Freedom of Information Request

7620 – Diabetic Incident Reports

Can you please send me a copy of all diabetic incident investigation reports relating to serious incidents; including information held on national systems such as STEIS, local databases and internal reports, investigation reports and root cause analysis and other documents in relation to patients with diabetes who were provided with care by EOEAS during the period: 1/1/2013 - 31/7/2016.

Incidents reported between 1/1/13 and 31/7/16 where the patient's presenting condition was diabetes

Reported Description If yes, please explain? Action taken (Investigation)

Lessons learned

12/11/2015 Had to book a journey from Broomfield Hospital to a London Hospital for ESS Ward for a 4 hour pick up at 1800 hours and specified that this could only go on a qualified paramedic vehicle. At 1945 hours a Thames unqualified vehicle turned up to take the patient and when she enquired with control why this had been sent they advised that nothing had been put in the notes about specifying a qualified vehicle.

Due to the high number of inappropriate Paramedic requests made by hospitals when requesting transport when a PAS vehicle cleared at Broomfield they were simply asked to check if they could transfer the patient. No delay in transportation was incurred as a result of this and no harm came to the patient.

15/11/2015 When completing an EPCR i forgot to add the paramedic that attended the job and carried out interventions such as cannulation, I.V drugs which has now been allocated my name as i was primary crew. The RRV attended and carried out these actions not as shown in paperwork.

Following the introduction of the electronic care record, some admin errors where expected to occur. Adding additional clinicians onto system during an incident can be overlooked with the need to deliver patient care.

Clinical care was delivered correctly by trained staff. Awareness raised that all attending clinical staff should be recorded onto the epcr and medications must have appropriate level of staff identified against administration.

21/12/2015 Whilst transfering a patient to hospital for ? diabetic ketone acidosis it was decided that administration of IV fluids would be clinically indicated. Inside an unsealed trust fluid bag, a 500ml bag of HARTMANS sodium lactate was discovered. No sodium lactate was administerted to the pt, NACL was adminsitered as normal.

Datix reviewed and staff member spoken to. This is an isolated incident and as we do not stock Hartmanns anymore then the presumption is that it was mistakenly put into our fluids bag (unsealed) after a transfer. The good thing to see is that there were proper checks conducted prior to administering a fluid. Immediate checks were made and no other fluid of this type was found.

22/12/2015 When leaving the scene of a property I had to pass through a narrow gap and misjudged the width of the wing mirrors on non drivers side. I was only travelling at a very slow speed and thought they would fit. The other vehicle was also a trust DSA. Its driver side wing mirror was cracked and broken. There was no damage

Staff member questioned. No issues identified, time critical patient and minor damage to a Trust vehicle.

Accident form completed. No further action required.

Spacial awareness and overhang of mirrors emphasized with staff member.

16/01/2016 I have got a needle stick injury. A diabetic patient had put the needle into her stomach through her t-shirt. She couldn't depress the plunger so she then took the needle out. I lifted her t-shirt up and then she put the needle back in but into my thumb by accident, through my glove. She drew blood on my thumb and the patient is a known Hepatitis C carrier.

Support and OH/GUM referral. All relevant paperwork sent to PAM OH Welfare

Confirmation that PAM OH & GUM appoints were made. Confirmation all PEP medications administered Awaiting blood results.

All IP&C procedures were followed - Patient caught in hand with own Insulin injection. Patient HepC positive.

19/01/2016 Pt require BM reading to be done as part of clinical assessment, new style BM machine came up error E1. Upon reading manufacture fault codes E1 was too cold or too hot working areas.

dealt with at point of origin. email to medical devies and equipment replaced.

19/01/2016 Female pre alerted to hospital with DKA, became unwell the night previous, was seen by a paramedic but remained at home. An ambulance attended the female on 18/01/16 at 2140 following a collapse episode, she was assessed and remained at home. During the incident on the 19/01/15 the females mum informed myself that when she had collapsed the night before she had to perform cpr (as advised by the call handler), this was not documented on the prf from the 18/01/16, her mum also informed that her ketones were elevated on that occassion and also her blood sugar was normal but the mother had administered extra insulin due to the sugar being high an hour before the collapse.

Call audit confirms CPR instructions were being given by call handler. No radio comms to RRV to inform CPR advice is underway No apparaent CAD notes or additional resources allocated due to CPR instructions being given.

PCRs attached to Datix from both attendances. Contact with the hospital to confirm how the patient is recovering.

Call Handler did not pass on to dispatch that cpr was in progress - feedback given

14/02/2016 EPCR equipment failure. The EPCR would not download any CAD information with a message stating that the CAD was not found.

ePCR would not download CAD details - crew reverted to paper PCR.

will investigate with crew when i see them face to face. If ePCR is faulty it will be sent back to IT. d/w crew and reviewed ePCR - likely user error as all CAD details are now downloading when DLO checked it. Advised crew to persevere using it and let me know if there are any further problems as it appears to be fully working at present

currently unstable and unreliable ePCR platform which will reduce compliance.

21/02/2016 Arrived at hospital. Began to move pt off the ambulance; on trolley via tail-lift. Tail-lift was at the highest point level with the ambulance floor. The trolley was pushed onto the tail-lift, the trolley wheels met the lip of the tail-lift and over-ran. The lip did not take the remain in upright position. This caused the wheels to drop off the tail-lift. (Paramedic) was able to keep hold of the trolley whilst (SAP) and (EMT) steadied the trolley and lowered the tail-lift to the ground. No injuries were caused to the patient or staff.

Reviewed Tail Lift ops on vehicle for safe use.

Fault found on the end lip and vehicle removed from service. Alpha Lifts and Full circle making repairs. No staff injuries reported.

Trust have a thorough TL service programme in place. This type of incident may have occurred previously and will review with data collected in cooperation with Trust Health Safty and Security managers

22/02/2016 When we arrived at scene the vehicle was parked on the main road so that we could quickly arrive at pt side. When my collegue was happy that pt was to be transported to hopsital and stable enough that he didn't require my asistance, I went out to move the ambulance from the main road, to reverse it back down the pt drive ready for pt loading. My collegue stayed at pt side because of the presenting condition, to monitor as necessary. The drive way to both pt house and pt neighbour is seperated by a small, low hedge and a fence post at the very start of the segrigation. While reversing I used my hazzards and lights as appropriate to warn oncoming traffic of the manoeuvre. While lining up the ambulance with the drive way I did not see the low hedge and preceeding fence post and hit it. I then moved forward and the post fell down.

Narrative reviewed. Incident reviewed. Datix for information only.

27/02/2016 Arriving at the property I planned to reverse the vehicle on the driveway to allow for easy extrication of the Patient. I drove just past the property and visually checked the driveway from the vehicle to see that the driveway was clear and that the only obstacle was the roof overhang of the bungalow. I began to reverse up the long driveway travelling at one MPH looking in both mirrors during manoeuvre. Just before coming to a stop my Crew mate and myself felt a small bump and were both surprised. Examining the rear of the vehicle I noted that it had collided with a fence post which was set forward from the end of the driveway. Upon my initial check this post was not visible and appeared to be part of the garage structure at the end of the driveway and due to it's complete vertical angle appeared as an optical illusion. There was no damage caused to the fence post and the Patient was notified of this however on the near side rear of the Ambulance, three circular plastic light casings were cracked and the bottom corner reflector became slightly bent on impact. All lights were still working after incident. During the reversing manoeuvre no reversing sensors alarmed and it is my understanding that there aren't any reversing sensors fitted to the vehicle.

hit fence when reversing. vehicle repaired. accident forms completed and attached to DATIX. Discussion with driver regarding ensuring a banksman is used when reversing.

02/03/2016 Lone Paramedic was called to patient by next-door neighbour who could hear him banging and shouting. On entering the property using the key-safe paramedic found the patient on the bedroom floor, thrashing around mostly naked save for a pair of underpants which were half on/off. Paramedic tested blood sugar which showed it to be low. Treated him with glucagon and found paperwork which stated the patient was a known type 1 diabetic. Paramedic was not aware before attending.

I spoke to reporter to clarify his concerns. He had two concerns. Firstly he was wondering if the Patient could b medically flagged for his Diabetes, as it took a while for him to establish this as minimal information was available.

I spoke to control regarding whether a medical flag could be put on the address. They informed me that this was possible and gave me the email address, which I emailed.

N/A

17/03/2016 Pt slipped from chair in the early hours of the morning but was unable to get self back up. Pt called 999 at 05:53 hrs. Ambulance disatched at 07:17 hrs. Pt was not able to take meds or have breakfast. Upon arrival, pt laying on living room floor, concious and alert. Pt BM level 2.5 mmol.

Dispatched at 05:53 but stood down at 05:56 as diverted to higher priority call. CCORD has inputted note to say non injury fall and pas vas suitable - however no PAS available. allocated at 07:17 once signed on and completed checks. No other resources available due to EOS policy.

CAD reviewed None - nearest available resource dispatched. EOS policy not allowing dispatch to allocate sooner

25/03/2016 Paper PCR used as RRV on scene had compleated one extensivly as he did not have an EPCR unit on his vehicle.

•Following the introduction of ePCR into the locality, crews have been instructed to complete a Datix for every occasion that a paper care record is completed. This is to help identify any trends or IT issues. •Initial attending resource did not have ePCR facility.

•Emergency packs of paper PCR’s are provided on every vehicle for this type of situation. •Correct process followed.

