HSIB: Local integrated investigation pilot 3 - Transfer of a patient who had suffered a stroke to emergency care (17 March 2022)

Summary

This report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a pilot launched to evaluate HSIB’s ability to carry out effective local investigations at specific hospitals and trusts, while still identifying and sharing relevant national learning. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB.

The investigation reviewed the case of a patient who had a stroke and was due to be taken to his local hospital emergency department (ED), but the ED advised paramedics this was not possible as their stroke service was closed. The alternative was to take him to a neighbouring hospital, but they also advised that they could also not take the patient. This was then referred back to the original ED, who restated their position, eventually leading to the neighbouring hospital agreeing to accept the patient. Once the patient arrived he then had to wait 40 minutes in an ambulance as the ED was very busy.

Content

A 75-year-old patient suffered a stroke in the early hours of the morning. He had woken feeling unwell (two hours after going to bed) and waited to see if his symptoms would improve. They didn’t improve and nearly three hours later, his wife called an ambulance.

Before they set off with the patient, one of the paramedics contacted the emergency department (ED) at the first hospital (Trust A) to ‘pre-alert’ them of his arrival. The ED advised that they could not accept the patient as their stroke service was closed between 11pm and 8am, and that the paramedics should contact a neighbouring hospital (Trust B). 

Trust B advised that they could not take the patient as he was outside of the window for immediate stroke treatment and should be taken to Trust A.

Trust A then reiterated that they could not accept the patient. The paramedic phoned Trust B again and they agreed to accept the patient. Once at Trust B, the patient had to wait 40 minutes in an ambulance as the ED was very busy.

It was then confirmed by CT scan that he had suffered an ischaemic stroke (a stroke caused by a blood clot in the brain), and he was taken to the intensive care unit.

Findings

The investigation found that: 

• There was no cross-trust policy in place that clearly defined which FAST-positive patients (patients who show symptoms outlined by the Face, Arms, Speech, Time acronym) should be taken to Trust B overnight. This resulted in different local interpretation of the overnight stroke arrangement.
• The different local interpretation resulted in the patient being “double bounced” between the two hospitals. Staff stated that this was “not uncommon” but would likely resolve once a centralised regional stroke treatment unit (a hyper-acute stroke unit) is in place.
• The electronic search tools accessible to ambulance crews provided inconsistent information about the availability of local stroke services. This was particularly confusing for the paramedics in the safety event, who did not routinely work in the local area.
• When the patient arrived at the hospital, his care was not handed over within the recommended 15 minutes.

Recommendations

The report makes the following local 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.
• 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.
• 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.