The exterior front entrance of a hospital emergency department, with ambulances parked outside.

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

HSIB legacy content

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:

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.