West Midlands Ambulance Service: Patient delayed on the back of an ambulance resulted in significant deterioration and ultimately death of patient (May 2021)

Summary

West Midlands Ambulance Service has highlighted the death of a woman which it says was due to “being delayed on the back of an ambulance”, just two days after it warned that lives were ‘at risk’ from long handovers. Below is the full account from the organisation's board paper.

Content

"For our May 2021 report, we are presenting a patient story of how a patient being delayed on the back of an ambulance resulted in significant deterioration and ultimately the death of a patient.

We have removed all patient identifiers from this account: The patient associated with this case was a lady in her early 90s who had a two hour history of epistaxis (the third episode within the space of a week), the bleeding would not stop despite direct pressure and the application of the 'rhino pinch' and packing of the patient’s nostrils.

The patient was extricated to the ambulance and conveyed to the hospital emergency department; during conveyance the patient remained stable, and the bleeding had begun to slow.

When nearing the hospital, the patient started to complain that blood had started to flow backwards into her mouth, and this was causing some discomfort. The patient was encouraged to use postural drainage (sitting forward and allowing it to free flow out of her mouth to avoid any airway compromise).

The crew had been denied access to the hospital Emergency Department, but recognising they had a situation that was proving difficult to manage they continued to attempt to get the lady into the department, but this was proving difficult.

Ten minutes after arriving at the hospital Emergency Department the crew still had their patient on the ambulance, despite a number of attempts to alert staff to the deteriorating position.

At this point, the crew gave a message to the triage nurse at the hospital that the lady needed to be seen by the Ear, Nose and Throat [ENT] surgeons rapidly as the bleeding was now uncontrolled and posing an airway compromise; this was met with resistance as the triage nurse stated that the hospital was at capacity and there were no available beds.

The crew were extremely concerned about the patient’s safety and contacted the WMAS emergency control room to see if they could take the patient on blue lights to a different emergency department or direct to an ENT service.

Unfortunately, at this point, 27 minutes after arriving at the Emergency Department the patient further deteriorated with a coughing episode, vomited, and then exhibited respiratory distress, and then had another episode of this and resultantly aspirated. 32 minutes after arriving at the emergency department the crew were allowed entry with the lady who was now extremely unwell and was moved directly to the resuscitation area of the department where a nurse assisted the patient, and the emergency button was used to alert other staff members to the peri-arrest state of the patient

The lady was requiring full advanced life support, and despite best efforts she was pronounced dead 58 minutes after being allowed into the emergency department."