29/03/2016 Whilst conveying PTS patient home we were waved down by pedestrian as 74 year old gentleman had collapsed in the street. He was unconcious but breathing but was bleeding from head wound.Emergency assistance had already been requested and a Community First Responder arrived 5 mins later. Applied swab to head to stem bleeding and put on oxygen. Established from available information that patient was diabetic so responder gave glucose to which patient responded. Advised initially that emergency ambulance was on way from Ipswich but this was redirected and RRV came from Saxmundham arriving approx 17.15.Back up vehicle arrived approx 17.45 and conveyed patient to Ipswich hospital.

Crew member spoke to ALO and informed what had happedned, was advised to DATIX. Crew member has recorded it also on vehicle daily log.

Welfare and debrief to crew members.

02/04/2016 Today we recieved a P4G2 from 111 for a 53 year old patient who has been having trouble with his blood sugars. Today, the patient was in a fit condition to be able to tell us his medical history and within that he told us that he was HEP C POSITIVE. Obviously with the crew needing to check his blood sugars regually, I feel that it is important that future crews attending this address be told in advance from a not on the MDT that the patient has a potient infection control risk / expousre to ambulance crew. This would particually come in handy if for whatever reason the pateint has a hypo or hpyerglemic episode and isn't able to tell the crew him self, if there is a not on the system to contact control or a note on the MDT telling the crew that the patient is HEP C POSITIVE then this would potienally prevent a crew memember or solo responder to be mindful and ensure they wear PPE. Even more so if we attend the address and he is unresponsive. We've all been exposed to doing some things with little or no PPE when the patient is time critical.

Discussed concerns with reporting crew. Raised to look at adding flag to address.

Made contact with IPC lead, advises marker not required as it will not affect treatment. All crews should be using appropriate PPE as required to protect against body fluid exposure.

Awareness raised.

07/04/2016 Call was duplicatedthe call had the same location but had different patient names - The DTL canceled the call as duplicate. call hours later called in requesting where ambulance was - ccord happy for call still to be Triaged.

DEO on duty escalated accordingly to CCORD and raised DATIX, next DEO on shift liaised with DTL and discussed events, PT outcome and learning outcomes.

DEO on duty escalated accordingly to CCORD and raised DATIX, next DEO on shift liaised with DTL and discussed events, PT outcome and learning outcomes.

awareness raised and working practice changed to acknowledge correct practice in closing duplicates

11/04/2016 Crew were called to a patient having diabetic problems. On arrival, there was a first responder present. The patient was presenting with low Glasgow Coma Score, lying on the bathroom floor, very confused and agitated. Family said the patient has a history of hypo glycaemia. The first responder was unable to confirm that face, but assumed she was having a hypo (first responders aren't allowed to take blood sugar readings.) After taking observations, the first responder gave the patient a tube of Glucagel (hypo stop) to treat the "hypo". On arrival of the crew, a blood sugar reading was taken which showed up as "high" on the monitor (approx 30+) which indicated the patient was actually hyperglycaemic. The patient was treated by the crew and conveyed to Basildon rescusitation with an alert call made prior to arrival.

This is the correct procedure for CFRs to follow. This has been confirmed with area clinical lead.

CFRs are informed that if in doubt treat for a hypo as this represents the more serious emergency and there is relatively low risk in a hyper patient receiving oral glucose.

18/04/2016 ECCH advise that they are withdrawing home services for a period of 3 months (reviewable)due to patient's demeanour towards staff. Staff are currently having to attend in pairs due to verbal and physical abuse. This is clarified in meeting minutes and by LSMS ECCH.

Patient known to be violent to 3rd party HCPs from ECCH whereby items have been thrown at HCPs as well as ongoing verbal abuse. This is substantiated and evidenced in the MDT minutes attached to this DATIX. Double staffed ambulance to attend if XX is present. Police not required unless risk assessment specifically indicates. R1 calls to be attended by nearest ambulance resource including RRV if appropriate.

1. MDT attended 14/04/2016 2. Portal interrogated 3. Future actions to include review of ambulance to ensure we are approriately responding to calls.

24/04/2016 Turning into a hotel car park through narrow barriers, to retrieve patients belongings, i turned left to enter car park through barrier. There was a concrete post approximately 2 foot high at barriers. As i turned left the rear left wheel arch scraped along the top of post causing damage to the plastic wheel arch underneath. No other damage caused to vehicle or porperty.

Information rcd off crew Accident form requested to be completed. Assessed damage as superficial.

Use crew mate if possible to assist with close spaces. be aware of Ambulances size.

08/05/2016 Forced entry, damaging front door. Concern for wellcare, called in by district nurse who couldn't gain access, pt normally opens the door to them. Today no anwser, and pt had a hypo yesterday (treated by district nurses, no ambulance attendance). O/a no anwser to door, crew (uni student) managed to sqeeze through tiny window, found pt on the floor and stated pt wasn't breathing, rest of crew and equipment still outside, so kicked down front door to gain entry (fire brigade had been called already but wasn't on scene yet) due to thread to life. Pt was then found deceased, ROLE completed as per protocols, and damage to doorframe reported via this datix.

Due to concern for welfare and no acknowledgement of Amb/DN by patient, desicion made by clonician on scene to gain access. On entry , patient deceased.

Fire and Police

29/12/2015 'Unresponsive' patient, not completely alert (details visible on MDT) coded as G2. Almost cancelled for a 111 R2 for a patient with a skin complaint but dispatcher correctly cancelled me from the 111 call and reassigned me to the G2. On arrival patient pain responsive, slouching over to her left side and drooling. Hot1 requested. Once ambulance request confirmed started to ask family about history of events and patient's medical history. Family mentioned patient was NIDDM and recent UTI. Blood sugar recorded at 1.6mmol. Reason for Datix - near miss. Possible incorrect triage for an unresponsive patient.

Incident submitted by the reporter as a near miss due to potentially being diverted from a higher prioritised job. The dispatcher reinstated the original job and passed the second job onto another crew.

Jobs are prioritised with the potential clinical needs of the patient and taking into account the availability of the most appropriate crews at the time.

05/07/2016 The crew attended a patient this evening, her second 999 ambulance call today. She had pulled her care line cord 7 times today. The same crew attended to her yesterday and the day before and noted that she had numerous other ambulance attendances over the past few days. The patient has ongoing long term heath issues including mental health issues. She is using the care line service and the 999 service inappropriately. The patient also denies calling for help. This needs to be flagged on the system for future calls.

We are aware of this lady and are trying to get a management plan for her.

18/07/2016 Crew responded to a Red 1 on the beach at Southend to an unconcious ptn, arrived and assessed the ptn, the ptn was found to be hyperglycaemic, once he had been assessed and explained he needed to go to Hospital, after a few minutes as we were leaving the scene he became aggresive and confrontational, ptn's name was known on the CAD system. Please can his name be flagged as he wants nothing from the ambulance service and is just aggressive. This was witnessed .

Following communication from the CAD Markers team stating "I have had a look at this one - unfortunately we cannot flag a patient by name on the CAD - only an address - as this person is of NFA we will not be able to place a marker about him on the CAD." Clearly if the call comes from a third party who does not know the patient his identity will not be known.

Communication from the CAD MArkers team to advise that this is not possible, currently.

20/10/2015 We were allocated to a job today. On the road that the job is on, there are 3 different caravan sites. The job was meant to be on a caravan site however it was inputted as the wrong one and so we were sent to the wrong address. There was a delay in getting to the patient. Also concerns as on one of these caravan's sites the residents can be aggresive and police assistance is normally required.

The tape has been listened to and I can confirm the address was given as originally inputted as XX and the postcode was confirmed by caller and the address verified as correct.

Tape listened to and correct address inputted by call handler as given by caller

None - correct address entered

22/10/2015 BM machine found to be wet so not working. Spoken to crew member - unit tested Unit replaced General awareness of leaving open vials in modules

26/10/2015 Pt was agitated and became aggressive towards female staff. His demeanour was calmed by a male friend who turned up on scene. The patient was then recognised by one of the crew from a previous experienec of his aggression. the patient had, had a flag on his previous address warning that female crew members should not attend solo. This patient's fists become clenched and aggression ensues with female crews.

Risk Assessment DISCUSSED THE FACT PATIENT IS DIABETIC WITH CREW.

