Introduction

1. This report is the opinion of Dr Vanessa Caldwell, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.

2. The report discusses the care provided to Master B by the private ambulance service, Registered Nurse (RN) D, Miss C, and Ms E.

3. The Nationwide Health and Disability Advocacy Service referred a complaint to this Office from Ms A about the resuscitation efforts made by onsite paramedic services after her son, Master B, collapsed at a public event in October 2020.

4. Sadly, Master B passed away in late October 2020.

5. The following issues were identified for investigation:

   • Whether the private ambulance service provided Master B with an appropriate standard of care in October 2020.

   • Whether RN D provided Master B with an appropriate standard of care in October 2020.

   • Whether Miss C provided Master B with an appropriate standard of care in October 2020.

   • Whether Ms E provided Master B with an appropriate standard of care in October 2020.

6. The following parties were directly involved in the investigation:

   Ms A                                                                            Complainant/mother

   The private ambulance service                                   Private ambulance service

   RN D                                                                            Registered nurse and first responder

   Miss C                                                                          First responder

   Ms E                                                                            (Now) registered paramedic

7. Further information was received from:

   An event stallholder
   Emergency call centre
   Health New Zealand | Te Whatu Ora
   (Health NZ)                                                                National health agency

8. Fire and Emergency New Zealand is also mentioned in the report.

9. Independent clinical advice was obtained from former paramedic Mr Mark Bailey (Appendix A).[1]
   

How matter arose

Introduction

10. In October 2020, Master B, aged 15 years at the time of the events, was attending a large indoor public event with his friends. The private ambulance service provides medical coverage for events and was providing onsite medical services for this event. Shortly after disembarking from an event ride, Master B stumbled and collapsed inside the event venue. The private ambulance service staff assessed Master B and commenced resuscitation attempts and continued until emergency call centre staff arrived and took over. Master B was transported to hospital, where he received care until life support was removed in late October 2020. Master B passed away shortly afterwards.

11. Ms A became concerned about the care Master B received after the cardiologist treating Master B in hospital raised questions about whether Master B’s death may have been preventable based on indications that Master B was without oxygen for at least 10 minutes, leading to hypoxia[2] and the presence of features commonly associated with a good outcome after a cardiac arrest.[3] Ms A has sought clarity around the events to ascertain whether anything could have been done differently and to learn from the event.

Master B’s collapse

12. After Master B collapsed, a nearby stallholder sought medical assistance. The stallholder recalled approaching the private ambulance service base[4] at around 9.40am. Accounts differ as to what the stallholder told private ambulance service staff. The stallholder recalled telling staff:

    ‘[S]omeone had just died in front of our stand and probably needed [CPR][5] and oxygen. I told them that someone had already started CPR as that’s what I thought was happening[.]’

13. In contrast, the private ambulance service stated that there was no mention of someone having died or that CPR had started.

14. The private ambulance service patient report form (PRF) states that the history presented to the private ambulance service staff was that Master B had ‘been on a ride, had seizures, walked away, then collapsed, hit head’.

15. Three private ambulance service staff members were providing services at the event — RN D, a registered nurse with some advanced skills and with the authority to practise as a first responder under supervision from a paramedic; Miss C, a first responder;[6] and Ms E, a registered paramedic and Clinical Manager for the private ambulance service.[7]

16. All three private ambulance service staff members completed incident report forms 10 days after these events.[8] According to their statements, Miss C and RN D arrived to support Master B with a resuscitation kit[9] and AED[10] approximately two to three minutes after the stallholder notified them. Ms E remained at the base to await further instructions on the equipment required.

17. At the same time, a different bystander called 111[11] to request assistance. The emergency call centre records indicate that this call was made at 9.44am. The call recording captured the bystander saying: ‘I’ve just witnessed someone fall over backwards and start seizing … [T]hey’re breathing [but] he’s not particularly responsive.’

Initial assessment by the private ambulance service

18. At 2.41 minutes into the 111 call recording, the bystander announced that ‘medical professionals’ had arrived, and at 3.04 minutes into the call the bystander announced that he could not see clearly as the private ambulance service was leaning over Master B and was in the way. The caller also said that Master B was in the recovery position and that he ‘took a deep breath’.

19. The incident report forms record that, on arrival, RN D attended to Master B, while Miss C spoke to bystanders. RN D told the Health and Disability Commissioner (HDC) that initially she did not consider a cardiac arrest because it had been reported that Master B had fallen, hit his head, and had a seizure. Her impression was that she was treating an unconscious patient, not in a cardiac arrest. RN D told HDC that she performed a primary survey,[12] which included checking Master B’s airway and breathing, and her incident form documented that at this point Master B was ‘gasping, non-responsive, [and] blue in colour’. RN D stated that ‘on reflection’, the blue colour seen on Master B may have been due to event lighting.

20. The incident form documents that RN D placed a non-rebreather mask[13] on Master B to assist with his breathing. The stallholder who alerted the private ambulance service of the incident also recalled a staff member attempting to fit an oxygen mask at this stage.

21. There is no description of the assessments RN D undertook prior to or after placing the non-rebreather mask. Subsequent statements provided also do not provide a full description of the breathing assessments performed, only that RN D noted laboured breathing, blue skin colouring, and that Master B was not responsive before administering oxygen. RN D confirmed that oxygen saturation was not checked with a pulse oximeter[14] as she did not have the device on her, but oxygen saturation assessment was instead based on Master B’s colour.

22. In several statements, the private ambulance service told HDC that, upon arrival, RN D checked for, and found, a pulse, which was neither fast nor slow. In contrast, when describing her initial assessment, RN D told HDC that she ‘did not take his pulse at this point’ and recalled ‘bystanders advising her, when she arrived, that [Master B] had a pulse’.

23. The PRF documents that staff were alerted to the emergency event at 9.45am, and Master B’s vital signs at 9.46am were Pulse — 0 and Respirations — 0, and Master B had a Glasgow Coma Scale (GCS)[15] score of 3. No subsequent recordings are noted on the PRF. The section of the form where staff document supplemental oxygen provided was crossed out with no values entered. However, the equipment usage log records that an adult non-rebreather mask was used at the event. No detailed breathing assessment is recorded. The PRF was completed after the resuscitation, and the timings on the form were estimated in retrospect, and therefore the private ambulance service has accepted that the clinical records are not adequate and ‘did not accurately record all assessment and treatments provided’.

24. The private ambulance service stated that, during this initial assessment, RN D and Miss C noticed the bystander on the 111 call.

25. In the call recording, the bystander can be heard saying that the private ambulance service staff were ‘telling [him] there’s no need’ for an ambulance and that a staff member was doing a ‘hand against her neck’, which was interpreted as a ‘signal to say cut it’. The bystander then explained to the call handler that the private ambulance service was investigating whether Master B needed to be taken to the on-site ambulance and said that they would call the emergency call centre if support was needed.

26. Miss C’s incident form documents that RN D gestured towards the bystander, and Miss C told the bystander that they would assess the situation before requesting transport. RN D’s incident form documents that she ‘stated hold fire [let’s] figure out what is going on first’ and then gestured to cut the call.

27. The private ambulance service told HDC that the intent was for the emergency response to be put on hold while staff assessed Master B’s condition and severity so that appropriate information could be passed on. The private ambulance service asserted that this miscommunication led the bystander to ‘cut the call altogether’. RN D accepted that ‘with the benefit of hindsight, [she] should have allowed the call to be completed’.

28. RN D told HDC that she then began her secondary survey[16] and made two attempts to take a blood glucose level, as both low and high blood sugar levels can cause collapse and seizures. Both attempts to take a reading were unsuccessful.

Deterioration in condition

29. Ms E’s and RN D’s incident forms record that Ms E radioed RN D for an update, and then RN D radioed Ms E back, initially requesting a wheelchair, but later requesting a stretcher and ambulance. The CCTV footage[17] from the event venue shows that, at approximately 9.52am,[18] the ambulance arrived at the nearest roller door leading into the venue hall from the carpark, and Ms E parked the ambulance just outside this door and moved the stretcher towards Master B with the assistance of Miss C. Varying evidence has been provided about the actions that took place next.

30. In her complaint submission, Ms A recalled that, on her arrival shortly after 9.52am (as per her phone records), no-one was on the floor attending to Master B, and no equipment (such as an oxygen mask) was being used. She said that she tried to approach Master B, and it was at this point that the private ambulance service staff arrived, and she was ‘actively distracted’ by a staff member. In her response to the provisional opinion, Ms A stated that, at this point, she thought that Master B might have fainted. She said that she would not describe herself as being in significant distress or hysterical. Ms A told HDC that it was only after being distracted by a staff member and seeing Master B outside having CPR undertaken that she became hysterical. All three incident forms documented that shortly after the stretcher was placed next to Master B, Ms A arrived at the scene in distress, and Ms E left the stretcher to intercept her. Ms A contests this, stating that she did not see Master B on or near a stretcher when she arrived at the scene. In response to the provisional decision, Ms A stated that staff were not getting ready to load Master B onto a stretcher, unless they had left Master B on his own to get equipment and returned just as she arrived. She said that she saw Master B lying alone on his side in the recovery position with bystanders around him.

31. Ms E’s incident form records the following:

    ‘I began to lower the stretcher in position for transfer. The mother came … down the aisle in significant distress, straight in line with [Miss C’s] + [RN D’s] treating. I left the stretcher with [RN D] + [Miss C] + intercepted the mother. Security arrived to assist.’

32. The incident forms recorded that while Ms E was speaking with Ms A, RN D requested that Ms E return to assist with transferring Master B to the stretcher. The forms document that while Ms E was walking back, Master B’s condition worsened, and he stopped breathing shortly after she returned to his side.

33. In an initial statement provided to HDC, Ms E told HDC that after placing the stretcher down, she conducted a brief handover with RN D and confirmed that there was a pulse but did not herself carry out a pulse check prior to talking to Ms A ‘briefly’. Ms E stated that Miss C informed her that Master B had stopped breathing, and on return to the stretcher, Ms E determined that Master B had a ‘clear airway and was blue in colour around his lips and face’.

34. A further statement provided by Ms E indicated that after placing the stretcher, she performed a quick primary survey, which included determining that the airway was clear, that Master B was breathing, and that a pulse was present. She stated that it was only after this primary survey had been performed that she left to speak with Ms A.

35. The private ambulance service told HDC that after arriving back at Master B’s side and determining that he was not breathing, the staff quickly continued to load Master B onto the stretcher and exited the building so that they had better lighting and were away from the crowds. Ms E estimates that the extrication took around one minute.

36. The private ambulance service stated that the non-rebreather mask was removed during the move as it was connected to the resuscitation kit and interfering with movements. The private ambulance service also told HDC that the reason for not dragging Master B outside or starting to perform CPR while he was on the stretcher was that there was a large gap at the doorway that could have caused Master B further harm if he had been dragged, and the stretcher had to be manoeuvred over the gap, making it difficult to perform CPR effectively.

Resuscitation efforts

37. The resuscitation efforts by the private ambulance service staff once Master B had been moved outside are captured by CCTV footage and a further 111 call recording.

38. The private ambulance service provided excerpts from its ‘Resuscitation Guidelines’, which state that staff should ‘follow current international CPR procedures (e.g. 30 compressions, two breaths) appropriate to [the] level of training, including [providing a shock]’. Following this, the document lists only when resuscitation should not be attempted.

