East of England Ambulance Service NHS Trust

8. Mr O, complains that, on 4 April 2025, the ambulance crew from the East of England Ambulance Service NHS Trust (the Trust) inappropriately made him walk to the ambulance after he suffered a serious neck injury.

9. Mr O says that he needed surgery to remove part of his spine, and surgeons inserted metal plates and pins. He then spent time in a high dependency unit, lying flat on his back and unable to eat or drink. He is worried that the crew’s treatment of him may have exacerbated his injuries.

10. He says he later spent several months on a spinal ward and required a catheter, which he still has. He has had to relearn how to walk and eat, and he still cannot use his hand properly. He can no longer drive and now walk with a stick. Before this, he was very active. He regularly walked long distances and climbed hills and mountains.

11. As an outcome of the complaint, Mr O wants to know whether what happened made things worse for him. He would also like financial compensation.

12. On 4 April 2025, Mr O fell and landed on his neck and could not move. Paramedics arrived and lifted him up to treat a cut on his head. They assisted him to walk into the ambulance without any type of stretcher.

13. The ambulance records show the crew completed observations, including Mr O’s pulse and blood pressure. The records show he reported some neck pain and difficulty using his hands.

14. Hospital investigations identified a fracture in Mr O’s spine and damage to his spinal cord. The spinal cord is the bundle of nerves running through the spine that carries messages between the brain and the rest of the body.

15. Mr O had surgery to put in plates and pins in his neck. Mr O spent a long time in the high dependency unit and months on the spinal ward.

16. Mr O was transferred into rehabilitation to re-learn to walk and eat.

17. In mid-June, he was discharged from the Trust. He can no longer drive and now walks with a stick.

23. We carefully considered the information provided by Mr O, the ambulance records, the Trust’s investigation, relevant clinical guidance and independent clinical advice.

24. Mr O says the ambulance crew did not provide appropriate care for him when he had his accident. He says the crew should have immobilised him and used equipment to help him to the ambulance.

25. Mr O was assisted to walk to the ambulance with his pain and injury to his neck. He believes this has impacted his injury further causing further damage to his neck and spine.

26. The Trust said the crew acknowledged that they underestimated the severity of the injuries and sincerely apologised for this. During the clinical debrief with the staff, they acknowledged that they should have rolled Mr O onto his back whilst maintaining his spine in neutral alignment through manual immobilisation and performed their primary and secondary survey.

27. The Trust said the crew acknowledged that had they identified the potential neurological deficit, and that Mr O should have been immobilised with a minimum of the head blocks and orthopaedic scoop stretcher.

28. The Trust also explained what the crew would do to learn from this.

29. The ambulance records show Mr O reported pain in the back of his neck after his fall. They also show he had difficulty controlling his arms and gripping with his hands.

30. The JRCALC guidance says neck pain, weakness in the arms or hands, and changes in movement or sensation can indicate a possible spinal cord injury. When these symptoms are present, clinicians should protect and stabilise the spine until a spinal injury has been ruled out.

31. The records show the crew completed some appropriate observations, including checking Mr O’s pulse and blood pressure. Our paramedic adviser explained the pain recorded around C7/T1 area of the spine, which is where the lower neck and upper spine meet, together with weakness in Mr O’s arms and reduced grip strength, should have prompted spinal precautions.

32. This meant the crew should have treated Mr O as having a possible spinal injury. They should have manually supported his neck and spine and used suitable equipment, such as head supporters and a scoop stretcher to transfer him. Walking could have increased movement through the spine when the injury had not yet been assessed.

33. In the event, the crew did not do this; instead, they helped Mr O stand and walk to the ambulance.

34. For these reasons, we consider that the care provided likely fell short of what should have happened.

35. The Trust reached the same conclusion during its own investigation. It accepted staff underestimated the seriousness of Mr O’s injuries, acknowledged he should have been managed with spinal precautions.

36. We considered whether the crew getting Mr O to stand and walk had any impact Mr O’s long-term outcome.

37. We recognise Mr O sustained a very serious injury when he fell. He required surgery to stabilise his neck using plates and screws and spent time in the high dependency unit. He completed rehabilitation to relearn everyday activities and now walks with a stick and can no longer drive. We recognise the significant impact this has had on both Mr O and his partner, Ms T.

