Ambulance trust failed to record patient care

What happened

When Mr H's health deteriorated, his daughter called 999. She asked that Mr H was taken to a specific A&E that had the facilities to treat his suspected condition. When paramedic staff declined this request, she drove Mr H herself.

Mr H and his daughter complained about the service he had received. Among their concerns was the level of information shared by the paramedics, the paramedics' attitude, and the decision to take Mr H to the nearest A&E rather than the one requested. Mr H also complained about the length of time the Trust took to deal with his complaint.

What we found

We partly upheld this complaint. The paramedics did not fill in a patient report form, a clinical record of care given by an ambulance crew, to show the advice and care they had given Mr H. Because there was no patient report form, we could not decide, on the balance of probabilities, what happened.

We did not find fault with the time the Trust took to deal with Mr H's complaint.

Putting it right

The Trust discussed this complaint with staff, and they now know that documentation should be completed every time they go to a patient. The Trust also apologised to Mr H for the impact its poor form filling had on resolving his complaint.