39. The footage captures the private ambulance service staff wheeling the stretcher to the front of the ambulance between 9.55am and 9.56am. Ms E remained near Master B’s head. She told HDC that she performed a quick primary assessment of Master B, including a pulse check, and then performed a jaw thrust and set up an oropharyngeal airway (OPA).[19] RN D began chest compressions, and Miss C set up equipment.

40. The CCTV footage shows that at 9.58am, the AED was used to provide Master B with a first shock. RN D continued with chest compressions, and Miss C and Ms E swapped positions, as Ms E needed equipment, and Miss C was not familiar with the placement of the equipment. Ms E told HDC that she then set up a bag valve mask (BVM).[20] Ms E considered that additional airway manoeuvres were not appropriate until CPR was under way.

41. Ms E then left Master B’s side to make a 111 call requesting further back-up. Ms E told HDC that she prioritised making this call over providing further treatment, as she wanted to ensure that timely support arrived. The emergency call centre’s records indicate that this call was made at 9.59am. In the call recording, Ms E can be heard advising their location and that Master B was in cardiac arrest. During this time, CPR continued, and a second AED shock was provided at approximately 10.00am. Ms E told HDC that she then chose to be a ‘hands-off team leader’ so that her team members did not lose focus by changing positions and to ensure that the basics of resuscitation were being carried out well by the team.

42. A member of the public then took over chest compressions, RN D took over the airway, and Miss C returned to the AED. Ms E left her cell phone with Miss C, and the call recording captured Ms E saying that she was going to talk to Master B’s mother. Ms E then moved inside the ambulance. The footage does not show clearly where Ms E went after moving into the ambulance, but she told HDC that she left to speak to Ms A, and Ms A also recalled Ms E speaking with her while CPR was in progress. Ms E explained that because of the placement of the ambulance and where Ms A was, the fastest route to Ms A was for Ms E to move through the ambulance.

43. The private ambulance service told HDC that, after the second shock but before the third analysis of Master B’s heart rhythm, Ms E directed RN D to check for a carotid pulse.[21] The private ambulance service said that RN D found a carotid pulse and Ms E confirmed this and located a radial pulse.[22] In contrast, CCTV footage shows that between the second shock and the third analysis, Ms E was at Master B’s feet and then inside the ambulance, and RN D is seen continuing to monitor the airway. The 111 call recording did not capture any clear discussions about measuring or finding a pulse.

44. The 111 call recording captured the AED analysing Master B’s condition for a third time at 10.02am and determining that a third shock was not advised. In the 111-call recording, Ms E can be heard asking the other team members to note down the timing of the AED shocks after they happened. Between approximately 10.03am and 10.04am, a female voice can be heard in the 111 call making a statement that Master B was attempting to breathe. The CCTV footage shows Ms E eventually exiting the ambulance with paperwork, which she began to fill out as the chest compressions continued. Ms E told HDC that she completed only the initial sections of the PRF before asking Miss C to complete the remainder while Ms E ‘continued to carry out care for [Master B]’.

45. Ms E then provided the 111 call handler with further patient history that she gathered from Ms A. The AED can be heard initialising for a fourth time between 10.04am and 10.05am and advising that a further shock was not needed. Shortly after this, a female voice stated: ‘He’s breathing.’ There is no evidence that vital signs were measured after the AED advised that no further shock was needed and staff identified that Master B had begun to breathe again. Ms E confirmed that she did not undertake further manoeuvres to secure Master B’s airway or attempt to gain intravenous (IV) access at this point. Ms E said that the AED remained on Master B until the arrival of the emergency call centre staff.

Arrival of emergency call centre staff and fire emergency services

46. Approximately two minutes later, a private ambulance service staff member announced that the fire truck and ambulance had arrived. The Ambulance Care Summary from the emergency call centre confirms that their first ambulance arrived at 10.06am.

47. The Ambulance Care Summary records that, on their arrival, Master B was breathing spontaneously, receiving high-flow oxygen via a BVM and had ‘palpable pulses present’. Emergency call centre staff documented that there had been return of spontaneous circulation (ROSC)[23] approximately two to three minutes prior to their arrival. However, Master B re-arrested shortly after their arrival, and CPR was recommenced. Emergency call centre staff asked Ms E to place an IV line.[24] ROSC was achieved, with the first recorded pulse at 10.15am.[25] Master B was transferred to the ambulance, where he received intensive care paramedic treatment. Miss C told HDC that she completed the PRF, with Ms E’s assistance, after emergency call centre staff had taken over care.

48. The emergency call centre’s records confirm that transport to hospital was commenced at 10.41am and that Master B was under the care of the Cardiovascular Intensive Care Unit. Health NZ told HDC that after Master B came out of sedation he showed evidence of a significant neurological injury and further assessments showed abnormal results. Based on this, in late October 2020, staff and Master B’s family decided to begin palliative care[26] and to remove life support, and Master B passed away shortly afterwards. Health NZ told HDC that, from the limited post mortem findings and discussion within the medical teams, Master B’s cause of death was considered to be hypoxic ischaemic encephalopathy[27] secondary to cardiac arrest (with the cardiac arrest thought to be secondary to myocarditis).[28]

Other information — staff training

49. The staff training plan provided by the private ambulance service shows that the fortnightly online training modules staff take include training on scene management, lifting and moving patients, comprehensive patient assessment (including forming diagnoses and selecting assessments based on patient condition), resuscitation (including when it is appropriate to begin resuscitation, and – for upskilled staff – the use of adrenaline), and a module on critical thinking and decision-making.

50. RN D’s training records show that in 2020 she completed the private ambulance service modules on resuscitation, patient assessment, cardiac conditions, and scene management. The private ambulance service told HDC that Ms E is involved in producing the online modules and helps to facilitate in-person private ambulance service training. The records for Ms E’s continuing professional development show that in 2020 she undertook IA Med’s training (now Impact EMS Training) on advanced airway management and scene management.
    

Responses to provisional opinion

Ms A

51. Ms A was provided with the opportunity to comment on the provisional report. She said that she appreciates the thoroughness of HDC’s investigation and is pleased to see the private ambulance service’s deficiencies in care noted so clearly within the report.

52. Ms A stated that she is concerned that there are different times given for when the incident was notified to the private ambulance service — the stallholder said that it was 9.41am, the private ambulance service said on the PRF that it was 9.45am, and the key private ambulance service medics think that it was anywhere from 9.30am to 9.40am. Ms A is also concerned about the differing accounts as to when the private ambulance service staff arrived.

53. Ms A agreed that Miss C was put in a difficult situation with poor guidance from those who were meant to be her mentors.

54. Further comments made by Ms A have been incorporated into this report where relevant.

RN D

55. RN D was provided with the opportunity to comment on the relevant sections of the provisional report. She said that she had no comments to make, other than providing an update on the proposed recommendations (which is included in the recommendations section of this report).

The private ambulance service and Ms E

56. The private ambulance service was provided with the opportunity to comment on the full provisional report. Ms E was provided with the opportunity to comment on the relevant sections of the provisional report.

57. The private ambulance service and Ms E responded jointly, stating that ‘[t]hey remain confident that, given the challenging environment and the information available at the time, they provided the highest standard of care possible for [Master B]’. They do not agree that the care they provided was below the required standard.

58. Ms E’s individual comments have been incorporated into this report where relevant. Other comments from the private ambulance service have also been incorporated elsewhere in the report.

Miss C

59. Miss C was provided with the opportunity to comment on the relevant sections of the provisional report. She had no comments on the decision.
    

Opinion: Introduction

60. At the outset, I acknowledge that this was a very traumatic, unexpected, and difficult loss for the family of Master B, and I express my sincere condolences for the loss of their much-loved son and brother. I commend Ms A for her diligence in seeking clarity and explanations about Master B’s passing. I also note that the Commissioner’s role is not to determine a cause of death (which has already been considered by hospital staff, as set out in paragraph 48) but instead to assess the appropriateness of the care Master B received prior to his passing.[29]

61. In forming my judgement, I am also mindful of the discrepancies associated with the timing of interventions. In this case, the timing of care, and in particular the timing of oxygen administration to Master B, were particularly relevant due to the link with the resulting brain damage. However, the discrepancies in the individuals’ accounts and the poor standard of documentation completed means that I am unable to make a definitive finding in relation to the delays associated with oxygen administration.

62. The private ambulance service, RN D, Ms E, and Miss C provided medical services at the event Master B attended. As such, they were healthcare providers who had a duty to exercise reasonable care and skill when providing event goers with services. In the case of the private ambulance service, this included the responsibility to ensure that staff were trained and equipped appropriately to handle an emergency response in the context of the services they provided.

63. To help determine whether the care provided to Master B in October 2020 by the private ambulance service and its staff was of an appropriate standard, I sought independent advice from former paramedic Mr Mark Bailey. Mr Bailey was a paramedic at the time of these events.

64. The Standards New Zealand ‘Health and Disability Services (Core) Standards’ (NZS8134:2008)[30] set out healthcare providers’ responsibilities to ensure that the services provided are safe. Standard 2.9.1 states: ‘Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.’ Standard 2.3.3 of NZS8134:2008 also sets out the following:

    ‘The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.’

65. I consider that the care Master B received departed from accepted standards, including deficiencies in the processes in place at the private ambulance service and in the care provided by RN D and Ms E, as outlined below.

Opinion: RN D — breach

66. RN D was one of the first responders. She performed a primary and secondary survey of Master B inside the venue and, during the resuscitation that took place in the carpark outside the venue hall, she provided chest compressions, airway management, and assessment after ROSC was attained.

Initial assessment — breach

67. RN D responded to the medical event, alongside Miss C, with a resuscitation kit and AED. The 111 call recording clearly documents that they arrived on scene 2.41 minutes into the call made at 9.44am, and RN D approached Master B.

Identification of cardiac arrest

68. RN D said that, on arrival, she saw that Master B was gasping, non-responsive, and blue in colour. Prior to this, staff had been provided with information that an event goer had had a seizure and had collapsed, hitting his head. RN D told HDC that because of the patient history provided, and her experience that cardiac arrest was unlikely for teenagers, she did not consider a cardiac arrest.

69. The PRF lacks details of the assessments and interventions performed on Master B – it indicates a provisional diagnosis of cardiac arrest, with pulse, respirations, or oxygen saturation levels documented as ‘0’ on arrival, and that no supplemental oxygen was provided. I accept that the PRF was completed after the event and not by RN D, and therefore the form may not represent her initial assessment or the care she provided accurately. I will discuss the issue of accurate documentation below.

70. According to RN D, the immediate assessments and interventions involved were checking Master B’s airway and breathing, placing a non-rebreather mask on Master B, and two attempts at performing a blood glucose level check. The description of assessments regarding airway and breathing relate to observing the colour of Master B’s skin and the presence of ‘gasping’ breaths. Oxygen saturation levels were not checked using a pulse oximeter as the device was not available. The private ambulance service and Ms E asserted that a pulse check was performed by RN D during her primary survey. However, RN D stated that she did not perform a pulse check during her initial assessment but was informed that a pulse had been found by bystanders. I accept RN D’s account.

71. Mr Bailey advised that when approaching a patient with Master B’s history and presentation, standard practice is to presume that the patient is in cardiac arrest until proven otherwise.

72. Mr Bailey has set out two scenarios of the steps that should have been taken after staff approached Master B – scenario one, where it was presumed or immediately recognised that Master B was in cardiac arrest, and scenario two, where staff were assessing an unconscious patient not thought to be in cardiac arrest.

73. Mr Bailey advised that if cardiac arrest had been appropriately presumed as a possibility by RN D, then assessments should have included checking for adequate respirations and then immediately commencing CPR if breathing was non-life-sustaining. This did not occur.

