Ambulance trust reveals patient’s death amid handover delays row

9 Comments

Woman deteriorated during wait and died in A&E resuscitation area
Ambulance crew desperately tried to arrange admission but were told no beds available
West Midlands accounts for substantial proportion of all ambulance handover delays

An ambulance trust 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.

West Midlands Ambulance Service University Foundation Trust’s board papers this month reveal the woman in her 90s — who has not been named — was taken to hospital because a severe nose bleed would not stop.

Its clinical quality board paper says the “patient story” showed ”how a patient being delayed on the back of an ambulance resulted in significant deterioration and ultimately the death of a patient”.

The crew were held outside the emergency department despite attempting to get her admitted. Ten minutes later, when the bleeding threatened to compromise her airway, they sent a message to the triage nurse to request ear, nose and throat surgeons saw her urgently.

The triage nurse told them the hospital — which has also not been named — was at capacity with no available beds. The board papers noted the crew contacted their control room to ask to take her to another A&E or direct to ENT, but, at this point — 27 minutes after arrival — she deteriorated further, vomited and went into respiratory distress.

She was admitted into the A&E’s resuscitation area 32 minutes after the ambulance arrived. She was given full advanced life support but died 58 minutes after entering the resuscitation area.

There have been major tensions between WMAS and trusts in the region over delays for a long period. It has repeatedly raised concerns about handover delays affecting its ambulances across the west midlands. Last September, it sent a formal warning letter to University Hospitals Midlands Trust, Dudley Group FT and Shrewsbury and Telford Hospital Trust over their deteriorating performance on ambulance handovers, adding: “Lives will be put at risk and patients will come to harm as a result.”

HSJ understands the incident involving the nose bleed took place just two days after the letter was sent, although it is not known if any of the three trusts the letter was sent to were involved.

The WMAS board papers also pointed out that on a single illustrative day this year — 5 May — two-thirds of the time lost to patients being held on ambulances in England occurred outside the 22 emergency departments in the West Midlands, with 40 per cent of the patients affected in the same area.

On the same day, nearly half of the time lost nationally outside hospitals involved University Hospitals Birmingham FT’s three hospitals with A&Es and 11 per cent at Shrewsbury and Telford Hospitals Trust’s hospitals.

“WMAS has more time lost to patients being held on ambulance outside emergency departments than the total of all other hospitals in England,” the board papers added. The national standard is for handovers to take place within 15 minutes.

The papers state: “The issue of patient handover delays has shown a significant deterioration over the last month, and this is causing significant serious patient safety concerns.

“As reported to previous meetings we are concerned that more increasing numbers of patients are being delayed at hospital on the back of an ambulance. This significantly increases risk for the patients in our care.”

A WMAS spokesman said: “All patients continue to receive clinical care until they are handed over to hospital staff. We are working with all local NHS partners to reduce delays so that our crews can respond to the next incident as quickly as possible.”

A UHB spokesperson said: “The trust has returned to pre-pandemic levels of A&E activity. We are doing everything we can to reduce ambulance handover delays.”

A SaTH spokesperson said: “We know that delays occur at peak times and on key days, and we are working closely with WMAS, the Welsh Ambulance Service and our local community services to manage the demand in different ways, including avoiding attendances at A&E.”

University Hospitals North Midlands Trust, said it did not recognise the incident and Dudley Group FT has been approached for comment.

Full account from board paper

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 hermouth 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.