Risk Assessment Amber Letter sent to patient advising of male crews only added to Wav tracker CAD flag

21/12/2015 The volunteer driver was called to a patient (Patient 1) in Great Yarmouth when the crew arrived at the premises, the volunteer driver pressed the doorbell. Patient 1 was unable to open the door because he had locked himself in the house. Due to the conversation with Patient 1 and the volunteer driver thought Patient 1 was very disorientated and unable to have a normal conversation. The volunteer driver left Patient 1 at the premises and he continued to travel to pick up Patient 2 and transport Patient 2 to the renal unit at the James Paget hospital. When the volunteer driver arrived at the renal unit he reported to the hospital that Patient 1 would not be coming in because he was locked in his house. The only help Patient 1 could get was from his mother, although she was unable to get to Patient 1's address because it was late at night. The volunteer driver decided to return to Patient 1's address to see if he could help Patient 1 in any way. When the volunteer driver arrived back at Patient 1's property, Patient 1 was still not making sense. The volunteer driver telephoned the police to see if they could gain access to Patient 1's address. After 15 minutes the police were able to get access through the rear of the property. The police opened the front door. The volunteer drivers stated 'by this time Patient 1 was looking a bit ill'. The volunteer driver helped Patient 1 get dressed and the police asked if it was okay to transport Patient 1 to the hospital, the volunteer driver said he could. The volunteer drove Patient 1 to the renal unit where he was taken for treatment. It was clear at that point that Patient 1 was extremely ill. Patient 1 was put on a machine for kidney dialysis and called a doctor. The doctor stated "Patient 1 was extremely sick and if he had not have been brought in, he may not have made it". Patient 1 is diabetic, he is currently an in-patient at James Paget hospital and he is having 24 hours of antibiotics

nfa - volunteer driver followed procedure nfa nfa

09/06/2015 CFR received an incidnt address via text system - called into EOC on dispatch line and this was not answered. They then contacted the Duty Manager line directly and the line was answered by the DEO - they correctly asked the DEO if they should attend the incident as they are required to do. They were asked to to attend. At no point was the CFR advised of the Special Situation on the address. The CFR was contacted by her partner who was proceeding to a safe place on the same call on a DSA as advised not to attend and called his partner and asked of she was in with the patient. When she confirmed she was the crew proceeded directly to scene.

A red 2 incident was received into Chelmsford EOC for a diabetic patient. Once the call had coded as a red 2 an auto alert was sent out to the local CFR groups. On receipt of this automated alert, self mobilised on the incident and consequently phoned into EOC. Due to the phone number that the CFR called through on I am unable to listen to the communication as this is a non recorded line. The time the incident occurred would have been on shift handover for the DTL’s and DEO’s within EOC. Due to the conversation not being recorded it is difficult to ascertain the exact communication between EOC & CFR for this incident. After speaking with the DTL’s on duty I am still unable to identify who had the conversation regarding this incident. On clearing from the incident the CFR did not mention any of the issues raised within this DATIX. It is vital that the dispatch team are constantly reviewing and revising incidents to ensure that all resource decisions are correct and no person attending incidents have their safety compromised at any time.

•Attempted to listen to communications between EOC & CFR – the phone line this was called through on is an unrecorded line within EOC. •Spoken to DTL on duty

•To be vigilant in checking incident details when CFR’s call in to ensure there are no scene safety issues. •Dispatcher to be efficient in reviewing in all incidents to ensure any new information added

15/05/2016 Crew have been sent to a Hostel. Crew were advised that there is a risk on the address due a lot of occupants having a history of drug abuse and difficulty exiting the property once inside. Crew were informed that the patient had diabetic problems. While control were being queried that the scene was safe while crew we en-route they were told another person was also with the patient. Upon arriving at scene, crew attempted to find the room number for the patient however could not. A member of staff appeared and assisted the crew. When asked about whether the scene was safe the member of staff stated that there were numerous intoxicated people in the room with the patient. The staff member stated "No, not really" when asked if it was safe for the crew to go into the room. At this point the crew asked the member of staff to ask the patient to come out of the room and come to the ambulance. Once the patient was in the ambulance, the patient also revealed a history of bipolar and schitzophrenia which had not been known to crew. There are Concerns that when the crew were approaching the scene there was a lack of adequate information on the circumstances and details of the patient, especially given the known reputation and history of the property that was being attended. The crew could have walked into a potentially volatile situation had they entered the room with the patient and not run into a staff member first.

E-mail from HEOC manager noted.When the call was taken everything appeared to be normal and HEOC had no reason to be unduly concerned for attending crews welfare. Contacted Management Team at the Hostel. Contact number and advice given to HEOC with regards contacting hotel manager when a call from the hotel comes into HEOC. It is noted that a general warning flag is already in place for the hotel and due to the hotel residents constantly changing it would be impractical to flag individual rooms.

Contacted the management team at the Hostel. the day manager said that their was normally 24 hour managerial cover at the hotel and that she would be happy for the ambulance service to contact the duty manager should the need arise. informed me that the hotel was not a bail hostel and that all the residents there were council tenants awaiting rehousing. Residents stay at the hotel varied from a few days to a few months and that residents could be single people or families.

The service now has the ability to contact the hotel management prior to crews arriving, this should assist crews in locating patients and orientating themselves whilst in the location. As already mentioned a flag for individual rooms would be impractical and could lead to confusion and delay in the service attending genuine patients.

18/12/2015 I work at a SRV car and I waited 2 hours backup, 40 minutes for a hot 1 and an hour and a half for a hot 2. The patient was having a Hypo. with chest pains. Patient was outside in the street I was unable to do an ECG on the patient because he was on the street.

During this time EEAST was working to surge Amber, this was specifically a problem in Beds and Herts due to the number of Green Calls unassigned. At the time the main issue was Green2 calls and HOT2 calls which were waiting. During this time there were also a large volume of crews that were on DND Breaks (GBs were completed)

CAD review, Tape, Cleric replay

- Mealbreak time exacerbation of issues - UHP issues in Hertfordshire.

18/10/2015 The call at ambulance cantrol came through to a call handler in regards to a gentleman at 13.28 it was not passed to us till 15.04 and we arrived to the patient at 15.25 and the job came through as loss use of legs. On arrival the patient was gargling, dribbling and altered level of conciousness and appearing like the patient had a CVA but the patient was having a hpyo. When the initially call had the patient was more alert and was told not to eat or drink anything by the call handler and was also told that they would get someone to call them back to see if they needed an ambulance if it was necessary. When crew arrived 2 hours later the patient had deteriorated. Wife became more confused because she was bombarded with many questions and all she wanted was an ambulance, and after treatment by crew patient be improved and was transported to Colchester hospital. Patient and wife are not aware of what the symptoms are of a hypo. We gave a sandwich and a cup of tea. Patient was given an Glucagon injection first.

Spoken to DEO in EOC and confirmed that the SPOC referrals were made.

As bove Unfortunately due to high demand of outstanding calls meant there was a delay in allocting the call to the crews. The questions asked were the standard and correct questions that are asked to correctly triage a call, these questions that are set for us to use, do not always allow for levels of understanding of the public, but we have to use them anyway. The crew treated and safeguarded the patient appropiately.

19/10/2015 Person making 999 call has condition of confusion. This was not identified causing a delay to the patient (the persons husband) who she was making the 999 call for. This presented with a 2 hour delay to the patient as the 999 caller was confused and the information did not correctly get through. Patient was semi conscious by the time the ambulance arrived, hypo episode. Referral as follows; Mr B is the carer for his wife, she suffers with confusion, she has no care package in place and today her husband had a hypo episode, neither her or her husband were aware of his symptoms, because of her confusion she was unable to get across to our call handler exactly what was going on, and a delay of treatment took place of about 2 hours. Mr B was semi unconscious on arrival of the ambulance crew. Person and her husband would benefit with a care package putting in place. The daughter lives about 40 minutes way. Crew stated Mr B possible had 5 hypos in the last couple of weeks. She was unable to tell crew the date of birth of Mr B due to the confusion. A GP Assistance referral was made for the person making the 999 call but the families GP needs to be contacted to review if a marker should be placed on this address highlighting the wife's condition of confusion so it does not make a delay for the husband in the future

reveiw call cand call taker actions. A 'flag' has been placed on this address to identify the concerns.

10/06/2016 Called to address in which patient is violent. This needs to be flagged so thst solos do no attend on their own. Patient is extremely violent. The reasoning for lone workers not to attend is because he spontaneoulsy becomes violent and can lash out.

call fits reqirements for a flag flag authorised

reviewed information

awareness

28/05/2016 pt deemed to have no capacity as unable to answer capacity questions and due to presenting conditions of profound hypoglycaemia complicated by hypoglycaemic seizures. Pt given iv glucose to reverse Hypoglycaemia, still not responding appropriately, pt aggresive verbally and combative. Crew had to move pt to the carry chair as a result of difficult access. pt became physically abusive, striking out at the crew members kicking and scratching. Being verbally abusive all the while. Crew then backed off as the restraints on hte carry chair were thwarted by the pt. Pt then refused to answer any questions to assess her capacity. Unable to make contact with Clinical advice so DLO contacted to come to the scene and for police assistance. DLO arrived on scene and patient still combative and refusing to talk to any crew member. pt torn cannula from arm and then refused all assistance from crew until bleeding did not cease and a bandage was applied by the crew. Pt bm went to 6.7 at the highest and then began falling again. Police attended scene but pt had capacity at this stage. pt bm continued to fall and crews concerned for her safety and reverting into hypoglycaemic induced coma, struggle to contact clinical advice for further guidance. when contacted said they understood the dilemma but crew would either have to wait for pt to lose capacity or leave with the knowledge that this was not in the pt's best interest. Brother who was on scene stated that the pt is violent towards ambulance staff. Crew members involved sustained bruising to arms and legs

23/06/2015 Student cannulated and administered 10% Glucose prior to paramedic arrival. The crew requested paramedic back up and was aware a paramedic was on route. On the arrival of myself I notice the patient had been cannulated (L ACF 20G) and a bag of 10% glucose running. I queried the crews qualifications as I was aware I was backing up an EMT crew (student had no epilletes displayed). I then queried who had cannulated and stated that he had, when I asked him if he wanted to explain and he declined. We carried continued to deliver patient care. 1mg Glucagon had been administered by crew prior to incident. Paramedic requested 1524hrs Paramedic arrived 1530hrs.

student cannulated a patient when he should have waited for a paramedic. He has dispensation to cannulate even though he is not a paramedic.