74. Mr Bailey said that the measurement of blood glucose levels for a patient in cardiac arrest would be a low priority and would take place in a secondary survey, which in turn would take place once any issues noted in a primary survey (such as cardiac arrest) had been addressed.

Treatment of an unconscious patient not in cardiac arrest

75. As RN D considered that she was treating an unconscious patient not in cardiac arrest, I will also discuss the assessments that should have been performed based on the condition RN D believed she was treating.

76. Mr Bailey said that ‘a full primary and secondary survey were required’, including checking that breathing and heart rate were able to sustain life. He advised that the ‘absence of an adequate primary survey and thorough secondary survey (with vital signs measured)’ was a severe departure from the expected standard of care.

77. Mr Bailey advised that the primary survey suggests that the first priority should be the airway, followed by breathing and circulation, and expected practice would be to assess the breathing of a gasping and blue patient thoroughly. Vital signs that would be measured in the secondary survey include respiratory rate, rhythm, depth and effort, blood pressure, capillary refill time, level of consciousness, blood oxygen level, temperature, skin presentation, airway noises, and lung sounds.

78. I acknowledge RN D’s position that some form of a primary and secondary survey did take place; however, given the 10 minutes that passed between the arrival of the private ambulance service staff and resuscitation commencing, the key concern for me is the adequacy and thoroughness of these surveys.

79. I accept RN D’s admission that she did not check Master B’s oxygen saturation with a pulse oximeter or perform a pulse check during the initial assessment, and instead she used visual cues and took the word of a bystander that a pulse was present. The absence of a pulse check is particularly concerning, as no additional equipment was needed for this assessment to take place.

80. Although RN D stated that ‘on reflection’ the blue colour seen on Master B may have been due to event lighting, this does not change the fact that at the time, RN D was presented with a patient who was gasping and blueish in colour, and this should have influenced her assessment of Master B.

81. I am concerned that RN D has been unable to provide any description of the assessments she performed other than that described in paragraph 70, and the incident forms and PRF provide no further elaboration. In particular, RN D did not describe how Master B’s breathing was assessed, and the result of this assessment. This fact, in conjunction with its omission from her incident form, indicates to me that an adequate breathing assessment was not performed. Failing to perform an adequate breathing assessment also meant that RN D was unable to identify easily whether Master B was experiencing life-sustaining breathing or ‘agonal’[31] (non-life-sustaining) breathing, as Mr Bailey has advised is a possibility in cases of cardiac arrest.

82. I am also concerned that in the case of an individual presenting as blue in colour with irregular breathing, RN D moved onto a secondary survey (blood glucose check) without fully completing her primary survey and performing an oxygen saturation or pulse check.

83. Mr Bailey also noted that there was no measurement of oxygen saturation, blood pressure, or temperature; the documentation of level of consciousness was done retrospectively; skin was not assessed for colour or temperature; there was no airway assessment; the pupils were not assessed for size and reactivity; and a secondary survey for injury did not take place.

84. I accept Mr Bailey’s advice that the level of primary and secondary survey by RN D was a severe departure from the expected standard of care and led to another missed opportunity to identify whether Master B was in cardiac arrest.

Provision of supplementary oxygen

85. I note that the provision of oxygen within the venue is a contested point.

86. The equipment usage log records that a non-rebreather mask was used, and this has also been documented in all three incident forms. The stallholder also confirmed that staff ‘attempted’ to fit an oxygen mask. While this evidence does not confirm that oxygen was provided within the venue, it indicates that attempts were made to supply Master B with oxygen.

87. Ms A recalled that on her arrival, an oxygen mask had not been placed on Master B. The incident forms indicate that Ms A arrived when staff were preparing to load Master B onto the stretcher, and the private ambulance service explained that oxygen was removed during transport as it was interfering with movement. However, Ms A stated that staff were not getting ready to load Master B onto a stretcher when she arrived, unless they had left Master B on his own to get equipment and returned just as she arrived. She said that Master B was lying alone on his side in the recovery position with bystanders surrounding him.

88. I am unable to resolve this conflict; however, I accept that it is more likely than not that RN D attempted to administer oxygen inside the venue. As noted by Mr Bailey, there is no documented assessment of the outcome of oxygen administration, and therefore I cannot comment further on the impact of oxygen administration. Again, I am critical of the lack of documented breathing assessments.

Interference with 111 call

89. During the initial assessment, RN D and Miss C noted the bystander calling 111 and told the caller to wait for them to assess the situation. The 111 call recording provided contemporaneous evidence that the caller said they were telling him that there was no need for an ambulance and that a person put ‘her hand against her neck’, which was interpreted by the bystander as a ‘signal to say cut it’. The evidence indicates that the person concerned was RN D. The key issue here is whether, through her words and actions, RN D conveyed that the call should be put on hold, or cut completely, while the private ambulance service staff undertook their assessment of Master B’s condition.

90. The private ambulance service has asserted that the intent of these actions was to ask that the call be put on hold while their assessment took place, and that ‘miscommunications occurred’, leading to the call being cut ‘altogether’. While I accept that the language used by RN D (as set out in paragraph 26) may have caused confusion about whether the call was to be cut or put on hold, I consider that her hand gesture gave a clear signal to the bystander that the call should be cut altogether, as this is a well-known gesture for asking for something to end.

91. Mr Bailey advised that the act of interfering with the 111 call in this manner, when the patient was unconscious, blue, and gasping, without having completed an assessment adequately, would be a severe departure from the expected standard of care for a first responder. I have already determined above that an assessment was not completed adequately. Therefore, I accept Mr Bailey’s advice that interfering with the call was a severe departure from the accepted standard of care. As rightly pointed out by Mr Bailey, allowing the call to continue would have caused no detriment.

Conclusion

92. As outlined above, I consider that there were significant deficiencies in the care provided to Master B by RN D regardless of whether Master B was in cardiac arrest upon her arrival.

93. Accordingly, I find RN D in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code)[32] for:

1. Failing to perform adequate assessments and treatment of Master B as an unconscious patient, including the absence of a pulse check and adequate breathing assessment; and

2. Interfering with the bystander’s 111 call, which delayed the arrival of back-up ambulance staff.

Resuscitation (outside of venue) — educational comment

94. Once Master B had been taken outside and resuscitation had commenced, RN D began chest compressions before taking over management of the airway from Miss C after becoming tired from performing compressions.

95. Mr Bailey advised that the care provided by RN D outside the venue was appropriate for a first responder. He said that it is accepted practice to rotate the person performing compressions approximately every two minutes, as performing compressions is a strenuous task, but that movement between other positions ‘should be discouraged as it wastes time and can generate confusion in roles and responsibilities’.

96. I note that RN D swapped with Miss C and took over the airway after ceasing compressions, rather than allowing Miss C to continue to monitor the airway uninterrupted while RN D took up another task not already being undertaken, such as monitoring the AED. This led to a change in airway management, which Mr Bailey advised should be discouraged. While I do not consider this to be a failure in care, it is a learning opportunity for RN D on best practice resuscitation procedures.

97. RN D told HDC that after the AED advised that no further shocks were required, she checked for a carotid pulse, which was found and confirmed by Ms E. This was documented in their incident forms. I note that a pulse check cannot be heard in the 111 call; however, as there are indistinguishable voices in the background, this does not conclusively rule out that a pulse check occurred. As the forms were completed soon after the day of events, I accept that it is more likely than not that RN D did perform a pulse check at some point after administering shocks to Master B. The issue of documentation is discussed below.

Documentation — educational comment

98. The lack of detail in the PRF has significantly contributed to difficulties in assessing the standard of care provided to Master B. In particular, Ms A is concerned about the accuracy of recorded timings of events. I acknowledge her concerns and have as far as possible reflected these issues in this report.

99. I accept that RN D did not complete the PRF herself, and I consider that she was not entirely responsible for its content. However, I agree with Mr Bailey that, as one of the practitioners providing care, it was RN D’s responsibility to check that the content of the notes regarding the care she provided was accurate. There was a period of approximately 35 minutes between care being taken over by emergency call centre staff and transport to hospital being commenced, during which review of the notes could have taken place.

100. I consider that reviewing the PRF following the resuscitation and making notes on her gloves as to the assessments and interventions performed, which Mr Bailey mentioned is common practice, would have significantly improved the accuracy and thoroughness of the documentation and aided this investigation. I trust that RN D will implement these learnings in her future practice.

Opinion: Ms E — breach

Introduction

101. Ms E arrived on scene after RN D and Miss C had undertaken their initial assessment. HDC was initially told that Ms E took over scene management after Master B stopped breathing sometime between 9.52am and 9.55am. However, Ms E subsequently told HDC that Master B was breathing on her arrival.

102. At the outset, it is important to note that as the only paramedic present on scene, Ms E was the highest qualified team member. As such, she was responsible for providing oversight of Miss C and RN D and taking leadership of the emerging situation.

103. Having considered the care provided to Master B by Ms E, I am concerned about the lack of clinical leadership she demonstrated. My concerns begin with Ms E’s decision to remain at the private ambulance service base to wait for further instructions on the equipment needed rather than to respond to the stallholder’s request for medical assistance for Master B.

104. Even if the private ambulance service staff believed that Master B had hit his head and was suffering from a seizure, and was not a patient in cardiac arrest, this is still a serious condition that I would have expected the most senior member of staff to be involved in treating. Ms E could have demonstrated effective leadership from the start by requesting one of the more junior members of the private ambulance service team to stay back at the base whilst she attended Master B.

105. During Master B’s care, Ms E was responsible for decision-making regarding moving Master B, performing assessments on Master B outside the venue, setting up Master B’s airway management, beginning CPR, attaching the defibrillator, calling 111 for back-up, speaking with Ms A, and gathering patient history. Whilst these are important functions, I consider that there were multiple failures in the care Ms E provided, which I set out below.

Assessments and interventions — breach

Initial assessment

106. Ms E provided varying information about the actions she took upon arrival on scene at 9.52am. Ms E’s incident form does not document a handover or primary survey. Instead, she specifically documents that Ms A was approaching ‘in line with [Miss C] + [RN D’s] treating’ and that she ‘left the stretcher with [RN D] + [Miss C] + intercepted the mother’. The incident forms completed by the other private ambulance service staff members also do not refer to a handover or assessment by Ms E upon arrival.

107. Subsequently, Ms E told HDC that she had a quick handover and confirmed a pulse with RN D, and, in a further statement, she said that she completed a quick primary survey herself upon arrival before approaching Ms A. In all cases, Ms E said that she chose to approach Ms A so that the private ambulance service’s care was not interrupted.

108. Mr Bailey advised that the accepted practice would be for the senior clinician to focus on the assessment and treatment of the patient, and it would be a severe departure if Ms E did not immediately and thoroughly assess a patient in a poor condition and who was unconscious, gasping, and blue in the face.

109. In the absence of a contemporaneous record, I consider Ms E’s incident form to be the most likely accurate record. The form was completed 10 days after these events, without a sense of urgency and for the purpose of having ‘a clear record of the [e]vent’. Considering this and the inconsistencies outlined in paragraphs 106 and 107, I find it more likely than not that Ms E did not perform her own assessment before intercepting Ms A.

110. For completeness, I also note that, even if I were to accept Ms E’s latter accounts that she performed a ‘quick primary survey herself’ or had a ‘quick handover’ and confirmed a pulse, this would still be a departure from the expected standard of care as she did not perform an immediate and thorough assessment of Master B.

