West Midlands Ambulance Service
NHS / Health Body
Action Taken
The paramedics attended further training which covered the Trusts expected standard of completing and checking documentation. The local management team for the Black Country have been reminded of the importance of providing statements in a timely manner. (AI summary)
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Dear Ms Lees
Re: Regulation 28 Report to Prevent Future Deaths – Elsie Taylor (Deceased)
Thank you for your email dated 11 December 2020 attaching your Regulation 28 Report. In your Regulation 28 Report.
Please see our response to your concerns, which has been formulated following a clinical review with the paramedic who attended the Inquest.
Concern 1 The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest;
Response During the meeting with the paramedic, he stated the patient was advised to attend hospital but refused, this refusal was not documented on the EPR. The paramedic also made admissions that he did not thoroughly check the EPR which the student paramedic had completed prior to him signing it. The importance of the EPR and the information contained in it was reiterated to the paramedic. Both crew members have attended further training which covered the Trusts expected standard of completing and checking documentation.
We would like to apologise for the delay you experienced in receiving the statement. The local management team for the Black Country have been reminded of the importance of providing statements for your office in a timely manner.
Concern 2 The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;
Response The paramedic acknowledged that the patient was on anti-coagulation medication, he informed the clinical review meeting that he advised the patient that she should go to hospital but the patient refused due to concerns about COVID -19. This discussion was not documented on the EPR. A safety net was put in place and the patient was asked to contact her GP or call 111/999 in the case of an emergency, this was documented on the EPR and discharge sheet. The patient was not asked to sign the EPR, this should have taken place for a non conveyance. As part of the further training attendend by the crew the importance of asking the patient to sign the non conveyance section of the EPR was covered.
Concern 3 There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased;
Response A discharge sheet was left with the patient, which detailed that the patient was to contact the GP or in the case of an emergency to call 999/111. The paramedic has confirmed that there was no family present but there was neighbour in attendance throughout the whole consultation. The neighbour was shown the bruise on the patient ribs and she informed the crew that she would stay with the patient for some time to keep an eye on her.
Concern 4 There was no note left by the attending paramedic crew detailing the outcome of the consultation;
Response Please refer response under concern 3
Concern 5 The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission;
Response The box ticked on the discharge form states that the patient had been advised to contact or attend her GP practice. If a referral had been made on behalf of the patient one of the boxes at the top of the form would have been ticked.
Concern 6 The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR).
Response There was a neighbour in attendance throughout the consultation including at the point of discharge and it was the crews belief that she would stay with the patent. The patient stated that her daughter was at work and that she did not want her to be disturbed.
Please be assured that both crew members have attended our training school and have completed a number of refresher training sessions to ensure they are fully trained in the areas discussed in their clinical case reviews.
Can I please take this opportunity to pass on my sincere condolences to the family of Ms Taylor
I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report.
If you require any further assistance, please do not hesitate contact me.
Re: Regulation 28 Report to Prevent Future Deaths – Elsie Taylor (Deceased)
Thank you for your email dated 11 December 2020 attaching your Regulation 28 Report. In your Regulation 28 Report.
Please see our response to your concerns, which has been formulated following a clinical review with the paramedic who attended the Inquest.
Concern 1 The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest;
Response During the meeting with the paramedic, he stated the patient was advised to attend hospital but refused, this refusal was not documented on the EPR. The paramedic also made admissions that he did not thoroughly check the EPR which the student paramedic had completed prior to him signing it. The importance of the EPR and the information contained in it was reiterated to the paramedic. Both crew members have attended further training which covered the Trusts expected standard of completing and checking documentation.
We would like to apologise for the delay you experienced in receiving the statement. The local management team for the Black Country have been reminded of the importance of providing statements for your office in a timely manner.
Concern 2 The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;
Response The paramedic acknowledged that the patient was on anti-coagulation medication, he informed the clinical review meeting that he advised the patient that she should go to hospital but the patient refused due to concerns about COVID -19. This discussion was not documented on the EPR. A safety net was put in place and the patient was asked to contact her GP or call 111/999 in the case of an emergency, this was documented on the EPR and discharge sheet. The patient was not asked to sign the EPR, this should have taken place for a non conveyance. As part of the further training attendend by the crew the importance of asking the patient to sign the non conveyance section of the EPR was covered.
Concern 3 There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased;
Response A discharge sheet was left with the patient, which detailed that the patient was to contact the GP or in the case of an emergency to call 999/111. The paramedic has confirmed that there was no family present but there was neighbour in attendance throughout the whole consultation. The neighbour was shown the bruise on the patient ribs and she informed the crew that she would stay with the patient for some time to keep an eye on her.
Concern 4 There was no note left by the attending paramedic crew detailing the outcome of the consultation;
Response Please refer response under concern 3
Concern 5 The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission;
Response The box ticked on the discharge form states that the patient had been advised to contact or attend her GP practice. If a referral had been made on behalf of the patient one of the boxes at the top of the form would have been ticked.
Concern 6 The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR).
Response There was a neighbour in attendance throughout the consultation including at the point of discharge and it was the crews belief that she would stay with the patent. The patient stated that her daughter was at work and that she did not want her to be disturbed.
Please be assured that both crew members have attended our training school and have completed a number of refresher training sessions to ensure they are fully trained in the areas discussed in their clinical case reviews.
Can I please take this opportunity to pass on my sincere condolences to the family of Ms Taylor
I hope this response provides you with the appropriate level of assurance that as a Trust we have dealt with the concerns highlighted within your report.
If you require any further assistance, please do not hesitate contact me.