Discussed with student inappropriate to cannulate without paramedic or contacting clincial advice.

Awareness raised. Patient safety

17/12/2015 1. Tasked verbally and via MDT to attend P5. Warned by EOC that address had a flag on it - no singletons to approach, as pt had been agressive due to hyperglycaemia previously. Call had come in at 2000hrs, our A/S time was approx 0030hrs. 2. My crewmate had personal experience of this aggression from a previous visit, to confirm this. 3. Pt spoke to us from his bedroom window, assuring us that his BM was now down to normal (from 11 to 14mmmol/L) and that he was fine and did not require an ambulance. He appeared good-natured, non-combative, no slurring of speach, so we withdrew. 4. I advised EOC of the above and then called Clinical Advice to confirm that we had no other need to pursue this patient other than to safety-net him with his GP via SPOC. 5. Clinical Advice told me that this patient had called at 2000h and advised EOC that he had taken an overdose of gliclazide medication in order to reduce his hyperglycaemia. He abandoned the call. 6. CA advised that as long as the pt was not slurring his speach there was no need to force access to assess him. I asked why this job had not come through as an overdose. 7. I contacted SPOC to get them to alert pt's GP to his poor diabetic control. 8. Why was this known overdose patient, who abandoned the 999 call put as priority 5 and left for nearly 5 hours before a DSA attended? 9. Why did control not tell us that this pt had overdosed on his medication prior to us attending?

Review of CAD-CAD notes. Call recordings. 8. Why was this known overdose patient, who abandoned the 999 call put as priority 5 and left for nearly 5 hours before a DSA attended? The patient was G3 as the patient was a diabetic with high blood sugars. The patient was not deliberately left for 5 hours. It was busy. As explained on the radio transmission, an attempt to dispatch on this call was made numerous times. A crew was dispatched on this call at 19:50, 20:34, 21:55, 22:22, 22:30, 22:33, 22:37, 23:02, 23:04, 23:05, 23:24, 23:35 and 00:12. Each time the resource was diverted to a higher priority call. 9. Why did control not tell us that this pt had overdosed on his medication prior to us attending? This was an EOC error that the crew was not informed the patient had

Ensure Dispatch digests and disseminates all relevant information.

potentially taken 6 Gliclazide but the notes for that information was taken by the Clinical Co ordinator at 20:14 so you would have had to have scrolled up quite a way to see that note as it was taken at 20:14 and the crew were dispatched at 00:28 and the emphasis was to inform the crew of potential scene safety issues.

13/07/2016 Today crew have come onto an ambulance vehicle and it has been found to be missing a BM kit. This has been reported to DLO and crew have attempted to find a replacement but have been unable to at Letchworth Ambulance Station this morning. Crew were told that there were no spares available and they would have to proceed without one. Crew have just attended a job where the patient was having seizures and crew were unable to perform a Blood Sugar check on the patient. Patient was pre-alerted to hospital and upon arrival to hospital it was discovered the patient had extremly high blood sugar and was a type 2 diabetic who had been non-compliant medication. Hospital staff were concerned that crew were unable to take blood sugar reading of the patient prior to handover. Due to being unable to measure patient's BM prior to hospital admission the crew were unable to treat the patient for his hyperglycaemia.

Report of missing blood sugar monitor from |DSA and no replacement available.

There was a number of blood sugar monitors available on station for use. It was mistakenly thought there were no stocks at the time.

Information updated.

10/07/2015 My crewmate and I were responded to a older gentleman weighing 140 kg. I managed his diabetic emergency however his conscious level did not improve so I called for a bariatric ambulance and further assistance to mobilise the patient down stairs. DOM arrived to support and made the executive decision to stand down the ambulance against my wishes. and called for an RRV from St Neots to assist. The decision was made to help the patient to mobilise onto a carry chair and from there to a stair chair and down the stairs. however there were two stair chairs covering either half of the stairs. This made for an extremely difficult extrication. My back was injured causing extreme pain from repetitive lifting. DLO left the scene before the extrication was finished stating he did not think it needed all four of us to complete. We were relieved by a second crew made up of three memebers of staff and only then were we able to safely extricate the patient to the ground floor. Without this entire group the patient would have likely been injured.

staff injured his back during the extrication of a bariatric patient.

Reviewed portal and aware of history of event. DLO performed a risk & TILE assessment based on his experience. staff disagreed and during the course of the extrication injured his back. This resulted in 11 days absence from work. staff is now fit for duty and full OH and management support in place.

Awareness raised. Bariatric equipment & training now available at local level.

13/06/2015 Whikst driving the ambulance off of the patients driveway to transport patient to hospital, I turned left from the driveway and struck the patients wooden fence causing it to break. There is no new damage to the vehicle, however there is already existing damage to that side of the vehicle

reported the incident to EOC immediately and reported it to me when she got back on station.

Advised that accident report needed to be done. inspected the vehicle to coroberate intial DATIX report and looked in to their driving background - which is excellent.

18/06/2015 Known diabetic presenting with hypogylcaemia, hypothermia and bradycardia. I cannulated and administered 100mld N/saline rather than glucose. Crew were on scene immediately afterwards and noticed erroe at which point I administered the IV destrose 10%. I documented error on PRF, notified staff in resus at point of handover and notified DLO .

Diabetic patient given 100mld N/saline rather than glucose. This was realised and Glucose given after.

x was called to request a statement for this incident. x was informed that she will have a Clinical variation completed and that she needs to do a reflective piece of evidence regarding medicine management. I am meeting with x on 21/10/15 to complete this investigation. Meeting help and QA3 complete.

Awareness raised

20/06/2015 Patient handed over to receiving ambulance crew. RRV parked under a canopy, pulled forward and to the left to drive off; not being aware of a post on my nearside which was not within my line of sight.

Incident reported at the time . Extent of damage required body shop repairs

Incident logged

26/03/2015 We have new and old BM kits and I was taking the blood sugar of a pnt yesterday with a new BM kit and it showed 3.4 mmls per litre. I double checked this with the old BM kit as I had both of them and it showed 4.9 mmls per litre. This affects whether the pnt is treated for hypoglycaemia or not. Which is quite a big difference. I would like someone to check how accurate the new kits are. We attended pnt in first instance due to pnt being involved in an RTC. The RTC happened in a field. We attended pnt

2 different readings from 2 different machines on the same patient

sent an e-mail to new clinical kit, to transfer the investigation to them

medical devices has requested implementation of new quality checks.

31/05/2015 Whilst attending to patient the crew found that their drug bag had no glucogel. The drug book indicated that there should have been 3 tubes but none of these were in the bag. Prior to being opened at this call the drug bag had been sealed since being signed out at the start of the shift. If glucogel had been available the crew would have administered some to the patient, but the patient was managed with alternative means and no harm resulted in this case.

Awareness raised with DLO team. Local medicinces management procedures currently under review to attempt to reduce drug stocking errors.

21/07/2015 Call passed to EOC from 111 service for a 32 year old female who is a diabetic descrived as lethargic, in bed for past two days. PT was uncons but breathing. Resource dispatched in good time by the dispatcher however upon arrival the PT was deceased. O/S time: 07:42 Police was requested @ 07:48

See final email from 111

26/07/2015 We was given an incident for job for a incident that was given for a diabetic categorised as P1 R2 unconscious, whilst on route is degraded to p2 G1 diabetic problem not alert. We had to run some distance as we were in Raleigh, Billericay. Patient was unconscious having a Hypo. This call should not have been downgraded.

request audit Audit attached confirms call was coded correctly and in adherence with the Trusts AMPDS protocol based on the information provided during the 999 call

03/08/2015 Attended patient, was in diabetic coma, treated it effectively and she came up to her normal blood sugar. When fully alert and orientated, she stated to tell crew they did not need to take her blood sugars again, they told her she did. Eventually crew did it, confirmed it was a perfectly normal reading. She then swore at crew and told them to go away. Patient calls ambulances out a lot but refuses hospital. Cannula removed and crew vacated premises.

Contact with crew regarding the Datix raised. They confirm that at present we are unable to attach a CAD warning to the address, however they felt that this time they were able to cope with the verbal abuse from the patient. No physical abuse was witnessed. Datix raised for information only.

Communication with RRV about job. Not able to put CAD warning on as the patient is in temporary accommodation and is not known when she is moving out.

Information only.

13/08/2015 Call to a 70 year old male, on arrival at address. Patient stated he did not know why he had called us this evening, also stated he did not need any help.Patient then asked to have his blood sugars tested as he hadnt been taking his insulin. We tested blood sugars which were high, we then asked patient if he would like to be conveyed to A&E, patient refused as he was in A&E 2 days ago and had to wait a long time. We then advised if we should contact OOH GP for patient which patient also refused. We asked patient what he would like us to do for him to which patient stated he was wasting ambulance time and asked us to leave property. Patient was very aggressive in his manner however he was not physically or verbally abusive.

No patient details to investigate or flag. Details taken from incident summary.

