Examples of learning

We always look to use any feedback we receive as a chance to learn, and so improve the service we provide to our patients.

We also believe that we need to focus not just on complaints, but the full range of enquiries received from patients and the public, as well as incident reports from other health and social care agencies.

The case examples on this page originated from a range of sources, and were highlighted to us through a number of different contact points. The most important issue from our point of view is that, once they have been received and looked into, we are able to address the causes so that we can better manage similar situations in the future.

Case studies

• An 83-year-old patient presented with symptoms that were suggestive of a possible stroke, however they were not fully explored by the call handler who received the 999 call. This led to the call being determined at a lower priority category and it being referred to our clinical telephone advice service. Subsequent 999 calls were not re-triaged and it was only following a fifth call that the position was realised. The lessons learned included the need to improve awareness of a patient’s symptoms to determine use of the  stroke protocol (which results in a higher level of priority being made), the importance of the re-triaging calls when further calls are received and increased monitoring and intervention of senior managers where a 999 call is being ‘held’ awaiting dispatch of an ambulance.

• A member of the public had received an answer phone message, apparently intended for the patient’s GP, from an elderly patient who was experiencing breathing problems. The patient sounded very breathless, and requested an urgent GP visit. The member of the public was concerned as she had no details of the patient’s phone number, but did have most of the address. We were able to confirm that we had not attended on that day. Our control room was contacted and an ambulance was dispatched to ensure the patient was safe and well. It was subsequently identified that the patient is a frequent caller and action is being taken to establish a care plan approach.

• A patient’s family was unhappy with the care provided and at the apparent lack of urgency of the attending staff. The family were concerned that the patient’s condition, later identified as severe bleeding in the brain, could have been alleviated if the crew had acted appropriately. A comprehensive response was provided explaining that the clinical care provided was appropriate and that the on–scene time was reasonable in the circumstances. The learning point was the need to better communicate with relatives so as to enable improved understanding of the care and treatment provided.