111. I also have concerns about Ms E’s rationale for needing to intercept Ms A rather than remain with Master B. Whilst I appreciate that Ms E would have been concerned about Ms A’s distress in finding Master B so unwell, I consider that, as the senior paramedic present, she could have directed one of the other staff members to assist Ms A at that time and maintained her focus on Master B’s care.

Further assessment after Master B stopped breathing

112. Ms E’s incident form does not record any assessments having been performed after Master B was reported as not breathing until after Master B was moved outside. In a later response, she stated that, upon return and prior to extrication, she determined that Master B’s airway was clear. A further response stated that a primary survey was performed once Master B had been moved outside. Considering the recollections mentioned above, I find it more likely than not that a primary survey was not performed prior to extrication and Master B’s condition was not assessed until after the move had taken place.

113. Mr Bailey advised that it would be a severe departure to leave a patient with circulatory compromise inadequately assessed, and not to complete a pulse check, unless there was an overriding circumstance such as physical inability to move the patient or danger to the first responders.

114. I consider that it was unacceptable for a primary assessment to be delayed when there was no immediate danger or physical inability to assess Master B. I accept Mr Bailey’s advice and agree that, as the most senior clinician onsite, it was a severe departure for Ms E not to assess Master B upon her arrival, and instead to prioritise speaking to Ms A, and to miss a further opportunity to assess Master B after he stopped breathing.

Resuscitation

115. Upon moving outside, Ms E assessed Master B’s breathing, performed a jaw thrust, and helped to set up an OPA and BVM. After undertaking these tasks, Ms E called 111 for back-up and to commence a ‘handover’ while her team continued with the resuscitation. Ms E considered that other airway manoeuvres were not appropriate until CPR had commenced, and she prioritised calling for back-up over providing further treatment. After calling 111, Ms E spoke to Ms A to gather patient history and commenced filling out the PRF. The conversation with Ms A is confirmed by the information Ms E can be heard providing the 111 call handler and also in Ms A’s complaint submission.

116. Mr Bailey advised that established practice for treating cardiac arrest once CPR is under way is for one person to manage the airway, one person (a paramedic or higher) to obtain IV access and administer medication, and for two or more people to continue chest compressions.

117. Mr Bailey advised that not securing the airway with a laryngeal mask airway (LMA)[33] would be a severe departure from the accepted standard of care, and not setting up IV access and administering medication, such as adrenaline and amiodarone, would be a moderate departure from the expected standard of care. I accept Mr Bailey’s advice that the failure to take the above two actions during the resuscitation would be departures from the accepted standard of care.

118. Ms E accepted that, with hindsight, she could have placed an LMA or IV access, but she said that given the makeup of the team, she wanted to focus on the basics of resuscitation and ‘decided to be a “hands off” team leader’ and focus on managing the team.

119. I am concerned that Ms E thought that this was an acceptable reason to delay providing additional treatment for Master B, and I consider this to be a further example of poor decision-making by Ms E, and a failure to perform the leadership role expected of her as the most senior clinician on site. The video and audio recordings clearly show that for a large part of the resuscitation Ms E was not near Master B or her colleagues, and therefore I cannot see the oversight she was providing. Instead, Ms E was calling 111, commencing the clinical record, and speaking to Ms A to get a patient history. On this basis, I do not accept that Ms E was focused on managing the team at this time.

120. Mr Bailey advised that prioritising the 111 call (rather than delegating this task) and commencing the clinical record, over providing further treatment, would both be severe departures from the accepted standard of care. He said that accepted practice for obtaining a patient history from the patient’s family would be to have the least clinically qualified member of the team undertake this task, and the senior clinician would speak to the family ‘once all treatment has been initiated and the scene is well managed … and there are no outstanding clinical tasks’.

121. I agree that it was inappropriate for Ms E to make the 111 call when this task could have been undertaken by a less experienced team member. As Mr Bailey noted, there is no need to provide a detailed handover to a 111 call taker, and, as evidenced by the call recording, Ms E provided little further information other than the location and that a patient was suffering a cardiac arrest. The audio and video recordings together capture that Ms E made the decision to speak with Ms A, after two shocks had been provided by the AED, but before the AED had indicated that a further shock was not needed. Ms E also commenced the clinical record before ROSC had been confirmed.

122. I am concerned not only that Ms E chose to be a hands-off leader rather than provide further treatment but also that she prioritised the three tasks described in paragraph 119 over providing further treatment, when it was not known whether Master B had a life-sustaining heartbeat or had begun to breathe again. Ms E was the most qualified member of the team, and the only member capable of performing advanced interventions (eg, placing LMA or IV access). As noted by Mr Bailey, even when the AED indicated that no further shock was advised, this did not mean that Master B’s heart was beating or beating sufficiently to sustain life. It could have meant that Master B’s heart was in a non-shockable rhythm and that resuscitation efforts may have still been required.

123. Ms E told HDC that after the AED advised that no further shocks were required, she asked RN D to check for a carotid pulse, which was found. Ms E said that she confirmed this alongside a radial pulse. There is no supporting documentation for this, apart from the incident forms. I note that a pulse check cannot be heard in the 111 calls; however, as there are indistinguishable voices in the background, this does not rule out that a pulse check occurred. In light of the incident forms, I accept that it is more likely than not Ms E did perform a pulse check at some point after shocking Master B. The issue of documentation is discussed below.

124. Mr Bailey advised that after the private ambulance service staff had determined that Master B was breathing again but remained unconscious, it would be a significant departure from accepted practice not to ensure that the airway was secured (with an LMA) and to cannulate (obtain IV access) immediately after this, if not already done. Mr Bailey noted that there is no record or mention of other vital signs having been measured during this time. In response, Ms E stated that there were only a few minutes between the private ambulance service staff achieving ROSC and back-up arriving, and I acknowledge the short period of time between the two events. However, I note that these assessments and interventions should have been performed earlier in the resuscitation, and, while there may not have been enough time to complete these tasks, I am critical that at the very least there were not attempts to start some of these assessments or interventions.

Conclusion

125. As outlined above, I consider that there were significant deficiencies in the decision-making and care provided to Master B by Ms E.

126. Accordingly, I find Ms E in breach of Right 4(1) of the Code for failing to assess Master B adequately after arriving on scene, and again prior to extricating Master B from the venue, and prioritising secondary tasks over performing paramedic-specific interventions (placing an LMA or IV access) during the resuscitation and for her decision to be a ‘hands-off leader’ in an evolving emergency that required appropriate clinical leadership, direction, and oversight, which was her role as the team leader.

Documentation — adverse comment

127. The lack of detail in the PRF has contributed significantly to difficulties in assessing the standard of care provided to Master B. I acknowledge that in the 111 call recording, Ms E can be heard asking the other team members to note down the timing of the AED shocks after they happened, and therefore there is evidence that Ms E attempted to ensure that important details were documented.

128. Ms E could have improved the accuracy of the documentation further by making notes on her gloves as to the assessments and interventions she performed, as Mr Bailey mentioned is common practice. Ms E also assisted Miss C in completing the PRF post-resuscitation. As Mr Bailey noted, as the most senior practitioner providing care, it was Ms E’s responsibility to check that the documentation was adequate. Regarding the resuscitation, Mr Bailey also noted that there was no documentation of the signs of ROSC, other than the PRF stating the return of a pulse and breathing. Expected practice would be for more details (such as oxygen saturation or vital signs) to be documented.

129. I am concerned that Ms E did not note the deficiencies in the PRF and seek to have them corrected. However, I do not find Ms E solely responsible for this matter and consider that a lack of policy contributed to the poor documentation, as discussed further below.

Extrication — educational comment

130. After RN D noticed that Master B had stopped breathing, Ms E was called back to him, and she made the decision to continue loading Master B onto the stretcher and to extricate him outside so that CPR could be performed in a location with better lighting and away from the crowd. There are several points of decision-making in relation to this portion of the care.

131. Mr Bailey advised that it is accepted practice that ‘when resuscitation cannot commence in the location the patient is found (typically because the space is too small or there are dangers present) the patient be moved so that resuscitation can be commenced’. Accepted practice, if a patient is not already loaded onto a stretcher, is to drag the patient the minimum distance needed and commence chest compressions as fast as possible after the move. Mr Bailey also stated that it is accepted practice to move into the back of an ambulance if necessary.

132. Ms E stated that as the stretcher was already set up next to Master B, she considered that it would be appropriate to extricate him so that ‘they could perform CPR outside with good lighting and away from a significant and growing crowd’, and she estimated that the move took one minute. She also explained that Master B was not dragged outside quickly because of a ‘large gap’ in the doorway, [34] which she was concerned would cause physical injury if Master B was dragged over it.

133. Although I consider that the environment did not make it impossible to commence resuscitation, I accept that the lighting, noise, and growing crowd would have created additional challenges for the staff, and, in the circumstances, it was appropriate to move Master B on a stretcher that had been placed close by.

134. Whilst I am not critical of the decision to extricate Master B, I am concerned that Ms E prioritised preventing a possible injury from the gap in the doorway over the effect that delaying resuscitation would have on a patient known to have stopped breathing. Further to this, Master B was shifted past the open entrance of the ambulance and moved a greater distance to the area in front of the ambulance. These two decisions indicate potential flaws in Ms E’s leadership and decision-making during this care. It is also possible that they were consequences of failing to understand the seriousness of Master B’s condition. I encourage Ms E to take this opportunity to reflect on Mr Bailey’s comments on the other actions available to staff when moving patients requiring resuscitation.

135. Mr Bailey also stated that if it is necessary for a patient to be moved via a stretcher, and it is possible to perform compressions while moving, then it would be a severe departure not to start compressions once the patient was on the stretcher, and it would be appropriate not to provide compressions only if it was not physically possible.

136. Ms E stated that CPR was not performed while moving the stretcher, because of a gap in the doorway that needed to be manoeuvred over. I accept that the three team members were utilised in moving the equipment and operating the stretcher, and, while not ideal, I do not consider that this aspect of the care amounts to a breach of the Code by Ms E. However, again I urge Ms E to reflect on Mr Bailey’s comments and the steps that should be taken in further resuscitations in which she is involved.

137. Ms E explained that supplemental oxygen was removed during the transfer as it was connected to the resuscitation kit and interfering with movements around the stretcher. Mr Bailey advised that it is acceptable to remove a non-rebreather mask if it is interfering with the movement of the patient. I accept this advice and do not consider this to be a departure from the accepted standard of care.

Resuscitation best practice — educational comment

138. I note that during the resuscitation, Ms E swapped positions with Miss C to rotate from monitoring the airway to setting up equipment, rather than continuing to manage the airway and guide Miss C on how to set up the equipment, leading to a change in airway management. Mr Bailey advised that movement between positions during CPR ‘should be discouraged as it wastes time and can generate confusion in roles and responsibilities’. While I do not consider Ms E’s shifting of position to be a failure in care, this is a learning opportunity for Ms E on best-practice resuscitation procedures.

Opinion: The private ambulance service— breach

139. As discussed below, I am concerned about inadequacies in the training, policies, and processes that were in place at the private ambulance service at the time of events.

140. The private ambulance service emphasised that the care provided to Master B ‘needs to be considered in light of the environment they were in (a crowded [event] with dim lighting)’. Ms E also told HDC that ‘it became apparent the team required further guidance and assistance, which made scene management and the clinical decisions difficult’.

141. I acknowledge that the circumstances were challenging. However, the private ambulance service provides emergency medical care and medical coverage for events. I do not consider that being at a ‘crowded [event]’ is a justification for deficiencies in care when staff should be trained appropriately to provide care in these circumstances and should have appropriate policies to guide their practice.