08/09/2015 Called to a patient that was reportedly a diabetic that was fitting. On arrival patient was lying face down on the bed twitching. Patient was asked to roll over and she followed instruction and stopped twitching. Patients’ Blood sugars was assessed and it was extremely low. IV Line sited and glucose 10% bolus given to moderate effect. Patient was certain that she did not want to go to hospital due to circumstances around her child and her estranged husband. Patients’ blood sugars then dropped again and a further bolus given to moderate effect. Patient still adamant that she does not wish to go to hospital. Advised that this was against our advice and that she was potentially putting her life at risk. Patient stated that she had been in this situation before and she had been far worse. Clinical advice contacted and they advised to contact the GP in the first instance. GP contacted who agreed with concerns and stated that the patient needed to go to hospital. Patient then spoke to GP on the phone and was still refusing to travel to hospital. Family stated on several occasions that they have been going through this for a while and that they have been dealing with it at home. Advised by family that they have a family friend who is a paramedic who has been dealing with it also. While on scene patient became unresponsive and then lacked capacity to make a decision. I made the decision in her best interest to convey to hospital for further treatment. Family were happy with decision in the end as Mum wanted her daughter to have further help as she believed that her daughter was having a breakdown. Further glucose bolus given to good effect and patient conveyed to ED for further care and assessment. Patient willingly walked to the carry chair and allowed us to convey to the vehicle.

All actions by crew correct. all actions in line with best practise.

19/07/2016 The crew were called to an address for the patient who was having a diabetic hypoglycaemic episode. The patient was believed to be having low blood sugar levels at the time and this can sometimes manifest as aggressive behaviour. On arrival the crew was the patient was using abusive language and pushing his wife to get into the bedroom. The patient was making verbal threats of further physical violence towards his wife. The patient made a threat to break the reporting paramedic's jaw. The crew left the property and contacted the police. By the time the police arrived on scene the patient had eaten, his blood sugar level had returned to normal and he was being apologetic about his behaviour. The paramedic would like to FLAG this address as being unsuitable for solo responders. If a call is received for address for a male patient having a diabetic hypo, the police should attend the address.

02/11/2015 I was approached by Staff Nurse who is the triage nurse at PAH today. He has made me aware of a patient welfare issue, the crew consisted of a Paramedic & EMT . In turn this crew had attended the patient in response to a HOT1 backup request byRRV, consisting of Paramedic . The patient had been assessed to have hyperglycaemia and hypotension by the RRV paramedic and the crew and although efforts to treat these are evident on the PCR, no hospital pre-alert was made and the crew didn't seek medical attention upon arrival but instead queued in the corridor with the patient from 11:29 till 11:43 when the patient was seen by the above named triage nurse. The patient was immediatle identified at this point as time critical by the nurse and the patient moved to resus. This patient has now been moved to intensive care and the nurse feels that the management of this patient falls short of expected standards. Further more on the PCR it states that the patient was given 10 units of their own insulin but no record of whome instructed the RRV/Crew to give this has been made.

Reviewed PCR Taken Statements from crew members

The information from all crew members present has been reviewed and put into context. Support and further learning has been arranged as required. Spoken to A&E consultant. See notes

Awareness raised.

02/05/2016 Male fitting in a locked car, smashed window to gain access, permission obtained via control first.

RRV paramedic reported having to break a car window to gain access to a 55 year old male patient who was inside the car having a fit.

Permission from control sought and granted. Police on scene

Patient transported to hospital.

10/07/2015 Sent to assist a crew with a bariatric extrication (>140kg). During lifting and manoeuvring patient down stairs between stairlift and carry chair, in a tight narrow space, and felt something give in right kneecap (beneath patella) and subsequently unable to properly weight bear and complete with assistance on extrication.

Sudden, shooting Right Knee (beneath Patella) pain during awkward essential lifting manoeuvres with Bariatric Pt. DLO unable to continue asisting with lifts. DLO sent to job by EOC, who initially advised a Bariatric DSA was not available for >3hours, so was sent for manager input - requested to attend scene and see if we could deal, without having to call one out. Pt was 22-23 stones, and not excessively large / broad (other than his abdomen - which we discussed 'corsetting' with a lifting belt, if required). Pt fitted on carry chair and in his own standard stair lift, so was deeemed not be too large for a standard DSA trolley. Local RRV requested for additional assitance. Fire Brigade considered, but would not have attended (to remove Pt through window, for example), as he was not time-critical. Sudden knee strain sustained during latter part of extrication process. Unable to properly weight-bear up stairs, or offer any further lifing assistance. Discussed need to leave with crew - and stayed on scene for another 20-25 mins, to offer guidance and confirm plan with staff on scene for continued extrication (4 people not actually needed, or able to lift in unison, due to space confines). Technique was being executed by 2-3 people only, throughout job. Cleared from scene and updated EOC and the Cambs DLO , to arrange a relief crew for the Cambs DSA. Returned to station to close off DLO work and secure office. Went home to take pain relief.

Self-treated and closed own Datix. Advised SLM and DLO colleague of incident. Considered Physio, if required. Checked upon the welfare of DSA crew.

There are no resonable methods to move such heavy patients, in such tight and awkward conditions. An injury during a job like this, has a high chance of occurring. A Bariatric DSA would not have had any suitable specialist equipment (other than their wider trolley) to get this patient out of his house any differently to the methods we used. The ongoing lack of availability of adequate local Bariatric support is very concerning.

Rested for weekend and had adequate recovery during Rest Days, to enable return to work on next shifts.

06/06/2016 Needle-stick injury from patients insulin pen. Having advised the patient to take his insulin I handed him his insulin pen the patient injected himself and handed the pen back to me. As I went to put the lid on the pen I caught the index finger of my right hand on the needle. I had not realized but the patient had pushed the needle in so hard that the sharp was sticking out sideways. having felt the prick of the needle I bled the finger and used alcohol gel to clean it. I washed my hands at the hospital with soap and water.

needlestick injury details from the crew: Needle-stick injury from patients insulin pen. Having advised the patient to take his insulin I handed him his insulin pen the patient injected himself and handed the pen back to me. As I went to put the lid on the pen I caught the index finger of my right hand on the needle. I had not realized but the patient had pushed the needle in so hard that the sharp was sticking out sideways. having felt the prick of the needle I bled the finger and used alcohol gel to clean it. I washed my hands at the hospital with soap and water

Email sent to check all procedures have been actioned as per IPC needstick injury protocol. Feedback regarding Blood tests and a/bs etc..

awareness raised. procedures followed.

25/12/2015 Details of safeguarding referral submitted as follows : Ambo called to pnt for query reduced responsiveness and high blood sugars. There was a lack of knowledge of pnt's history by staff. Staff reported that pnt had been bleeding from his catheter for a few days - but they had not recorded how much/what colour/times and they it seemed they had not reported this to pnt's GP or anyone else. Pnt's relatives have major concerns about the care pnt is receiving at the Nursing Home. Pnt has end of life dementia.

Safeguarding already been completed by crew. External Organisation letter sent to care home.

safeguarding completed. Sent an External organisational letter to care home.

External Organisation have been made aware, safeguarding raised and letter from the care home investigating the incident was sent to sent to the CHC (investigators for safeguarding team) a copy of the letter was also sent to the Ambulance service in reply to the external organisation letter that was sent. Invstigation conclusion the agency were contacted regarding the nurse and it has been deemed that she will not be returning to the care home again to work.

09/09/2015 Ambulance crew arrived to take a transport patient home. Patient was a hoist patient. Doctor decided the patient needed admission to hospital Princess Alexandra. Attempts to get the ambulance crew that came for her to take her to Princess Alexandra Hospital were unsuccessful therefore another ambulance was ordered for within the hour.The ambulance arrived four hours later.

see closure email sent

08/02/2016 Patient was found this morning unresponsive by wife. GCs3/15 on Ambulance arrival, respiratory rate 4/minutes. I-Gel was inserted and bag ventialtion. Brought in ED-Blue light, pre alert. When he arrived in ED GCS4/15, I-Gel + bag ventialtion. On VBG Glucose was 1.1, glucose been given with immediately inprovement of GCS until 14/15. BM was not measured by ambulance, which delayed treatment

Statements requested from crews involved

29/07/2016 Crew member got patients’ blood in her eye, crew carried out a blood glucose test, crew had pricked the patients finger and then squeezed it and the blood squirted out into the crews eye, about 1 to 2 ml.

Follow EEAST IPC safe practice guideline 1. Attend A/E 2. Datix 3. Report to OH Policy followed and appropriate forms completed

Take care during interventions involving blood and other bodily fluids.

11/07/2015

Dispatched to backup DSA on scene over finish time, as per end of shift policy. Initial call time of 17:47. Upon arrival on scene, St Neots RRV also in attendance. Informed by DSA that pt was stuck on stair lift and needed assistance moving pt to the vehicle to be conveyed. I informed DSA and RRV that pt needed bariatric resources due to his size, rather than weight, to be informed that crew had been in attendance and stated that he was not bariatric and would fit on a normal stretcher. It was also reported by the crew that DLO said to the crew that he needed to get off on time so left scene without resolving the issue, leaving the crew with a patient in a dangerous and unmanageable position. Once agreed that bariatric capability was needed, EOC and silver contacted and bariatric provision arranged. Pt was stuck on the stairlift, but we were unable to move pt off due to the banister as we could not turn the patient round; pt’s legs positioned going up the stairs and they were very oedematous. The pt was sliding off the stairlift upwards onto the stairs, which was potentially dangerous for the patient due to his position. Advice sought from silver re removal of banister which was agreed at cost to the family, the banister was subsequently removed. Pt positioned onto carry chair as pt’s own bariatric wheelchair was too wide for the house door widths. Initially informed by EOC that DLO was running from Bedford with bariatric equipment in RRV as both PAS Bariatric DSA committed to jobs. Later informed after making call to EOC that, as per silver request, the DLO from Bedford was stood down and they were sending the Bury DLO with the Newmarket Bariatric stretcher and equipment. After 1hr 50 min since DLO bariatric request (and 5hr 27min from crew bariatric request); partially due to the A14 being shut, DLO from Bury turned up but did not have a spanner to be able to move the stretcher into the middle of the DSA. Pt was conveyed on a normal stretcher using the bear as he was too wide for the sides of a normal trolley, which could have been achieved by the Bedford DLO 1 hour earlier. Pt pre-alerted to Hinchingbrooke A&E.

