a single episode of care. 12 Patients experience coordinated care with clear and accurate information exchange between relevant health and social care professionals. 13 Patients' preferences for sharing information with their partner, family members and/or carers are established, respected and reviewed throughout their care. 14 Patients are made aware of who to contact, how to contact them and when to make contact about their ongoing healthcare needs. floor. This in turn may have facilitated receipt of more urgent treatment, reduction in subsequent health problems and quicker recovery No: Lack of proactive assessment by provider meant the patient was not appropriately assessed by a healthcare professional until an Emergency Care Practitioner attended after 2.37 hours. Care staff provided appropriate general care but were necessarily not trained to provide appropriate specialist healthcare. No; Until paramedic attended only minimal healthcare was provided No: Provider failed to communicate effectively with care staff. Part 1: The Patient s Story The story of Mrs BI and her daughter Mrs MI Mrs MI wrote to complain on behalf of her mother Mrs BI. Mrs MI advised the CCG that her mother is 95 and living in residential care. On 7 th November her mum suffered a severe fall at the care home sustaining a serious cut to her leg which was bleeding profusely. Care staff responded immediately and dialed 999 for an ambulance. This was 12.24pm. EMAS call handlers advised care staff that Mrs BI should not be moved in case she had sustained a broken hip. Care staff therefore made Mrs BI as comfortable as possible on the hard wooden floor, covering her in blankets to keep her warm. They contacted Mrs MI, and the residential care nurse attended to the patient s leg injury which appeared to be a serious cut down to the bone. They attempted to reduce the bleeding and waited for the ambulance to arrive. At 15.01pm an Emergency Care Practitioner arrived at the care home and with the assistance of care staff was able to assess and attend to Mrs BI care needs, which included her requiring stitches in her leg wound. During the 2.37 hours wait for the ambulance, care staff and Mrs MI made five emergency phone calls to EMAS. Mrs BI became increasingly distressed. Mrs MI has told us that following her experience her mother continues to suffer from a serious chest infection which her daughter believes was caused by her (just less than three hour) ordeal lying on
the wooden floor. Mrs BI leg injury has also failed to heal and generally her physical and mental health has significantly deteriorated. In their response to the complaint, EMAS have advised that the five 999 calls were all coded appropriately by their call handlers. However at 14.34 the case was passed to their Clinical Assessment Team (CAT) to carry out a welfare call due to the length of time that had passed without assistance being sent to (the patient). The CAT team noted on the EMAS system that the patient had a laceration to the leg which was down to the bone.this further information enabled the call to be upgraded by the CAT team to require a response within 20 minutes EMAS have advised that due to the high demand for emergency responses on the day of the incident, there were no ambulance resources available at the time of the emergency call to allocate. Mrs MI has described her mother s ordeal as appalling. She is clear that she feels completely neglected by the ambulance service. Also as this is the second time she has had to lodge a formal complaint about what she experiences to be their failure Mrs MI is clear that she has no confidence if she needs to call for an ambulance in the future. Such is Mrs MI concern that she has taken her complaint to her MP. Whilst praiseworthy of our, she remains dissatisfied with the response she has received from EMAS which she advises is inaccurate and in parts, untrue. Mrs MI is seeking our involvement to facilitate a local resolution meeting with EMAS representatives to discuss her complaint further, in person. Her MP Anna Soubry has also taken her complaint forward with EMAS and has formally approached the north CCGs which have lead commissioning responsibilities for the provider. Part 3: Quality Improvement 1. The provider failed to provide an ambulance to a frail elderly patient in an appropriate and timely manner causing avoidable and unnecessary suffering to both the patient and her family. 2. The provider failed to proactively update the patient or family members with regards to the provision of an ambulance thereby enhancing rather than reducing anxiety levels 3. The system used by the provider to triage emergency calls failed to alert them to the seriousness of the patients condition and situation until two hours after the initial 999 call was received 4. The patient has suffered considerable ill health since the incident, which may have been significantly reduced had she received immediate and appropriate attention 5. The complainant is clear that the response (and explanation) provided by EMAS is inaccurate. It also fails to acknowledge this is the second complaint made by this complainant about their organisation within one calendar year. Recommendations: As above, lead commissioning responsibilities for EMAS rest with the north CCGs, who have advised they have taken the following steps to facilitate change and improvement: - 1. Concerns have been raised with the lead commissioner of the ambulance service and are assured that an action plan to address the concerns is being developed. 2. Locally, CCGs are supporting EMAS to improve their capacity and response times through the provision of additional non-recurrent monies and additional dedicated capacity for GP urgent admissions and people who have fallen.
3. In the longer term, CCGs (with EMAS) have commissioned an independent review of their capacity and service model and will be using this to inform the commissioning and development of the ambulance service over the coming years. CCGs have agreed improvement metrics for response times locally rather than the overall trust target to ensure our residents have a safe and equitable service. 4. A CQUIN for complaints management has been developed and Erewash CCG have agreed to use this with EMAS. This involves using the Patient Association methodology including an external peer review of complaints and a complainant satisfaction survey. From this areas for improvement will be identified and an improvement plan generated, monitored by commissioners.