Policies and processes — breach

Documentation

142. As noted, the documentation relating to the private ambulance service’s care of Master B was incomplete and of poor quality. In particular, the lack of detail in the PRF has contributed significantly to difficulties in assessing the standard of care provided to Master B. Mr Bailey advised that if Master B was not in cardiac arrest when the private ambulance service staff approached him, then the quality of documentation would be a severe departure from the expected standard. I have already determined that the private ambulance service staff did not consider that Master B was in cardiac arrest upon first assessment, and, as such, I accept Mr Bailey’s advice that the standard of documentation was a severe departure. The private ambulance service has acknowledged that the PRF was inadequate and inaccurate, and I am very critical of the standard of documentation.

143. The private ambulance service has not provided HDC with any information about the policies or guidance in place at its organisation relating to documentation, only that the organisation ‘prioritises treating patients over completing paperwork’. The staff training plans provided do not show that staff are provided specific training or guidance on completing their documentation. While I agree that treatment should be the priority, as noted by Mr Bailey and mentioned at paragraphs 100 and 128, staff can assist with accurate documentation by, for example, taking notes on their gloves while providing care. I also note that staff had a further 35 minutes between the arrival and departure of emergency call centre staff in which documentation could have been completed.

144. These factors lead me to conclude that the private ambulance service did not have adequate training or policies in place for staff regarding completing documentation at the time, and this contributed to the poor standard of documentation noted above.

Resuscitation policy

145. In his advice, Mr Bailey noted that the ‘Resuscitation Guidelines’ provided by the private ambulance service do not ‘provide adequate guidance for resuscitation’ and that ‘the apparent absence of adequate clinical practice guidelines is a severe departure from accepted practice’. Apart from the ‘Resuscitation Guidelines’, the only other policies the private ambulance service provided to HDC were guidelines for oxygen administration and information on oxygen flow rates. I have been provided no further evidence to support that the private ambulance service has sufficient policies and procedures in place to guide staff in providing safe care.

146. I accept Mr Bailey’s advice and agree that the information contained within the excerpts provided does not provide meaningful guidance for staff on the expected practice during resuscitations. These guidelines do not cover many of the areas in which I found the care to be lacking, notably, expected assessment of a patient, decision-making regarding commencement of CPR, shifting a patient and scene management, and the interventions expected during resuscitation.

Conclusion

147. The above points highlight that the quality of documentation fell far below what was required and that the private ambulance service did not have adequate policies in place for staff, particularly in relation to resuscitation procedures and completion of documentation. Based on the NZS8134:2008 standards set out in paragraph 64, I consider that, by having poor documentation and not having these policies, the private ambulance service breached Right 4(2)[35] of the Code.

Staff training — adverse comment

148. The topics of staff training identified in paragraph 49 directly relate to the areas in which I found the care provided by RN D and Ms E to be lacking. Although HDC was not provided details of the specifics of the training, had the training plan been sufficient, staff should have obtained proficiency in the areas of care outlined in this report. However, my findings in relation to the care provided raise serious concerns about the adequacy of this training. This, in combination with the lack of guidance and policies for staff, is very concerning. I encourage the private ambulance service to consider strengthening staff training to ensure that staff can manage emergency situations effectively in the context in which they are most likely to be providing care.
     

Opinion: Miss C — educational comment

149. Miss C, as a first responder, was the least qualified member of the team and was under the guidance of Ms E.

150. Miss C’s initial involvement inside the venue was limited to obtaining patient history and assisting with moving the stretcher. After shifting outside, she assisted with equipment set-up, airway management, and operating the AED.

151. During the initial assessment, RN D and Miss C noted the bystander calling 111 and told the caller to wait for them to assess the situation. I accept that the language used by Miss C, as set out at paragraph 26, may have caused confusion about whether the call was to be cut or put on hold, and I do not consider that this amounts to a breach on her part. However, I remind Miss C of the need to ensure that communication with bystanders is clear and easily interpretable.

152. Mr Bailey advised that the care provided by Miss C outside the venue was appropriate for the level of care expected of a first responder. I note that Miss C swapped positions twice during the resuscitation, once with Ms E to rotate from setting up equipment to monitoring the airway, and again with RN D, when she rotated from monitoring the airway back to the AED, leading to a change in airway management. While I do not consider this a failure in care, I encourage Miss C to reflect further on this incident and on best practice resuscitation procedures when taking part in future resuscitations.

153. The lack of detail in the PRF has contributed significantly to difficulties in assessing the standard of care provided to Master B. Primarily, Miss C completed the PRF. I acknowledge that Miss C was the least qualified member of the team, and this was her first resuscitation. She recognised that she needed assistance to fill in the PRF and sought guidance from Ms E. Given these factors, I do not find Miss C solely responsible for this matter and consider that the lack of policies and training outlined above contributed to poor documentation.
     
     

Changes made since events

The private ambulance service

154. Immediately after the events, staff ‘revalidated their resuscitation training as required every [six] month’s and debriefed about the events to identify key focus points and implement training for these points. After Ms A’s concerns were raised, the private ambulance service reiterated the importance of correct protocol and procedure.

155. The private ambulance service’s Operations Manager attended the New Zealand Resuscitation Council CORE Advanced Course, receiving a Certificate of Resuscitation and Emergency Care in June 2022, and has remained compliant with the New Zealand Resuscitation Council Emergency Care Instructor certification, which contains a basic resuscitation component.

156. The private ambulance service has also ensured that all paperwork is completed in a comprehensive and accurate manner following all events and that forms are signed by the member completing them. External audits have been implemented, which include PRF auditing. Compliance with NZS and ISO standards has been granted and maintained voluntarily.

RN D

157. RN D has reflected on her actions when standing down the 111 call and agrees that she should have allowed the call to be completed. Now she would not intervene if she was aware that a member of the public was calling 111, and instead she would make a further call to 111 to ensure that the support was appropriate and to discuss the clinical picture.

158. RN D has reported that she now carries a pulse oximeter when working at events. She also told HDC that this incident highlighted the need for clear and accurate clinical notes. She now checks that the PRF is accurate regarding the care she provided prior to handover.

159. RN D also enrolled in a basic life support course to upskill and has undertaken New Zealand Resuscitation Council training on intermediate resuscitation.

160. In response to my proposed recommendations, RN D provided HDC with a written apology to Master B’s family for her breach of the Code, which has been forwarded to Master B’s family. RN D also provided evidence of attendance at training courses on ‘Basic Life support and Airway’ and ‘Deteriorating Patient Resuscitation’ run by Health NZ and said that she would be undertaking further training through the New Zealand Resuscitation Council CORE Advanced course in January 2025.[36]

Ms E

161. Ms E has reported that she now takes time to understand and build capabilities of her team members to optimise use of their skillsets. She also oversees all documentation on jobs she attends and has voluntarily undergone an internal audit of her documentation so that she can improve this area of her practice.

162. Ms E attended the New Zealand Resuscitation Council CORE Advanced Course, receiving a Certificate of Resuscitation and Emergency Care in June 2022. Ms E told HDC that she actively seeks out further professional development courses to improve her skills.

163. Ms E has also undergone further internal training to improve her communication and leadership skills, including simulations of high-stress situations involving multiple team members.

164. Ms E has also completed training on recognising the symptoms and signs of agonal breathing.

Miss C

165. Miss C reported that she has worked on, and participated in, more training on PRF paperwork and has partaken in team-building activities. She has also worked on communicating information and instructions clearly to the base. Miss C told HDC that currently she is working on a higher medical qualification to improve her knowledge and broaden her authority to practise.
     
     

Recommendations

166. I acknowledge the changes made by the private ambulance service. In addition, I recommend that the private ambulance service:

     a)    Provide a written apology to Master B’s family for the breach of the Code identified in this report. The apology is to be sent to HDC within one month of the date of this report, for forwarding to Master B’s family.
     b)    Review its policies and training on resuscitation and documentation, and its overall staff training plans, and update these documents to address the issues identified in this report. As part of this recommendation, I suggest that the private ambulance service consider having an independent industry expert conduct the reviews. The private ambulance service is to report back to HDC with the updated policies within three months of the date of this report.
     c)    Conduct an audit of all PRFs completed by RN D within the last six months, to ensure that PRF documentation is being completed with sufficient detail. The private ambulance service is to report the results of the audit to HDC, alongside the results of the audit already undertaken for Ms E and any corrective actions to be implemented, within three months of the date of this report.
     d)    Use this report as a basis for staff training at the private ambulance service, focusing particularly on the breaches of the Code identified, and provide evidence of that training and attendance to HDC within three months of the date of this report.
     

167. I acknowledge the changes made by RN D and her proactive completion of my proposed recommendations. In light of this, I recommend that RN D:

     a)    Review her practice in light of my clinical advisor’s comments and the breaches identified in this report, and report back to HDC on her learnings and her plan to address the identified shortcomings, within three months of the date of this report.
     

168. I acknowledge the changes made by Ms E. In addition, I recommend that Ms E:

     a)    Provide a written apology to Master B’s family for her breach of the Code. The apology is to be sent to HDC within one month of the date of this report, for forwarding to Master B’s family.
     b)    Review her practice in light of my clinical advisor’s comments and the breaches identified in this report, and report back to HDC on her learnings and her plan to address the identified shortcomings, within three months of the date of this report.
     

169. In light of her limited involvement, the recommendation for an audit mentioned above, and the changes already made, I have no further recommendations for Miss C.
     

Director of Proceedings referral

170. Based on the multiple severe departures identified, I have given careful consideration as to whether the private ambulance service and Ms E should be referred to the Director of Proceedings under section 45(2)(f) of the Act. However, many of the departures noted for Ms E are direct consequences of her first decision to be a ‘hands-off’ leader. Further, I consider that the public interest in accountability and safety can be met by my breach opinion, recommendations, publication of my final report, and circulation of my investigation to other agencies, and, therefore, a referral will not be made.
     

Follow-up actions

171. A letter to the Ministry of Health under section 59(4) of the Act will be sent to ask the Ministry to consider the requirements for regulating providers of event services, and the appropriate level of training of their workforce.

172. A copy of the sections of this report that relate to RN D will be sent to the Nursing Council of New Zealand, and a copy of the sections of this report that relate to Ms E will be sent to the Paramedic Council of New Zealand.

173. A copy of this report with details identifying the parties removed, except the independent advisor on this case, will be sent to the Ministry of Health, the Nursing Council of New Zealand, the Paramedic Council of New Zealand, the New Zealand Ambulance Association, and the Australasian College of Paramedicine and will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

Appendix A: Independent clinical advice to Commissioner

The following independent advice was obtained from Mark Bailey, paramedic:

‘The author has been asked to provide an opinion to the Commissioner on case number C21HDC00192 and has read, and agrees to follow, the Commissioner’s Guidelines for Independent Advisors.

