Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care

Investigation summary

This investigation explores a real patient safety event. It looks at the local stroke emergency care pathway and the co-ordination between the NHS ambulance trust and two hospital trusts involved in the event.

It is part of our local integrated investigation pilot.

Safety event

The 75-year-old patient suffered a stroke in the early hours of the morning. He had woken feeling unwell (two hours after going to bed) and waited alone to see if his symptoms would improve. They didn’t improve and nearly three hours later, his wife called an ambulance.

Before they set off with the patient, one of the paramedics contacted the emergency department (ED) at the first hospital (Trust A) to ‘pre-alert’ them of his arrival. The ED advised that they could not accept the patient as their stroke service was closed between 11pm and 8am and the paramedics should contact a neighbouring hospital (Trust B).

The neighbouring hospital advised that they could not take the patient as he was outside of the window for immediate stroke treatment and should be taken to Trust A.

Trust A reiterated that they could not accept the patient and the paramedic phoned Trust B again and they agreed to accept the patient. Once at the second trust, he had to wait 40 minutes in an ambulance as the ED was very busy.

It was then confirmed via CT scan that he has suffered an ischaemic stroke (a stroke caused by a blood clot in the brain), and he was taken to the intensive care unit.