Local integrated investigation pilot 3

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Background

Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.

The pilot published three investigations focused on cross-boundary and multi-agency safety events.

This is the third pilot investigation.

The other pilot investigations are:

Pilot 1: Incorrect patient identification
Pilot 2: Incorrect patient details on handover

Report summary

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.

Safety recommendations

Anonymous

HSIB recommends that Trust A and Trust B update the information provided to the Directory of Service on the availability of stroke services once they have created a harmonised cross-trust stroke policy.

Trust A and Trust B responded to the safety recommendation as follows:

Both Trusts will update the information they provide to the Directory of Service on their overnight stroke services on completion of reorganisation these services.

Response received on 13 June 2022 and updated on 12 September 2022.

Anonymous

HSIB recommends that the Ambulance Trust works with Trust A and Trust B to ensure that their local stroke policies are aligned and direct ambulance crews to the most appropriate service.

The Ambulance Trust responded to the safety recommendation as follows:

The Ambulance Trust will work with Trust A and Trust B to review stroke pathways.
The Ambulance Trust will remind clinicians that stroke pathways are available on the Directory of Service and in Trust guidelines.

Response received on 10 May 2022.

Anonymous

HSIB recommends that Trust B works collaboratively with Trust A to develop a harmonised, cross-trust stroke policy with a clearly defined joint emergency department overnight stroke protocol for FAST-positive patients.

Trust B responded to the safety recommendation as follows:

Trust B is working with Trust A to develop a joint overnight stroke admissions protocol for FAST positive patients.

Response received on 13 June 2022 and updated on 12 September 2022.

Safety observations

It may be beneficial for the clinical commissioning group to provide oversight of stroke pathways until a hyper-acute stroke unit is established, to ensure that there is a clearly understood pathway for FAST-positive patients between 23:00 hours and 08:00 hours.

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

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HSIB legacy content

Background

Report summary

Safety recommendations

Anonymous

Anonymous

Anonymous

Safety observations