Qualifications, training and experience relevant to the area of expertise

Chair of the National Ambulance Sector Adverse Events Review Group (current)

Member Regional Child and Youth Mortality Review Groups (Capital and Coast DHB, Hutt Valley DHB, Wairarapa DHB)

Root Cause Analysis training

Clinical incident investigation and reporting

Clinical audit

Contributing author: “Beyond the pre-shock pause: the effect of pre-hospital defibrillation mode on CPR interruptions and return of spontaneous circulation”

Extensive work (several years) reviewing cardiac arrests attended by Wellington Free Ambulance, with a focus on resuscitation efficiency and CPR continuity. This included analysing each chest compression, pauses in chest compressions and the provision of individual treatments (airway care and drug therapy). This role included providing feedback to paramedic staff of all qualification levels

Member of P8156 review committee: NZS 8156:2019 Ambulance, paramedicine and patient transfer services

Member National Ambulance Sector Clinical Working Group

Ambulance Communications Centre (Dispatcher) Bachelor of Health Science (Paramedic)

Extensive experience working in rural and metropolitan ambulance services, including as an Intensive Care Paramedic, Flight Paramedic, mentor

The Commissioner is seeking an opinion on the care provided by [the private ambulance service] to [Master B] (now deceased) in October 2020.

…[37]

Information reviewed

The following information was provided and has been reviewed.

1. Letter of complaint dated 28 January 2021 and attachments.

2. [The private ambulance service]’s response dated 8 April 2021.

3. [The private ambulance service]’s response dated 2 December 2021.

4. Training information from [the private ambulance service].

5. Clinical records from [the private ambulance service].

6. Statement from Dr [F] (… DHB).

7. Response and clinical records from [Emergency call centre].

8. Response from […], dated 2 November 2021 and attachments.

9. CCTV footage from October 2020.

 Resources consulted

• NZS 8156:2019 Ambulance, paramedicine and patient transfer services

• St John Clinical Procedures and Guidelines, Comprehensive Edition 2019–2022

• Medicines (Standing Order) regulations 2002

• Land Transport Act 1998 (Part 1, section 2, paragraph (1))

• Accident Compensation (Ancillary Services) Regulations 2002, (secondary legislation), Section 3

…[38]

High-level overview

In October 2020, [Master B] (aged 15) attended an event in ….

[Master B] collapsed shortly after arriving, suffering a cardiac event. He was tended to by three staff members from [the private ambulance service] – the provider of clinical services at the event.

[Master B] was subsequently taken to [hospital] by [emergency call centre staff], where he was placed into an induced coma. [Master B] sadly passed away […] days later.

Evidence provided by Dr [F] stated that [Master B] died as the result of brain damage caused by a lack of oxygen. [Dr F] also stated that such brain damage would require a period of ten minutes without oxygen.

This report considers the evidence provided and seeks to establish if the care provided meets the expected standards and accepted practice. It identifies the likely time that the episode of hypoxia occurred.

The evidence provided by [the private ambulance service], in the form of staff statements, conflicted the clinical record documented on the day. The statements and the clinical record conflicted with verifiable timepoints and statements by others.

…[39]

Summary

After reviewing the evidence provided, I have highlighted the following pertinent points:

• [Master B] did not have a hypoxic brain injury (caused by lack of oxygen to his brain lasting ten or more minutes) prior to his collapse

• [Master B] died of hypoxic brain injury

• [Master B] had myocarditis, but this does not directly cause hypoxia

• No cause for hypoxia, other than cardiac arrest, was found

• Unrecognised cardiac arrest without CPR will cause hypoxic brain injury

• High-performance CPR, commenced immediately, prevents hypoxic brain injury

• [The private ambulance service] staff are the healthcare professionals who were responsible for [Master B’s] initial care and resuscitation during his initial cardiac arrest

• The [private ambulance service] clinical record states that [Master B] was in cardiac arrest when they arrived (a conflicting statement)

• [The private ambulance service] staff state that [Master B] was breathing and his heart was beating when they arrived (a conflicting statement)

• [The private ambulance service] staff statements reflect that [Master B] suffered the initial cardiac arrest sometime (minutes) later whilst in their care (a conflicting statement)

• The [private ambulance service] clinical record shows they were able to restart his heart

• When [emergency call centre] staff arrived, [Master B] had a pulse

• Just after [emergency call centre staff] arrived, [Master B’s] heart stopped

• [Emergency call centre staff] were able to restart [Master B’s] heart with CPR within six minutes with CPR only

• [Emergency call centre staff] closely monitored and documented [Master B’s] vital signs

• There were no episodes of hypoxia during [emergency call centre staff] care

…[40]

…[41]

Conflicting evidence

The conflicting submissions and evidence suggest two alternative time sequences. I have used these two sequences to determine the associated likely scenarios, which I outline as follows:

Scenario one …[42]

[Master B] was already in cardiac arrest when [the private ambulance service] staff arrived on scene and this was not recognised.

[Master B] had agonal respirations, which were mistaken for life-sustaining breathing, and further assessments were not adequately performed (if at all). Once [Master B’s] agonal respirations ceased, it was recognised that he was in a critical condition. Resuscitation commenced shortly afterwards. [Master B’s] clinical presentation matches this scenario, as do the hospital findings, and other evidence such as the 111 call and [Ms A]’s statement.

…[43]

Scenario two …[44]

[Master B] was initially unconscious but breathing adequately and had a pulse.

[Master B] suffered a cardiac arrest some minutes later while being monitored and assessed by [the private ambulance service] staff. This was immediately recognised and [Master B] was appropriately resuscitated by [the private ambulance service] staff. In this scenario there is a period of time after [Master B] started breathing again, while he was still in the care of [the private ambulance service], during which hypoxia could feasibly have occurred.

…[45]

[Master B] was resuscitated from the cardiac arrest; however, his brain had been catastrophically damaged by a lack of oxygen. This resultant brain damage led to his death. In the second scenario, if [Master B] were to have collapsed but not suffered a cardiac arrest until the point at which [the private ambulance service] staff observed it, then the episode of hypoxia would most likely have occurred between the point that [the private ambulance service] staff state they detected a pulse and the arrival of [emergency call centre] paramedics. Myocarditis can cause an irregular heartbeat. It is possible that an irregular heartbeat could have caused the events described; however, in this scenario, [the private ambulance service] staff state that they checked [Master B’s] pulse and it was neither fast nor slow and that he was breathing. No respiratory cause for hypoxia was found in the ED or ICU.

Conclusion

…[46]

If scenario one is correct, then:

1. The care (and lack thereof) provided to [Master B] falls far below the acceptable standard. …[47]

2. [The private ambulance service] staff prevented bystanders, including [Master B’s] mother, from performing first aid under the guidance of the 111 call taker. …[48]

If scenario two is correct, then:

1. [Master B] suffered a period of hypoxia after being resuscitated by [the private ambulance service] staff, and this occurred during the period prior to the arrival of [emergency call centre staff]. There is no recorded care for [Master B] during this time.

…[49]

Review

1. The adequacy of the crew’s assessment of [Master B] once he had collapsed.

…[50]

Commentary: It is a well understood concept by clinicians that a thorough assessment of the patient is required to ensure a good understanding of the patient’s condition and needs. In the absence of a thorough examination, vital aspects may be missed, resulting in a negative impact on the patient’s outcome.

To objectively evaluate the evidence provided, I have considered two separate scenarios, that when [the private ambulance service] staff arrived at his side, a) [Master B] was already in cardiac arrest, and b) [Master B] was not in cardiac arrest. See Appendix One (c).

1. The assessment of patients in cardiac arrest

The minimum expectations for the assessment of an unresponsive patient who exhibits gasping respirations, is to check for adequate respirations (breathing that appears able to sustain life). If the respirations appear to be agonal (non-life sustaining) and the patient is unresponsive then CPR should be commenced immediately.

2. The assessment of unconscious patients not in cardiac arrest

If the patient is not in cardiac arrest when first attended by clinicians, then the unconscious patient requires a full primary and secondary assessment. The primary survey includes checking that the patient’s breathing and heart rates are able to sustain life while the assessments continue. The secondary survey includes the measuring of a full set of vital signs.

The [private ambulance service] assessment

The evidence of assessment: [the private ambulance service] personnel provided a clinical record to [the emergency call centre] when [Master B’s] care was handed over to their paramedics. It reflects that [Master B] was found at 9.45 a.m., on the ground, unresponsive, gasping and pulseless. He had a GCS (level of consciousness) of three. It lists the provisional diagnosis of “cardiac arrest”.

Retrospective statements, provided to the HDC by [the private ambulance service] staff contradict the above clinical record and assert that [Master B] was found unconscious but breathing and with a pulse. There is independent evidence (from the 111 call and [Master B’s] mother) that [Master B] was unconscious with some respirations (noting that this evidence does not determine if the respirations were life sustaining (see Appendix One (e), Agonal Respirations).

I note that in the absence of clinical records documenting assessments, procedures and findings, the assertion that these were undertaken cannot be substantiated.

If [Master B] was in cardiac arrest at the time that [the private ambulance service] staff arrived at his side, then the assessment documented was adequate and resuscitation should have commenced immediately. Further assessment should have followed if/when time allowed.

The clinical record provided by [the private ambulance service] staff does not match statements later provided by the same [private ambulance service] staff, which describe that they were alerted to [Master B] having a seizure, approximately 5 to 15 minutes prior to the time stated on the clinical record. They assert that his pulse was checked and was present and that he was breathing and that his breathing was laboured. In this situation, once oxygen is applied, it is then necessary and appropriate to conduct a detailed assessment of the patient. This will allow the clinician to determine what is wrong, and what treatments are required. A detailed assessment is not documented (nor detailed in the subsequent statements by [the private ambulance service] staff).

On several occasions [the private ambulance service] evidence describes a detailed examination being undertaken. It states that a primary survey, a secondary survey and a full set of baselines were undertaken. There is no evidence in the clinical record to support this claim.

Conclusion

[The private ambulance service] has provided a clinical record for the assessment of [Master B]. The staff who authored the clinical record have subsequently provided statements which conflict with that record. Both sets of information conflict with verifiable times. Therefore I provide two alternative options:

If the [private ambulance service] clinical record is correct (scenario two):

[Master B] was found by [the private ambulance service] staff at 9:45 a.m., determined to be in cardiac arrest at 9:46 a.m. and resuscitation was commenced immediately. In this context, the initial assessment meets the accepted standard of assessment. I note, however, that the venue’s security video shows that resuscitation commenced at 9:56 a.m.

Additionally, in this scenario there is a period of ten plus minutes after [Master B’s] heart was restarted during which no further assessment or care occurred. This is a severe departure from the expected standards of assessment.

If the verifiable information is correct:

[Master B] was found by [the private ambulance service] staff at 9:46 a.m. and resuscitation did not commence until 9:56 a.m. In this context, the absence of an adequate primary survey and thorough secondary survey (with vital signs measured) are a severe departure from the expected standard of care.

Recommendations for improvement

I make the very strong recommendation that:

• clinicians employed by private ambulance services be required to provide the same level of care as Crown-funded emergency ambulance services, when providing clinical care to people in life-threatening situations

• Private ambulance services comply with NZS 8156:2019 Ambulance, paramedicine and patient transfer services

• New Zealand legislation be developed to include legally binding definitions of:

  • ambulance

  • ambulance service

  • ambulance-based clinical care

…[51]

2. The adequacy of the crew’s interventions and treatment of [Master B] once he had collapsed.

Expected standard of care (see Appendix Two (a):

Cardiac arrest treatment: The standard of care/accepted practice (summarised from the national ambulance clinical procedures and guidelines) is:

• Immediate, continuous CPR

• Defibrillate immediately

• Perform two-minute cycles of high-performance CPR

• Place an LMA (airway) and gain IV access, but high-performance CPR takes priority

• Perform a rhythm check every two minutes and defibrillate if appropriate

• Administer adrenaline every four minutes

• Administer amiodarone if the rhythm is VF or VT at any time after the first dose of adrenaline

• Back up from an Intensive Care Paramedic must always be requested

• Complete the cardiac arrest checklist

   

IV access and drugs

• Gaining IV access and administering IV drugs has a lower priority than providing high-performance CPR.

