Decision Report 201703141

Summary

Mr C complained about the way in which the ambulance service handled him after he had a seizure and fell at home, injuring his lower back. Mr C was concerned about the lack of assistance he received from the ambulance crew before they took steps to immobilise his spine and transfer him to hospital. It was later established that Mr C had sustained two fractures of his spine.

We took independent advice from a consultant in emergency medicine. Given that there had been restricted space in the room that Mr C had fallen, together with a number of factors that made it unlikely that he had sustained such fractures, we considered that it was reasonable of the ambulance crew to have provided spinal immobilisation in an area with greater room to do so. However, we noted that there was no evidence of a clinical assessment of Mr C's back and neurological function, nor evidence of a risk assessment prior to the decision to move Mr C. We considered that the assessment of Mr C was unreasonable and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of clinical assessment of his back and lower limb neurological function. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Where a patient has potentially sustained a spinal injury staff should carry out a full clinical assessment and risk assessment prior to making decisions about moving and handling the patient. The assessments should also be clearly documented.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.