Source · HSSIB Patient Safety Investigation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care
HSSIB’s introductionBetween April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
Published 23 March 2022
Published
HSIB Legacy
Emergency care
Indexed content
3 recommendations
1 observation
3 of 3 responded
Safety Recommendations
HSIB recommends that Trust A and Trust B update the information provided to the Directory of Service on the availability of stroke services once they have created a harmonised cross-trust stroke policy.
AI-generated response summary Trusts A and B committed to update the Directory of Service information on their overnight stroke services once the reorganisation of these services is completed.
Response received 13 June 2022, updated 12 September 2022
Trust A and Trust B responded to the safety recommendation as follows: Both Trusts will update the information they provide to the Directory of Service on their overnight stroke services on completion of reorganisation these services. Response received on 13 June 2022 and updated on 12 September 2022.
HSIB recommends that the Ambulance Trust works with Trust A and Trust B to ensure that their local stroke policies are aligned and direct ambulance crews to the most appropriate service.
AI-generated response summary The Ambulance Trust committed to work with Trusts A and B to review stroke pathways and will remind clinicians about existing stroke pathway information in the Directory of Service and trust guidelines.
Response received 10 May 2022
The Ambulance Trust responded to the safety recommendation as follows: The Ambulance Trust will work with Trust A and Trust B to review stroke pathways. The Ambulance Trust will remind clinicians that stroke pathways are available on the Directory of Service and in Trust guidelines. Response received on 10 May 2022.
HSIB recommends that Trust B works collaboratively with Trust A to develop a harmonised, cross-trust stroke policy with a clearly defined joint emergency department overnight stroke protocol for FAST-positive patients.
AI-generated response summary Trust B confirmed it is actively working with Trust A to develop a joint overnight stroke admissions protocol for FAST-positive patients, as recommended.
Response received 13 June 2022, updated 12 September 2022
Trust B responded to the safety recommendation as follows: Trust B is working with Trust A to develop a joint overnight stroke admissions protocol for FAST positive patients. Response received on 13 June 2022 and updated on 12 September 2022.
Safety Observations
It may be beneficial for the clinical commissioning group to provide oversight of stroke pathways until a hyper-acute stroke unit is established, to ensure that there is a clearly understood pathway for FAST-positive patients between 23:00 hours and 08:00 hours.
HSIB notes the following national safety risk
The investigation noted a delay in the handover of the Patient’s care from the paramedics to the emergency department. Handover delays will be explored in a future HSIB investigation.