38. The spinal surgeon adviser explained that Mr O’s spinal injury and central cord syndrome were caused by the fall itself, rather than by the way the ambulance crew manged him afterwards. Central cord syndrome is a type of spinal cord injury that can occur when the spinal cord is stretched or compressed during trauma, even where the bones of the spine do not move out of place.

39. The hospital records show Mr O had a very rigid spine before the accident, meaning it was particularly vulnerable to injury during the fall. The fracture was sometimes described as a ‘chalk-stick-fracture’ because a rigid spine can break in a similar way to a piece of chalk.

40. Although he should have been immobilised because this gives patients the best possible chance of recovery, the MRI imaging scan showed that the fracture had not moved out of position.

41. This is important because it does not indicate that movement while Mr O was being transferred caused the fracture to become displaced.

42. The neurological symptoms recorded by the ambulance crew, including weakness in Mr O’s arms and difficulty gripping, were the same symptoms recorded when he arrived at hospital. His neurological condition remained stable and later improved during his admission. This means, fortunately, there is no evidence Mr O deteriorated between the accident and his arrival at hospital.

43. To summarise, our spinal surgeon adviser explained Mr O would still have required the same spinal surgery regardless of whether the ambulance crew had immobilised him correctly. The surgery was required because of the fracture caused by the fall, not because of anything that happened during the ambulance journey.

44. Although we have not found that the crew’s actions worsened Mr O’s long-term physical outcome, we recognise that he did suffer short term pain, and longer-term uncertainty as a result.

45. Mr O sustained a serious spinal injury. Being helped to stand and walk in those circumstances was likely to have caused him avoidable pain and discomfort in the short term.

46. We also recognise how distressing it was for Mr O to later learn that he should have been immobilised and transferred using specialist equipment.

47. It was entirely understandable that this caused him to worry that walking to the ambulance may have caused or worsened his injuries. Mr O experienced uncertainty, not knowing whether the crew’s actions had caused additional harm. We hope that our work helps him to put those worries to rest.

48. We considered whether the Trust has done enough to put matters right in terms of the short-term impact and longer-term worry.

49. The Trust acknowledged what went wrong. It apologised to Mr O and Ms T.

50. The Trust arranged a clinical debrief and reflected account with the crew. This required the Trust to review the assessment, identify what should have happened and consider how they would manage a similar situation in future.

51. The Trust also identified that the crew should use the relevant trauma assessment tools and share important information with the receiving hospital. It said the learning would be shared more widely.

52. Our Principles for Remedy say organisations should acknowledge mistakes, apologise, explain what went wrong and learn from complainants to prevent recurrence.

53. The Trust has acknowledged the failure, apologised and taken action aimed at reducing the risk of the same error happening again. We recognise that no action can remove the distress caused or change Mr O’s experience at the time.

54. Taking account of the nature of the injustice we identified, and the fact that the crew’s actions did not worsen Mr O’s long-term physical outcome, we consider the Trust’s response is proportionate. We do not consider further action is required.

1. We are sorry to learn of Mr O’s dissatisfaction following his experience with the Trust. He has understandably been left with a loss of faith in the Trust after worrying whether the crew’s actions worsened his serious injury.

2. We have carefully considered Mr O’s complaint about the Trust. Having done so, we have decided we will not investigate this complaint further. We hope our decision provides him with some reassurance that even though the wrong actions were taken, this did not make things worse for him.

3. We consider that the ambulance crew should have treated Mr O as having possible spinal injury and immobilised him. We did not find this caused his need for spinal surgery or his long-term physical outcome. Sadly, that would have been required, as a result of his injury.

4. We agree that Mr O suffered unnecessary discomfort at being asked to walk to the ambulance. This should not have happened.

5. The Trust has acknowledged this, apologised for it, and taken steps to learn from what happened. We think that goes far enough to put things right.

6. We understand this was and continues to be an incredibly difficult time for Mr O. Our decision is not made without recognition of the upsetting experiences he had with his care and its outcome.

7. We have explained the reasons for our decision below and we hope this provides Ms T and Mr O with some reassurance that his injury and outcome was not worsened by what happened with the crew.