Issues on scene with manual handling of a large patient on scene. Crew and RRV on scene with DLO who did not feel patient required bariatric equipment. Further officer arrived sometime later and requested bari equipment. Prolonged job 7.5hours to get patient to hospital.

Discussion had with DLO and cad notes reviewed. DLO arrived on scene at 18.39 to assess for bariatric requirement and RRV arrived at 19.14. As per the email statement from DLO he did not feel the patient required bariatric equipment. The patient had a stairlift on both flights of stairs. The difficulty was helping the patient to move from one seat to another due to his weakness caused by the illness he was suffering with. DLO states that the patient fitted on a normal carry chair and weighed approx 140kg and the carry chair can hold a max of 200kg and the stretcher 200kg also. DLO believed the patient to be of a size and shape which meant he would fit on a normal stretcher. DLO remained on scene with the crew and RRV and assisted them with moving the patient

DLO accepts that the patient did not fit adequately on the stretcher due to his width. This was not obvious to DLO at the time. There is now bariatric equipment available at both Cambridge and Peterborough stations which should prevent a delay such as this from occuring in the future. A 4th pair of hands on scene would have assisted the DSA and RRV crew but was unable to continue due to the knee injury he had sustained. did not feel there was a requirement for scene management and a plan had been agreed by those on scene. spoke to EOC and another DLO before leaving scene to advise of the difficulties on scene. reminded of the bariatric requirements for future reference.

Informed whilst on scene that this morning an ambulance attended the patient but he was not conveyed Pt’s call to hospital time 6hr 25 min. Picture attached (consent gained from wife) of pt in the bear overhanging a normal trolley width. Pts width hip to hip over abdo 50”, pt’s width hip to hip over back 23”. Trolley width 19.5”.

down the top flight of stairs. It was at this point thatDLO injured his knee and felt he was unable to continue on the job as was unable to weightbare (this led to a sickness period).DLO states that it was impossible for all 4 staff on scene to fit around the patient on the stairs at any one time so they were taking it in turns and after his knee injury he felt he could not be of further assistance. A plan for moving the patient had been decided and agreed by all crew members and they did not state at the time that they wished for DLO to remain on scene. DLO then realised that the crew, crew were a day crew and he told them he would arrange for EOC to send a crew to relieve them so they could go home. cleared from scene at 20.44 (finish time is 20.00). On clearing from scene called the Cambs

south DLO and advised him of the ongoing job and that there was a day crew on scene. EOC also informed and cad notes reflect this. At the time of leaving scene the patient and crew members were safe and positioned on the middle landing. There was not space for 4 of them to be around the patient and the patient had a stairlift so carrying him down the stairs was not required. CAD notes also state that were aware of the back injury sustained by one crew member and had requested a crew to relieve them on scene.

12/06/2016

Was assigned in the ambulance assessment on the night shift and received the handover from Sister from the day shift. At 8pm, the waiting time for ambulance to be assessed was 1hr and 50mins. I was assessing patient on time order on the queue. There were 3 patients on the trolley in the ambulance assessment area. As soon as I had space, I was able to call the next patient but she wasn't around nor the ambulance crew that brought her. Tried to check even in waiting area and reception but patient not around. On the system the patient arrived in ED at 18:04. Presenting complaint: 999 diabetic problem.

05/01/2016

Visited patient for Diabetic problems. On arrival , GCS 15, Paramedic taking observations, taking blood pressure, patient started swearing at paramedic.Carer calmed patient down. Crew member started doing FAST test. Patient then kicked them. Carer calmed patient down again. Paramedic asked patient if she could take temp, she said yes, but then spat at paramedic, then kicked Paramedic.

Crew were faced with verbal abuse and aggression when dealing with this patient. She has learning difficulties and lives in a home. The staff and carers were also present and were unable to control her actions. No injuries sustained.

A request has been made for a permanent warning on the patient on a previous investigation.

27/06/2016

Called to a 65 year old male who is bed bound, for diabetic problems. District nurse unable to maintain his blood sugars and requested bariatric transport to take patient to hospital. Notified HEOC that we were not bariatric transport but as they were unable to get estimate of his weight we needed to attend. On arrival, blood sugars were maintained, insulin withheld by district nurse on scene as patient not eaten and she would return at lunchtime to reassess patient. District nurse was surprised we were not a bariatric vehicle as she had told despatch that the patient would require bariatric transfer and also that he was verbally abusive screaming, shouting and swearing at them, this was not passed onto attending crew, infact despatch, when asked by crew whilst running on this job, had told crew that they did not have information available. There was a DNAR in place and also a Preferred Place of Care for the patient to remain at home. When approaching patient, he was extremely abusive, swearing at crew with no apparent reason, being very demanding and rude. Patient stated that in no uncertain terms was he going to hospital and that we could 'f*** O**'. Patient allowed us to do minimal observations (with intermmitent verbal abuse and swearing) which showed normal for him, this was confirmed by a number of Patient Report Forms already on scene from previous visits this month by other crews. Capacity to Consent form completed which confirmed patient has capacity to refuse transport so with that in mind and the preferred place of care, crew contacted GP. GP said she would contact Diabetic Team but if there were any other issues we needed to put them in writing as she was too busy with her clinic at that time and that she was with a patient. I attended this patient on 4th May and received the same abusive treatment from this patient and witnessed the patient being verbally abusive and rude to a carer who was trying to encourage patient to eat something more substantial than Jelly Babies. At that time the patient just wanted Jelly Babies and red wine. On completion of that

Pt verbally abusive to crew and carers, is possibly a frequent caller, patient is bed bound.

E-mailed for patients address to be flagged to make crews attending aware of his behaviour, Also noticed that this address had been asked for a flag following previous datix . E-mail attached.

Continue to raise awareness of such incidences for the safety of all staff.

job I completed a datix to flag the address so that no lone workers, or other staff, were sent without being made aware of this patients abusive behaviour to ambulance staff and carers. When this was mentioned to HEOC they said they had nothing on their system regarding this address. We would like this address now to be flagged so solos/crews are aware before they go into this patient and also make staff aware that this is a frequent caller. We would also like to know any information regarding this job as despatcher states they did not have the information available yet district nurse on scene stated she gave all information requested including weight and the fact that the patient was being abusive and aggressive.

14/10/2015

Pt found hypoglycaemic, rrv on scene made iv intervention for 10% glucose, dsa backed up rrv - no improvement in pt condition noted, dsa crew attempted glucagon and were sucessful in raising BM. DSA crew state that iv was removed, acf shows obvious tissued area and small haematoma. Glucose known to be necrotic to tissue, unknown if para who placed iv line flushed adequately etc.

RRV paramedic responded to unconscious diabetic. On arrival at 1741 patient found to be unresponsive, BM 2.7 and hypotensive. Glucogel given on arrival. I.V.Glucose given at 1750, BM dropped further after administration when checked 5 minutes later. Concerns raised over patency of cannula as flow from bag also noticed to be slow and intermittant. DSA back up on scene at 1749, IV taken out by RRV and re-cannulated in righ dorsum. In addition DSA crew administered Glucagon to good effect. Obvious swelling seen round the first cannulation site indicating the cannula had tissued. RRV paramedic stated in accont that the patient had bent their arm once cannulated

Verbal summary and written account from RRV paramedic. Job and actions by RRV reviewed. DSA summary taken from PCR.

Ensure patent cannulation, well secured and flushed before administering drugs.

17/09/2015

The patient is insulin diabetic; he had high blood sugar reading since the morning of the 11th September. There is no reading form the 12th September. Since the 13th of September the reading has been high. On arrival the patient was Peri-arrest. Patient taken to resus in Addenbrookes and in now in ITU.

Concerns from crew noted. Contact made with Care home to attemt to get contact for care home manager. No email suplied from care home despite calling to request contact to be made. Spoke to care home manager over phone who states medical assessmsnts deemed necessary by GP will always be undertaken. states the Blood Sugars would be monitored daily prior to insulin administration. States there may have been misscumunication between staff and crew and they may not have access to the correct nursing documentation. Discussion regarding the access to patient details and importance of medical history. Will feedback to staff at next meeting.

contact with care home concerns notred from staff memeber attempts made to contact care home via email failed.

importance of good history taking. be mindful of information given by care home staff, always reassess and make own judgement on patient in your care.

09/11/2015

While conveying a patient to hospital under blue light conditions, the ambulance driver was forced to brake sharply. The ambulance was transporting a very poorly patient to hospital and Student Paramedic was standing to change the arm the blood pressure cuff was on and he was as knocked off balance and thrown against the front of the saloon of the ambulance, landed on ZOL. ZOL undamaged. Medic experienced pain on left hip and buttock. Medic felt he did not need further assessment at the time but will self-monitor .

