Paramedic failed to identify severe condition of patient who later died in hospital

The patient was taken to Colchester Hospital Picture: COLCHESTER HOSPITAL UNIVERSITY NHS FOUDATION TRUST (Image: Archant)

The Health and Care Professions Council (HCPC) ordered that Colchester paramedic Kielye Mitchell be removed from the register for a year after its recent tribunal found her mistakes amounted to serious breaches of standards.

The panel upheld all nine allegations against Mrs Mitchell, including failing to 'blue light' the patient to hospital or inform staff about the "significant deterioration" of her condition, which had seen her lips and fingertips turn blue.

The patient, a learning support assistant, had been unwell since the early hours of March 8, 2016, when he her husband had been woken by her shaking in bed.

She had been vomiting, did not go to work and was still ill when her husband returned that evening.

He called 111 for emergency help. Mrs Mitchell, a paramedic with 12 years' experience and of previous good character, was sent to the patient's home, along with an emergency medical technician.

But although the husband had told the operator about a "bruisey mark" on his wife's back, Mrs Mitchell did not identify any rash.

The panel concluding it was "highly unlikely" not to have been present when she examined the patient.

Mrs Mitchell was also found to have walked the patient out of her home, contrary to proper practice.

An Area Clinical Lead for the East of England Ambulance Service Trust (EEAST), who carried out an internal investigation, told the tribunal the patient's low blood pressure should have been a "red flag in relation to allowing the patient to walk" and she should have been transferred by a carry chair or stretcher.

The clinical lead also said the patient's condition, which suggested poor blood flow and a possible infection, required "urgent assessment in hospital" and a "blue light" transport.

But the emergency medical technician, who was driving the ambulance, said Mrs Mitchell had refused when asked whether to travel under blue light.

The panel found Mrs Mitchell should have also made a "pre-alert" to the hospital, but chose not to do so.

Arriving at the hospital at 6.19pm, there was a significant delay in handover.

The hospital was on 'black status', and struggling to cope with the demands it faced.

Despite the patient showing visible signs of deterioration, Mrs Mitchell was said to have continued to assert she "did not look seriously unwell".

A hospital nurse told the panel Mrs Mitchell had said the patient was in the ambulance suffering with diarrhoea, vomiting and low blood pressure but "she had no other concerns".

The panel found the deterioration was "critical information" that Mrs Mitchell was obliged to tell colleagues.

It also found Mrs Mitchell should have carried out additional temperature readings and observations in the two hours-plus spent in the ambulance.

The patient's husband had commented on his wife's deterioration, including the discolouration of her lips and fingertips. The clinical lead said the husband's concerns were "warranted and should have been acted on".

They told the panel that the "root cause of this case" was that Mrs Mitchell did not recognise the severity of the patient's condition.

The panel found these failings, together with not alerting the hospital to her true condition resulted in patient being denied timely care.

When the patient finally entered the hospital, she was placed in intensive care, but died in the early hours of the following morning.

Her husband complained about the hospital and ambulance trust, both of which carried out internal investigations.

He was not satisfied, however, and complained to HCPC in December 2016.

The panel noted Mrs Mitchell had acted professionally when engaging with the complaint and was considered by colleagues to be kind and caring but also that she had shown a lack of insight or remorse.

EEAST expressed its condolences to the family and said it would give careful consideration to the tribunal decision.