Treatment following return of spontaneous circulation (getting a pulse back)

• Gain IV access if not already gained

Treatment for seizures

If [Master B] had suffered a seizure, as a [private ambulance service] statement suggests, then the standard care following the seizure is:

• position the patient on their side

• maintain airway and breathing

• monitor pulse oximetry and administer oxygen if required

[The private ambulance service] clinical guidelines

[The private ambulance service] provided a copy of its resuscitation guidelines. These do not provide meaningful guidance for the resuscitation of patients in cardiac arrest. See Appendix Two (b).

I have broken down the adequacy of the crew’s interventions to those occurring inside the venue, where resuscitation did not take place, and outside the venue, where resuscitation occurred.

Inside the venue

Summary of treatment and interventions:

• a bystander placed [Master B] in the recovery position

• [The private ambulance service] staff claim that oxygen was administered to [Master B] (noting there is no documented evidence of this, and [Ms A] provides evidence that this did not occur)

• when [Master B] stopped breathing, he was loaded onto a stretcher and taken outside

Points from the evidence provided:

…[52]

• The first two [private ambulance service] staff on scene with [Master B] requested assistance from their colleague, a registered paramedic. There is no documented treatment by the paramedic. In her own statement, the paramedic describes arriving at [Master B’s] side and then immediately “intercepting the mother, to ensure treatment is not interrupted”. The paramedic does not return to [Master B] until it has been identified that he is no longer breathing.

The paramedic did not describe what treatment was occurring that could have been interrupted, nor does she describe any form of handover from her colleagues.

There is no evidence that personnel monitored [Master B’s] breathing, pulse or pulse oximetry. …[53] There are no treatments documented during this period.

Additionally, standard practice for an unconscious patient of unknown cause includes the insertion of an IV. This allows for immediate medication administration if the patient deteriorates further. Such a deterioration could include further seizures and cardiac arrest.

Oxygen administration

[The private ambulance service] staff assert that oxygen was provided while still inside the venue. This treatment is not documented on the clinical record and therefore presumed not to have occurred.

Evidence provided by [Master B’s] mother that she saw [Master B] inside the venue without an oxygen mask on his face. She states that she has a vivid memory of seeing all of [Master B’s] face.

[The private ambulance service] refute [Ms A’s] evidence and suggest that she simply did not notice the mask, and that she was behind [Master B] so wouldn’t have seen it.

…[54] See in Appendix Two (c) for an image of a non-rebreather mask.

If [Master B] was breathing and placed on a non-rebreather mask with oxygen flowing at a rate of 10 litres per minute, then he would have been inhaling close to 100 percent oxygen. This reduces the likelihood of [Master B] sustaining a prolonged period of hypoxia, which is in conflict with the outcome of the situation.

Security camera video footage appears to show (but not conclusively) a [private ambulance service] staff member connecting/turning on a bottle of oxygen shortly after CPR had commenced outside the venue. See Appendix Two (d).

Further, I note that if oxygen was actually administered inside the venue, there is no documented evidence provided by [the private ambulance service] staff that [Master B’s] breathing was sufficiently adequate for the supplemental oxygen to be beneficial. Additionally, there was no assessment of the outcome of the oxygen administration attained by measuring [Master B’s] oxygen saturations.

If [Master B] was already in cardiac arrest at this point, then oxygen without CPR provides no benefit.

Interventions and treatments provided outside the venue (resuscitation)

Summary of treatment

• CPR (initially by the [the private ambulance service] nurse, then by two bystanders)

• AED defibrillation

• Oropharyngeal airway inserted (unconfirmed, undocumented)

• Ventilation with bag/valve mask and oxygen

• Emergency ambulance requested (111 call)

…[55]

The resuscitation begins and is conducted at the clinical level of First Responder. There are no paramedic-level interventions, such as IV insertion and drug therapy.

CPR is then commenced. This is appropriate.

One [private ambulance service] staff member remains at [Master B’s] head. The statement by the [private ambulance service] paramedic indicates that this was her and that she was performing an airway manoeuvre (holding [Master B’s] airway open). However, [Master B] was not spontaneously breathing, nor was she ventilating him.

A defibrillator is attached. This is appropriate.

[Master B] is defibrillated. This is appropriate.

…[56]

The [private ambulance service] staff member at [Master B’s] head can be seen to start ventilating [Master B].

The staff member performing CPR tires and is changed out for a bystander. This is appropriate as CPR is a very strenuous activity and high-quality CPR is vital to the outcome.

Two [private ambulance service] staff change positions. This should be discouraged as it wastes time and can generate confusion in roles and responsibilities.

[The private ambulance service] staff member (the paramedic, according to her statement) can be seen walking away from the resuscitation and speaking on a cell phone. This staff member then walks around, speaking on the phone for quite a few minutes. Once she has placed the phone by her colleagues (who are performing the resuscitation), the paramedic goes into the ambulance to collect what appears to be the clinical record form and begins to fill it out. I note there were security personnel and bystanders in attendance who would have been quite capable of phoning for an ambulance. Additionally, I note that [the private ambulance service] states that clinical care takes priority over completing clinical records.

Notably, there is no attempt to secure [Master B’s] airway with a laryngeal mask airway. This is a severe departure from the expected standard of care for a hypoxic patient. There was no IV cannula inserted and no medications administered. These are moderate departures from the expected standard of care. Additionally, after [Master B] begins to breathe again there are no records of vital signs being measured.

In the 111 call recording, there are two instances where someone states that [Master B] is breathing. There are no audible statements that his pulse is being checked. There is an audible question, asking if CPR should be restarted. The prioritising of making a phone call (which could have been delegated) over treating a patient in cardiac arrest is a severe departure from the expected standard of care.

The prioritising of commencing the clinical record over providing care to a patient in cardiac arrest is a severe departure from the expected standard of care. …[57]

Conclusion: I consider that the interventions and treatments provided to [Master B] to be a severe departure from the expected standards of care. The senior clinician should be treating the patient, providing higher levels of clinical care and supervising the resuscitation team. The delegating of tasks such as calling for emergency services can go to competent bystanders such as security personnel.

Conflicting evidence:

• If [Master B] was in cardiac arrest when the first [private ambulance service] staff arrived at his side, then the care provided inside the venue is a severe departure from the expected standard.

• If [Master B] was not in cardiac arrest when the first [private ambulance service] staff arrived at his side and had a pulse but was blue and his breathing was gasping, and if 100 percent oxygen was not provided, then this represents a severe departure from the expected standard of care.

• The care provided to [Master B] while he was being resuscitated outside the venue represents a moderate departure from the expected standard of care for a paramedic (lack of laryngeal mask airway, lack of IV access, lack of drug therapy).

• The prioritising of making a phone call (which could have been delegated) over treating a patient is a severe departure from the expected standard of care.

• The prioritising of commencing the clinical record over providing care to a patient in cardiac arrest is a severe departure from the expected standard of care.

• The care provided to [Master B] while he was being resuscitated outside the venue was appropriate with the level of care provided by first aiders.

…[58]

3. Whether you consider it was appropriate for [RN D] to gesture to the member a public to cut the call they had made with emergency services, shortly after [Master B] had collapsed.

I considered whether [Master B] required urgent treatment and/or immediate transport to hospital and if it should have been immediately obvious that this was required. For a patient who appears unlikely to be experiencing a life-threatening event, it would be appropriate to ask the ambulance service to hold. If this cannot be quickly established, then allowing a member of the public to complete their call provides no detriment to the patient.

The accepted practice for decisions about transporting patients is that paramedics must be able to confidently exclude serious illness or injury. See Appendix Three (a).

…[59] I have considered whether it was necessary for the [private ambulance service] staff member to interrupt her assessment of [Master B] in order to intervene and prevent an ambulance being requested via the 111 call. There was no need for this, as the ambulance could easily be stood down once the assessment had been completed.

When there is no 111 call currently under way, I would consider the act of calling for assistance once the primary assessment had been completed as normal practice. However, I consider the act of intervening in a 111 call, without having adequately completed the assessment, as a severe departure. This is because it prevented urgent care being summonsed for [Master B].

Conclusion:

If [Master B] was unconscious and blue and gasping, then I consider this a severe departure from accepted practice.

If [Master B] was in cardiac arrest, then I consider this to be a severe departure from accepted practice

If the primary assessment had been completed, and [Master B] was unresponsive but breathing normally and with a normal heartbeat, then I consider this consistent with accepted practice.

4. Whether you consider it was appropriate of the crew to load [Master B] on to a stretcher and move him outside before starting CPR when it was noticed that he had stopped breathing.

The standard of care/accepted practice is to commence CPR immediately.

If the patient must be moved because they are unable to be resuscitated in the immediate environment, then they should be moved to the new location as quickly as possible. Moving the patient on a stretcher allows for CPR to continue whilst the patient is moved.

If there is sufficient space, then bystanders can be ushered away to create privacy. Lights can be turned on if the environment is dark. Commercial venues usually have lighting that is more than adequate. I note that security personnel were present and could have controlled members of the public to ensure [Master B’s] privacy. I also note that members of the public were able to approach the location where the resuscitation took place. These aspects contradict [the private ambulance service’s] assertions that they needed to move [Master B] for privacy and lighting reasons.

To load [Master B] onto a stretcher and move him from a location where CPR could be performed is a severe departure from expected standards of practice. To move [Master B] on a stretcher without performing CPR during the move is a severe departure from the accepted standard of care or accepted practice.

Conclusion:

It is my opinion that the decision to load [Master B] and then take him outside, particularly without CPR during the move, was a severe departure from the expected standard of care.

…[60]

5. The adequacy of the training provided to each [private ambulance service] staff member.

The training plan provided by [the private ambulance service] ([The private ambulance service] training plan — 2020) lists a wide variety of topics. It provides very limited detail about what is included within the computer-based learning components (Moodle) and extremely brief bullet points about the face-to-face plan.

The lack of detail in the plan means I am unable to assess the adequacy of the training programme based on the documentation provided.

The training plan does not detail the lesson plans and structure, nor any assessment criteria. It appears that the training plan was formed by [Ms E], who appears to have been responsible for delivering the training and presumably assessing those undertaking it. The response from [the private ambulance service] appears to suggest that Ms E was considered to have undertaken the training.

I do note, however, that comprehensive patient assessment, BGL acquisition, and resuscitation (including airway care, pharmacology (indications of adrenaline in cardiac arrest) and scenarios) are topics that are listed. The level of care provided to [Master B] on 25 November 2020 failed on all of these points.
 

Conclusion

Therefore, I conclude that the training plan did not produce the level of competency and currency that was required for these staff members.

Private ambulance services are not required to adhere to any minimum standards for training.

…[61]

6. The appropriateness of the experience and skill set mix of the three staff members.

First aiders, without the benefit of an AED, were capable of performing CPR until the ambulance arrived. This would have prevented hypoxia and allowed [the emergency call centre] paramedics to save [Master B’s] life.

First aiders, with an AED — and particularly if under the guidance of a 111 call taker, would have been able to restart [Master B’s] heart and save his life prior to ambulance arrival. I draw this conclusion because a member of the public, and a member of the security team performed the majority of the CPR on [Master B]. An AED was used to successfully restart [Master B’s] heart. A 111 call taker was speaking to a bystander and beginning to assess [Master B’s] breathing when [the private ambulance service] staff intervened.