Checked GRS for originator's history of sickness/absence. No episodes relating to this incident. No harm to patient. No further action required

The safety of staff should be our highest priority and seatbelts are provided for use in the back of ambulances, however, when transporting sick patient’s rapidly, it is not easy to provide the levels of care required while remaining seated with a seat belt correctly worn. Dynamic risk assessments and good communication between driver and attendant are essential to reduce risks as much as is practicably possible under the circumstances.

25/12/2015

111 service dispatched ambulance today for a patient who was having a hypo. The 111 call handler advised family to not give patient anything to eat or drink, due to call stacking ambulance arrived 2 hours after call was made, if 111 had advised patient's family to give sugar/food ambulance attendance would not have been necessary. This caused deterioration in the patient due to delay of getting sugars. Ambulance crew treated and left patient at home.

Reviewed CAD with staff member as to the reasons why. 111 triage non clinical advised not to eat or drink. EOC recognised carbs would have prevented attendance but an amb had already been dispatched. Overall Amb attendance managed the incident better.

01/07/2015

On arriving at the address I was driving and as I exited the ambulance I twisted my ankle on some uneven cobbled pathway. This propelled me forward and to prevent myself from falling over I had to put my arms to stop. I have no ankle pain but have exacerbated an existing shoulder injury.

spoke and she twisted and as she fell she put her hand out jarring her already injured shoulder. Although this was an injury on duty, the shoulder injury was not an injury on duty it is an ongoing issue which. It would appear that this fall has just aggravated it.

She has been receiving treatment for her ongoing shoulder injury, but is now back to work doing full operational duties.

correctly reported the incident and is now back to work.

15/06/2015

crew attended diabetic pnt in hypo, crew gave pnt 1mg glucagon and susequently found out 15 minutes later that husband had already administered this, after telling crew he had given hypostop gel. this was highlighted to staff at watford general hospital, who didnt seem to bothered about it. crew were unable to gain IV access, due to pnt being so shut down.

See description of incident. Crew gave Pnt Glucagon but sometime later the husband stated he had all ready given it. There was no obvious evidence that he had given it. Even when he witnessed the crew giving it he didn't mention it.

When crew arrived at the Pnt she was found to be a diabetic in a Hypo. All around the pnt were some tubes of Hypo-stop. The husband stated he had given her some but to no effect. Crew tried to give IV glucose but couldn't find a vien. Glucagon was given by the crew. While waiting for the glucagon to work they asked the husband what had happened and getting PMX, Meds etc the word injection was mentioned. The husband then stated he had given glucagon to his wife and thats when it became apparent that she had had two doses. The crew didn't witness any ill affect to the Pnt after the second dose. The Pnt required conveying to hospital The crew stated to the hospital that she

The crew acted appropriately by reporting to the hospital. Technically the crew were at fault for not checking that glucagon had been given. Having said that I believe the husband is also partly to blame as the crew had asked him what had he done to reverse the Hypo as he had tried by giving the hypo-stop. After speaking to the reporter he stated that this incident was a learning curve and will in the future check to make sure that it had not already been given The hospital were not in the least concerned. We as a service only give one 1mg dose. The hospital stated it would not be detrimental to the Pnt. After speaking to the reporter, definatly lesson

had been given 2 doses and they didn't seem bothered.

learnt. This type of incident is not a persistent issue.

27/12/2015

Was called to patient in Chesunt, . Upon arrival was given handover by ECP for loss of memeory, query blackout. Blood sugars of the patient was 23.6. ECP didn't seem concerned about BM. There was only one set of observations on the paperwork although he had been there for one hour and fourty five minutes. When challenged with regard to BM or whether the patient needed to go into resus, ECP advised didn't need to go into resus as patient had recently been changed from metoformin tablets to insulin, about eight to ten weeks ago. Upon arrival at hospital, triage nurse redid the sugars and ketones. Sugars had increased to 24.1 and ketone was 6.3. This means patient is BKA and needed to go into resus and should have been blue lighted to hospital. The ECP should have given fluids and travelled with crew as he would have been the highest clinician available.

Initial delay in allocating this datix due to sickness and annual leave. Email sent to ECP on 9th May asking for his summary of the job. He was unable to remember the job but provided a statement, which has been attached, describing the actions he would take if faced with a similar patient.

see statement and email attached

notes the contents of the datix and has responded with actions and considerations he would have in mind when attending similar incidents.

05/05/2016

Pt's blood sugar was checked with true twist glucometer, reading came back as 'high', blood sugars checked at hospital found to be normal. Pt was therefore conveyed for no good reason.

There have been a few documented incidents where the TrueResult meters have failed. The trust is in the process of replacing the old black meters with a pink version that has been quality control tested.

New meters ordered.

10/09/2015

As part of a crew attending a morbidly obese patient we requested the bariatric vehicle which patient normally requires for transport to hospital - we were advised by control that the trust no longer had a contract for this vehicle - control arranged for DLO to cont6act us on scene and he attempted to get hold of an additional vehicle but one was not available - we undertook the job but had to enlist the help from members of the patient's family (they were not pleased with doing this) - because there was no other vehicle available the patient was delayed by about 1 hour. Both the referrer and other crew member sustained back and other pain as a result of undertaking this conveyance.

Mobidly obese patient with one leg and the use of only one arm. This presented the crew with difficulties getting the patient out of the house and into the ambulance. Bariatric ambulance requested - no one available to bring the Trust bariatric stretcher to the address. The patient had an extra wide wheel chair that would not have fitted into the ambulance alongside the bariatric stretcher for the patient to transfer over. With the crew late off and the relatives becoming impatient, they, with the crew and some bystanders all helped to manoevure the patient over onto the normal sized ambulance trolley cot. This resulted in both crew members hurting their backs. Neither reported sick for following shifts.

Verbal statement from crew

16/10/2015

This pt was having a diabetic hypo when work collegues called 999. They were advised not to give the pt anything to eat or drink prior to ambulance arrival. This is the exact treatment she required prior to ambulance arrival to prevent the hypo worsening. It was also 36 minutes before I arrived on scene with the pt.

Reviewed CAD. Call triaged by AMPDS and graded as Green 1 response (within 20mins). 3 resources were assigned and subsequently diverted to higher priority calls. The standard advice from AMPDS pre-arrival instructions was given, i.e. "Do not give the patient anything to eat or drink as it may make them sick or cause problems for the Doctor". The added benefit of this is that the average lay person is not accurately able to assess level of consciousness, so this advice prevents the additional hazard of choking presenting.

Reviewed CAD. Call triaged by AMPDS and graded as Green 1 response (within 20mins). 3 resources were assigned and subsequently diverted to higher priority calls. The standard advice from AMPDS pre-arrival instructions was given, i.e. "Do not give the patient anything to eat or drink as it may make them sick or cause problems for the Doctor". The added benefit of this is that the average lay person is not accurately able to assess level of consciousness, so this advice prevents the additional hazard of choking presenting.

12/12/2015

Called to R2 patient - diabetic - given as unconscious - blood sugar of 1.9. Upon subsequent request for information - given as 54 year old male. On arrival informed by patient's wife that patient had collapsed, but now got himself up and gone into bathroom, but had not heard anything since. I approached the closed bathroom door, knocked, received no response so slowly entered to find patient staring into mirror. As I began to introduce myself to the patient - he spotted me in the mirror, turned, very confused and rushed at me, swinging punches and yelling "Get the f**k out of my flat, who the f**k are you? Get out! Get out". Unfortunately due to the tight confines of the property and the layout of the doors, I was unable to turn and exit quickly and became trapped up against the door of the property as the patient lost footing and collapsed against me, pinning me against the door. The patient obese weighing probably in the region of 15-20st. The patient then slumped to the floor, hitting his head on the floor and became subdued. After I had composed myself I again attempted to introduce myself and ensure the patient was not critically injured by the fall and was met with the same aggressive, confused reaction. I eventually managed to subdue the patient enough to administer some intramuscular glucagon and the patient recovered with no recollection of the incident and was very apologetic. I requested HOT2 backup as no backup had been deployed and the patient was subsequently conveyed due to an arrythmia discovered on further investigation.

crew suffered some slight neck pain as an old injury had been exacerbated. Stood down at 16:30. Not booked as sick due to nature of incident. The patient was not aware of the incident due to his Hypoglycaemia. No action to be taken.

Spoke to staff Spoke to DLO

Hypoglycaemic patients can be unpredictable and not accountable for their actions. Care needed when approaching.

24/11/2015 pt scratched my head and pulled my hair in a deliberate act after my colleague and i had explained we were helping her into a wheelchair.

Spoke with crew. Elderly female with dementia. Datix for information only. No further acton.

For information only

04/06/2015

On several occasions caller and his colleagues have been out to patient up to 50 times with diabetic hypos and other clinicial issues. Caller and collegues have reported their concerns through Datixing, Spoc Referral, Crisis Team and the Hypoglyacemic Team. Patient has been sent into hospital on a number of occasions and being discharge without any package in place. GP services have also been made aware and unfortnately this patient has died at the age of 42.

Staff member has highlighted good practice in referrals made. Multiple engagement with community based teams including GP and hospital. Patient appears to have had several co-morbidities and due her age will probably become a coroners case. No further action required from the Trust.

