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Care provided by paramedic during patient transfer (13HDC01190)
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Paramedic ~ Ambulance officer ~ Medical officer ~ Rural
hospital ~ Chronic shortness of breath ~ Rights 4(1), 4(2)
A 69-year-old woman lived in her own home in a rural area. She
had multiple co-morbidities including diabetes, ischaemic heart
disease, and chronic obstructive airway disease (COAD). She was
using oxygen at home because of her COAD.
The woman had had a cough for approximately three days. Her
daughter was with her overnight. At around midnight, the woman was
finding it difficult to breathe, and had chest pains. The daughter
activated her mother's medical alarm and 111 was called.
The responding ambulance was manned by a paramedic and a
volunteer. They found the woman sitting in a chair using oxygen.
Her observations were abnormal, in particular, her oxygen
saturations were low and her temperature was low. The paramedic
telephoned the duty medical officer at the local rural hospital.
The medical officer recalls being told that the woman's vital signs
were stable, and there were no other associated symptoms besides
her baseline chronic shortness of breath. The woman was not
transported to the hospital. The paramedic and volunteer told the
daughter that if things got worse, she was to call the ambulance
About two hours later, the daughter called the ambulance again.
The paramedic went to the volunteer's home to pick him up, but he
was unable to wake him, so he responded to the call alone. On
arriving at the woman's home a second time, the paramedic
recognised that the woman was seriously unwell. He rang the medical
officer again, reporting her vital signs, and was advised to
transport the woman to the hospital.
The woman had to walk eight metres to a wheeled chair outside
the front door. Her daughter and the paramedic then wheeled the
woman to the ambulance, but during that time she had no oxygen as
the paramedic had not brought any portable oxygen up to the house.
When they got to the ambulance, the chair tipped over. The woman
was still strapped in, and the paramedic then tilted the woman
upright. The woman collapsed and fell to the ground as they
attempted to get her to move into the ambulance. The daughter and
the paramedic lifted her onto a stretcher to transfer her into the
The paramedic put the woman on oxygen via an acute mask, and put
her on a monitor so that he could record her heart rate and rhythm.
Despite alarms sounding because the woman's oxygen levels were low,
the paramedic did not stop the ambulance until they reached the
hospital. The woman died during the journey.
It was found that during the second attendance, the paramedic
did not take sufficient steps to obtain the volunteer's assistance
or other support. The paramedic should have obtained assistance
prior to moving the woman when he arrived at her house and became
aware of her condition. The paramedic decided to move the woman
without portable oxygen when she was seriously unwell and dependant
on oxygen. When the woman collapsed, he failed to assess her
sufficiently, and took no action when the alarms sounded during the
journey to the hospital.
The cumulative effect of these failings was that the paramedic's
assessment and treatment of the woman was seriously inadequate. The
paramedic failed to provide services with reasonable care and skill
and, accordingly, breached Right 4(1). The substandard
documentation in this case represented a departure from accepted
standards of care. Accordingly, the paramedic failed to provide
services in accordance with relevant standards and breached Right