Health Investigation – Man suffers two amputations following breach in his care

Deputy Health and Disability Commissioner Kevin Allan today released a report finding an ambulance service and a paramedic in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for their care of a man who later required two amputations.

The man, aged in his late eighties at the time, had been working underneath a van for a few hours when his left leg became painful and numb. He rang for an ambulance and, after a clinical assessment on the phone, a paramedic and an emergency medical technician (EMT) attended the scene.

The paramedic and the EMT assessed the man’s leg but did not remove the man’s sock during the assessment. They considered his pain was musculoskeletal and decided not to transfer him to hospital.

The following day, the man awoke with severe pain and a blue foot, and was admitted to hospital with an ischaemic left lower limb, and required two amputations of his leg.

The Deputy Commissioner considered that the paramedic’s assessment of the man was incomplete and resulted in the decision not to transfer him to hospital. He also considered that the paramedic’s documentation fell below accepted standards and did not adhere to the ambulance service’s guidelines.

The Deputy Commissioner accepted that the EMT was not the most senior clinician responsible for the care provided to the man. However, he was critical of the lack of reflection and responsibility shown by the EMT in response to these events, and reminded him of the importance of reflection as a tool to improve one’s practice.

Mr Allan said the need for effective communication, collaborative working, and collective ownership of the challenges are evident in this case. He reminded the ambulance service of the importance of having strategies in place to promote these aspects in its organisation.

The paramedic has since retired as a paramedic, and has provided the man with a written apology. Considering this, Mr Allan recommended that should the paramedic return to practice, he arrange for further training on clinical procedures and guidelines, challenging assumptions, and managing inter-professional relationships.

Mr Allan recommended that the ambulance service report to HDC on the outcome of the EMT’s competency review and subsequent training, and provide HDC with evidence of training to its staff on conflict and communication breakdowns, once completed.

The full report on case 19HDC02285 is available on the HDC website.