Decision Report 201401710

Summary

Mr C had a fall at home. An ambulance crew attended and examined him for a possible dislocation of the shoulder. It was decided that he did not need to be admitted to hospital, as there were no indications that his shoulder was dislocated. Three days later Mr C contacted his GP, who came out to see him, and advised that he attend A&E. Mr C did this and was found to have a dislocated shoulder.

Mr C complained that he was not given a reasonable assessment by the ambulance crew. He also said that when he had complained, the Scottish Ambulance Service (the service) had told him that a clinical review of his treatment would be carried out. However, he had not heard anything further about this.

The service told us that they thought Mr C may have experienced another fall in the intervening days between being seen by the ambulance crew and the visit from his GP.

We took independent advice from one of our GP advisers about Mr C's injury and assessment. The adviser said that it was not possible from the medical records to say with certainty when Mr C's dislocation injury occurred. The adviser also said that there was nothing in the ambulance crew's report to suggest the assessment Mr C received was unreasonable so we did not uphold this aspect of Mr C's complaint.

We did, however, have concerns about the clinical review that the service said they would carry out. This was conducted nine weeks after the complaint response letter to Mr C and five days after we initially contacted the service about Mr C's complaint. We were concerned that there was no formal procedure and that it may be unclear to complainants whether or not they are still in the complaints process or not. We upheld this complaint and made recommendations.

Recommendations

We recommended that the service:

• review procedures for clinical reviews, having regard to our findings; and
• apologise to Mr C for the delay in conducting and communicating the clinical review outcome.