13/09/2015

The crew were called to attend a patient today who was unwell. The crew were told that the patient is a diabetic on insulin and lives out of area. The patient went out yesterday to a rave party and she did not have her insulin with her. She did not eat much food either, and took a small quantity of amphetamine sulphate (speed) at this rave. She became progressively unwell, agitated and appeared to be catching her breathe. Her brother and friend became concerned for her health and drove her to the Peteborough Minor injuries unit. The patient remained in the car whilst the brother and friend went inside to see the receptionist there and explained their concerns for the patient's health. The brother and friend were apparantly told that the patient would not be seen there and were advised to go back home and dial 111. The brother and friend did this afterwards. Via the 111 service an emergency ambulance was deployed to attend the patient. On arrival to the incident there was a community first responder present who had completed a set of baseline observations and had administered oral glucogel to the patient. The crew checked the blood glucose levels using a glucometer and found that the patient's reading's were very high (although there were no number's given which indicated it was off the scale). The patient was conveyed to Peteborough City Hospital under emergency conditions and was handed over in the resuscitation department. Due to the critical health of the patient and in hindsight, learning the facts about the history, it is possible that the patient could have recieved the correct treatment much earlier. The doctor and nurse at the hospital advised that this incident must be highlighted via datix. In the case of the first responder who administered the glucogel, this had an adverse effect on the patient's health. It is understood that the first responder does not carry a glucometer to measure blood sugar level's, and it is beoynd their scope of practice. In the case of the patient attending the minor injuries unit, if they were turned away investigations need to be made as to why as this prolonged wait for treatment had an adverse effect on patient's health. Crew were given the job at 11:59, ptient s thought to have attended minor injuries unit at approximately 11:30. Telephone number given for patient below is for the brother. The family were quite upset/ distressed that the patient was not seen in the

two issues: 1) pt attended MIIU and was not seen by clinician but advised to return home and call 111. this resulted in delayed treatment. 2) CFR administered hypostop prior to arrival of ambulance crew without completing BM. Pt was hyperglycaemic and this treatment detrimental to their care.

1)the comissioners for MIIU (lincs PALS) contacted to highlight incident for theor own investigation. 2) contacted to highlight incident and CFR conduct.

Awareness

minor injuries unit.

10/06/2016

high risk alert to be raised on an address. called to male pnt for a hypo and pnt was extremely aggressive. tonight whilst crew were there crew had to call police to restrain pnt and pnt has assaulted his father twice. crew beleive its not safe for single man crews to attend. pnts father said the only way this would be resolved was if someone was killed at the address.

This patient does have underlying health problems as well as being a diabetic,he has started to become a more regular caller, he is also becoming more unpredictable and showing aggression towards our staff especially when having a hypo, also his aggression would seem to be selective and not always to do with his medical condition,

I will be placing a flag on the address to suggest solo's do not attend and crews should approach with caution, retreat if threatened and to then request the Police,

Through staff reporting such incidents it allows us to identify potential patients that might hold a threat to our staff, and gives us the opportunity to flag an address so staff will be advised by control before arriving on scene,

01/04/2016

Repeat attendance to a diabetic patient. 3 crews overnight, final attendance resulted in cardiac arrest. Pt had DNACPR in place.

Datix transferred from DMR 3/5/16 Datix raised as a concern as 3 attendances to this patient, the last attendance resulted in a cardiac arrest.

From Named Professional for Safeguarding) Norfolk Police have been in contact with regards to this Incident. PCR checked @ 20:52 . Hypogylcaemia Bm2.1mmol/l O/A assessed by an ECP left at home, Bm leaving scene 7.4mmol/l. Poor PCR recording and at times illegible content,Breathing noted as abnormal why no details of breathing No ECG, No Fast Test - poor worsening advise and details of referral, no details of gliclazide noted, why 200ml Saline IV infusion?, no capacity to consent noted on the PCR. No capacity to consent form and no non conveyance check sheet completed. PCR checked 00:54 . Hypoglycaemia Bm2.8mmol/l O/A. good thorough PCR. Left at home -

Capacity to consent form completed although at 03:15 15mins after his bm was 2.5mmol/l when recorded at 03:50 it was 6.7mmol/l. A non-conveyance form completed Bm leaving scene 6.7mmol/l. DNAR in place. PCR checked 08:08 . Hypoglycaemia 1.7mmol/l on arrival - pt went into cardiac arrest on scene when glucose set up. good PCR completed. DNAR presented ALS stopped. ROLE completed. Emails sent to all staff whom attended the 3 calls for a statement, attached are guidance documents and witness form.

27/02/2016

Ambulance requested to back up a technician/ECA crew for a diabetic hypoglycaemia. Crew member handed over to paramedic crew that they had given the patient GTN spray whilst the patient was GCS3, due to query LVF as patient presenting with audible crepitations in chest and hypertension. During the job, paramedic crew did speak with the other crew in regards to it, it was contra-indicated to give that drug. Spoke to crew member who said they would do a reflective account and have learnt from the outcome, no harm came to the patient and made a recovery from his hypoglycaemia episode.

Debriefed member of staff. No harm to patient. Discussed clinical reasons and background. Evidence has subsequently researched this subject. QA3 completed.

Learning taken place.

10/06/2016

02.00, paramedics arrived, Blood Sugar levels were low. Paramedics wished to take pt to hospital but he refused. pt was deemed to have capacity to make that decision. They inserted a cannula and proceeded to give glucose through a drip, 03.35 Blood Sugar Levels were 4.1 after 100mls of glucose, 03.50 Blood Sugar Levels were 6.7 after another 50mls of glucose. Cannula left in and advice to call GP in the morning for meds review. Paramedics left at 04.10 07.50 pt not feeling well, Blood Sugar Levels were 2.2, ambulance requested, food given to bring up BSL’s. Operator was still on phone and giving advice, when pt became unconscious, 5 staff lowered pt to the floor. pt was put into the recovery position due to having a fit. Paramedics arrived about 08.30 and read the information from the previous paramedics visit and questioned the cannula that was in situ. They then proceeded to undertake CPR. The Manager advised the crew that a DNAR was in place and showed them the signed paperwork. The Crew continued to deliver CPR for at least 20 minutes. The manager asked the paramedics to stop. pt pronounced dead at 9am

19/05/2016

Dementia PT's diabetes isn't being managed at the care home. For example - PT refused to eat at 1700 yesterday but was given insulin at 1800. On previous occasions the Pt has been given food but not received insulin doses. When the blood sugar goes low the PT is administered short acting glucose syrup but no long term carbs are given. The PT's sugar levels are always changing. The PT's blood sugar records appear to be all over the place. Some values recorded on a computer system but not on notes. There are instructions in the blood sugar level care plan for a blood sugar to be recorded before bed time which seems to be missing entries. The GP who has given instructions on certain timings for the insulin and food to be administered has been ignored by the care staff. The GP is aware of this and will be implementing a referral to the Ipswich Hospital.

Details from the crew:Dementia PT's diabetes isn't being managed at the care home. For example - PT refused to eat at 1700 yesterday but was given insulin at 1800. On previous occasions the Pt has been given food but not received insulin doses. When the blood sugar goes low the PT is administered short acting glucose syrup but no long term carbs are given. The PT's sugar levels are always changing. The PT's blood sugar records appear to be all over the place. Some values recorded on a computer system but not on notes. There are instructions in the blood sugar level care plan for a blood sugar to be recorded before bed time which seems to be missing entries. The GP who has given instructions on certain timings for the insulin and food to be administered has been ignored by the care staff. The GP is aware of this and will be implementing a referral to the Ipswich Hospital.Falls, safeguarding and Diabetic referrals. Spoken to the GP

crew has completed the referrals: SPOC, Falls referral, Ssfeguarding and GP referral. No further action required as patient being referred by the GP and SPOC/Safeguarding re the Care home. Discussed with ACL-crew has been thorough and informed all services.

Crew has informed all the services appropriately.

28/05/2016

Crew went to a hypo patient who was very violent and she hit both crew members on the leg. Slight bruise to one crew members leg unsure if any markings on other crew member.

Attended scene with crew

Liaise with crew regard any injuries - very minor Liaised with Police on scene MH Capacity completed- intially no capacity due to Hypo- second capacity assessment when patient recovered shows patient had capacity No police action due to patients medical condition and lack of awareness of actions during Hypo

N/A

22/07/2016

I attended a patient suffering a diabetic hypo at the above CAD. After treating the patient and finding he had suffered multiple hypos in a 12 hour period, I deemed it necessary to transport the patient to hospital for further assessment. The patient advised me he required a bariatric vehicle for transportation as his weight was over 200kg. The DLO on duty attended with an ambulance and the bariatric stretcher which the patient was able to mobilise on to and we moved the trolley to the ambulance. Due to the way the slope goes on to the tail lift, we had to pull the stretcher onto the ramp with some difficulty. Several hours later, I now have pain in my right wrist which I believe has been caused by this manouevre. I have verbally reported the injury to the DLO now on duty and have been advised to fill out a DATIX to that effect.

Minor injury caused by moving a heavy patient

No sickness occured due to this, for information only

Awareness of manual handling techniques and risk assessing larger patients as a team

01/05/2015

Crew would like to flag the patient's address for the safety of future crew visits. Patient at the address wants to commit suicide, has done it several times prior to tonight, he lies about taking an overdose on insulin, he knows the effects of his actions of taking an overdose. When confronted he becomes extremely violent and can flare out at any time towards ambulance staff, police and he has kicked off in A&E with nurses and doctors before. He does the same thing every time.

Following discussion with crew it was decided that a CAD risk marker should be placed on the address. Request made for CAD risk marker.

Discussion with crew.