Source · SPSO (Scottish Public Services Ombudsman)

Scottish Ambulance Service

SPSO (Scottish Public Services Ombudsman) Upheld Reference 201507996 Sector Health Category clinical treatment / diagnosis Decided 01 June 2016

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Full decision

Summary

Mrs C complained about an ambulance crew who attended her following a fall in her garden. After the fall, Mrs C knew she had damaged her back; she was in severe pain and could not move her legs. The crew attended without carry equipment and pulled her up into a garden chair and gave her gas and air. The crew appeared to be unsure about whether or not to take Mrs C to hospital but eventually did so (after an hour) and she was diagnosed as having fractured three vertebrae.

We took independent advice from an A&E consultant and found that, given Mrs C's reported symptoms, the location and severity of her pain, it was highly suggestive that Mrs C had suffered a lumbar (lower back) spinal fracture. As a result, she required a hospital assessment for an x-ray or CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) as required. It was not appropriate for the crew to have attempted an assessment of Mrs C on scene or to have tried to sit her on a chair, and her spine should have been immobilised. We upheld the complaint and noted that the service had already arranged for the Area Service Manager to review the case and allow the crew to reflect on their actions.

Recommendations

We recommended that Scottish Ambulance Service: apologise to Mrs C for the failings identified.

Related reading

View Decision Report 201507996 as a PDF (12.26 KB) Updated: March 13, 2018

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