Elderly lady's leg fractured by ambulance crew

What happened

Mrs Y, who was in her nineties, was taken from her nursing home to her local A&E by ambulance because she had a suspected gastric bleed

When the ambulance arrived, the manager of the nursing home told the ambulance crew that Mrs Y needed to be transferred using a hoist, as she was unable to stand or to move her legs. The manager was then called away and did not see what happened next.

When Mrs Y was admitted to hospital, she was found to have a fractured left tibia (shinbone). She told her daughter and nursing home staff afterwards that she had been transferred without a hoist. She said that the crew had ignored her warning about not being able stand and she experienced great pain in her leg during the transfer. Mrs Y passed away in early 2013 and her death certificate stated that the fracture was a contributory factor to her death, although not the direct cause.

Mrs Y's daughter complained to the Ambulance Trust and it carried out an investigation. It found that the ambulance had been supplied by an independent provider commissioned by the Trust. This had been necessary because the Trust themselves did not have sufficient capacity to meet the need in the area at that time.

The Trust's investigation was hampered because it could find no Patient Care Record for the journey. This is the written record which should be completed for every ambulance journey; one copy should be retained by the Trust and the other copy should be filed in the patient's hospital records. Neither could be found in this case. There was a delay before the ambulance crew were asked for their statements about the complaint, by which time they said that they could not remember the incident.

The Trust concluded that it could not clarify what happened, but apologised that the standard of care she had received was below what was expected.

What we found

On the balance of probabilities, Mrs Y's leg was broken while she was under the care of the ambulance crew as a result of an inappropriate transfer without a hoist. It was likely that no Patient Care Record had been completed for the journey. This was in breach of the independent provider's contract with the Trust.

The Trust's investigation of this incident was poor and Mrs Y's daughter was not kept updated as to the reasons for lengthy delays in the Trust's response. The response itself was inconclusive and did not acknowledge the full extent of the failings, or indicate that appropriate action had been taken to address them.

The Trust had, however, taken appropriate action to ensure that its monitoring and oversight of independent ambulance providers had been significantly improved since the time of these events. We saw evidence that it had made a number of changes to avoid similar problems happening in future. The Trust continues to make improvements both in its service and its complaint handling.

Putting it right

The Trust apologised to Mrs Y's daughter and paid her £7,000 in recognition of the distress caused by its failings.

It carried out its own retrospective Serious Incident Investigation, as this was not done as it should have been at the time. It met Mrs Y's daughter to discuss its findings

The Trust considered whether further action was needed to ensure that Patient Care Records are completed for all patient journeys and whether it takes robust action when this requirement is breached.