Ambulance personnel at First Responder level, with First Responder-level equipment, have the capability to save the life of someone in [Master B’s] situation. This includes detecting, preventing and/or treating profound hypoxia occurring both prior to, and during, the resuscitation. If [Master B] had suffered hypoxia prior to their arrival, the insertion of an airway device and administration of oxygen would have rapidly reversed the hypoxia.

Ambulance personnel at paramedic level should have inserted a laryngeal mask airway, ventilated using oxygen, manually assessed the heart rhythm, inserted an IV and administered drugs. These additional treatments were not necessary to restart [Master B’s] heart, but they may have allowed it to restart sooner. Manual assessment of the heart rhythm would have allowed a better understanding of what was happening during the period of cardiac arrest and helped guide medication administration.

Ambulance personnel, with normal levels of training and several years of practical experience (as indicated by their time with [the private ambulance service]) should be very competent and capable of performing the appropriate assessments and treatments finding a patient who is unconscious and/or cardiac arrest.

Conclusion:

It is my opinion that ambulance personnel with the level of training, experience and competence claimed by the [private ambulance service] staff should have been very capable of saving [Master B’s] life.

…[62]

…[63]

…[64]

8. The adequacy of the documentation (patient records)

NZS 8156:2019 requires that complete and accurate records are documented for each patient. See Appendix Four (a).

Commentary

The security video shows a [private ambulance service] staff member putting down the cell phone that she had been talking on and getting what appears to be a clinical record form from the ambulance. She then leans on the front of the ambulance and appears to start filling it in. This occurs while the resuscitation is still under way.

The clinical record provided by [the private ambulance service] staff is neither fully legible nor accurate. It does not record treatments and observations claimed by the [private ambulance service] personnel in subsequent statements. See Appendix Four (b).

The provisional diagnosis is listed as cardiac arrest.

The section on oxygen therapy has a line scrawled through it. This is the deliberate recording that no oxygen was administered, which is consistent with the observations by [Ms A]. The contention that oxygen was administered, and the timing thereof, is discussed elsewhere in this report.

There are no recorded treatments, or assessments of vital signs, from 0952 hours until the arrival of [emergency call centre] personnel at 1007 hours. This is the period of time that concerned [Dr F].

I note that during the 111 call recording, voices in the background talk about [Master B] beginning to breathe again. There is no audible dialogue suggesting that anyone has checked his pulse. The AED can be heard advising that no shock is advised. This means that [Master B] is in a non-shockable rhythm but does not mean that his heart is beating, nor, if it is, that it is beating sufficiently strongly to produce a life-sustaining pulse. CPR may still have been required. The [a]mbulance that transported [Master B] to hospital departed the […] at 10.41 a.m. This allowed [the private ambulance service] staff about 30 minutes to complete accurate, legible documentation.

Conclusion

…[65]

If [Master B] was attended by [the private ambulance service] staff between the time of 9:30 a.m. and 9:40 a.m., and found to be breathing and with a pulse, as indicated by [the private ambulance service] staff statements, the standard of documentation is a severe departure from the accepted standard of practice.

If [Master B] was attended by [the private ambulance service] staff who initially arrived at his side at 0946, as the clinical record appears to show, and was found to be already in cardiac arrest, then the documentation of care is a moderate departure from the accepted standard of practice. I am very reluctant to draw this conclusion as [the private ambulance service] staff still had 30 minutes or more after handing over to [emergency call centre staff] during which the clinical record could have been appropriately completed.

…[66]

9. Any other matters in the care provided by [the private ambulance service] that you consider warrant comment/amount to a departure from the accepted standard.

…[67]

Clinical Practice Guidelines

If [the private ambulance service] staff work at any clinical level above that of first aid, then the apparent absence of adequate clinical practice guidelines is a severe departure from accepted practice. First Responders, Emergency Medical Technicians (private ambulance service) and Paramedics must be able to immediately refer to their guidelines in order to check procedures and drug doses. Staff must be adequately equipped and capable of providing the clinical care appropriate to their scope of practice.

In New Zealand, ambulance personnel are able to provide clinical care above the level of first aid via the delegated scope of practice from a doctor. This includes the ability to administer medications in particular circumstances. This places a number of obligations on the doctor, which are contained within the Medicines (Standing Order) Regulations 2002. See Appendix five (b)

…[68]

…[69]

Behaviours

The following behaviours do not conform with normal practice by the senior clinician during resuscitation:

• The [private ambulance service] paramedic arrived at the scene after being requested to assist her colleagues, but there is no record (in the clinical record or staff statements) that the paramedic looked at, assessed or treated [Master B] at this time

• The [private ambulance service] paramedic immediately took [Master B’s] mother off to the side, talking to her and distracting her (instead of assessing and treating [Master B])

• Once the resuscitation of [Master B] began, the paramedic assisted with care for approximately three minutes, then spent many more minutes on the phone (which could have been delegated), before commencing paperwork. She did not re-engage with clinical care.

The Commissioner may wish to give consideration to the above points whilst reviewing the conclusions contained within this report.

…[70]

Discussion

Myocarditis

Myocarditis is an inflammation of the heart muscle. It is often mild, but can cause the heart to beat less strongly, irregularly, or rapidly. Myocarditis is not a direct cause of seizures or lack of oxygen, but these can occur if the myocarditis causes blood clots, heart arrhythmias or cardiac arrest. 

Hypoxic seizures

When a person suffers cardiac arrest, blood stops flowing to the brain. The resultant lack of oxygen will cause a seizure in approximately 13 percent of cases.[71] This is particularly common in younger, male patients who have a shockable heart rhythm (able to be defibrillated). Seizure-like activity is considered a sign of cardiac arrest. 

Agonal respirations

40% of patients in cardiac arrest will present with agonal breathing. This is an abnormal breathing pattern that is often audible, and is characterised by deep, laboured, irregular gasps. It is a natural reflex and is not representative of the patient breathing. It is frequently difficult to observe respirations in a person who is breathing normally. It is often very easy to observe the deep, gasping agonal respirations of a person who is in cardiac arrest. It is easy for a bystander to assume that this type of gasping means the person is breathing. Ambulance 111 call takers will instruct 111 callers to commence CPR when they are reporting someone who is unresponsive and not breathing normally. 

Cardiac Arrest

In summary: People suffering cardiac arrest will often collapse, experience seizure-like activity for a short time, turn blue and take gasping respirations.

[Master B] collapsed, had a short period of seizure-like activity and turned blue.

There is no verifiable information suggesting that he had a pulse from that point until the arrival [emergency call centre] personnel at 10:07 a.m. 

Initial presentation

Bystanders witnessed [Master B] collapsing, having a short seizure, turning blue, and start gasping. The bystander who summoned [the private ambulance service] assistance told them that a child had collapsed and had a seizure. [Master B’s] friend told [Ms A] that [Master B] had turned blue. The bystander who phoned 111 told the call taker that [Master B] had fallen over backwards, had a short seizure, and was breathing. The caller did not establish the rate of breathing, or if it was adequate, simply that it was occurring to some degree (the 111 call taker’s attempt to ensure the breathing was adequate was cut short by [the private ambulance service] staff).

[The private ambulance service] personnel report that they found [Master B] unconscious. This statement is supported by their clinical record, the bystander’s 111 call, and supported by comments from [Master B’s] mother.

[The private ambulance service] personnel retrospective statements assert that [Master B] had a pulse that was neither fast nor slow. This assertion is not supported by any other evidence. It is contradicted by their own clinical record. There is not a single recorded pulse rate during the 25 or more minutes that [the private ambulance service] staff were in attendance with [Master B] prior to [emergency call centre staff] arrival (with the exception of “0” at the point that it was established that [Master B] was in cardiac arrest).

A palpable pulse is normally associated with a blood pressure of greater than 80 mmHg, and therefore very unlikely to be the sole cause for a person being unresponsive with a Glasgow Coma Score (GCS) of 3/15. A pulse that is “neither fast nor slow” is likely able to pump sufficient blood to the brain so as to sustain life.

Whilst myocarditis can cause irregular, rapid, and weak heartbeats, the findings asserted by [the private ambulance service] staff in their statements, if correct, point to adequate heart rate and blood pressure at the time of their assessment.

[The private ambulance service] personnel retrospectively report that when they found [Master B] his respirations were present but laboured. This is confirmed by the written description in the clinical record (“unresponsive, gasping”) but contradicted by the documented respiration rate of zero. The 111 call confirms that [Master B] had some respirations that were visible to the bystander.

Respirations that are present but laboured could be a sign of a serious medical event causing hypoxia and unconsciousness. Such a condition could also progress to cause cardiac arrest and hypoxic brain injury; however, this would most likely cause cyanosis (blueness of the skin). [The private ambulance service] clinical record does not record any blue tinges to [Master B’s] skin. No causes for such respirations were found during [Master B’s] treatment in ED and ICU (other than cardiac arrest). Respirations that are present but laboured and gasping are often a sign of cardiac arrest.

The treatment provided to [Master B] was chest compressions and ventilations. A medical condition causing a collapse such as [Master B] experienced is very unlikely to spontaneously resolve in the absence of specific treatment (other than chest compressions and ventilations). The assessments by [emergency call centre] paramedics, Emergency Department and ICU staff detected no such condition. Therefore, I conclude that a respiratory condition was unlikely to be the cause of [Master B’s] collapse. His laboured breathing, however, was a very significant sign of the seriousness of his condition.

…[72]

…[73]

…[74]

Appendix one (c)

Possible scenarios

To objectively evaluate the evidence provided, I have considered two separate scenarios: that when [the private ambulance service] staff arrived at his side, a) [Master B] was already in cardiac arrest, and b) [Master B] was not in cardiac arrest.

1. The assessment of patients in cardiac arrest

The minimum expectations for the assessment of an unresponsive patient who exhibits gasping respirations is to check for adequate respirations (breathing that appears able to sustain life). If the respirations appear to be agonal (non-life-sustaining) and the patient is unresponsive then CPR should be commenced immediately.

In this setting, resuscitation is commenced (CPR continued and a defibrillator is connected to the patient), the heart rhythm is analysed and if appropriate, a defibrillation (a shock) is delivered. Next, the patient’s airway is assessed and further resuscitation measures are implemented. Establishing a full resuscitation takes several minutes (organising the personnel who are on scene, laying out and applying equipment). Once the resuscitation is fully under way, additional assessments should occur. These include an assessment of the patient’s airway, potential causes of the cardiac arrest, and the sequence of events leading to the patient’s collapse. These assessments may help determine the cause and dictate the course of treatment.

2. The assessment of unconscious patients not in cardiac arrest

If the patient is not in cardiac arrest when first attended by clinicians, then the unconscious patient requires a full primary and secondary assessment. This includes checking that the patient’s breathing and heart rates are able to sustain life while the assessments continue. A full set of vital signs, including

• respiratory rate, rhythm, depth and effort — pulse rate, rhythm and strength

• blood pressure

• capillary refill time

• level of consciousness

• blood oxygen level

• blood glucose level

• temperature

• skin presentation (colour, sweating etc)

• airway noises

• lung sounds

An assessment of the events leading to the patient’s current presentation, along with the patient’s medical history are important.

Appendix one (d) [The private ambulance service]

The [private ambulance service] assessment

The evidence of assessment: [The private ambulance service] personnel provided a clinical record to [emergency call centre staff] when [Master B’s] care was handed over their paramedics. It reflects that [Master B] was found at 9.45 a.m., on the ground, unresponsive, gasping and pulseless. He had a GCS (level of consciousness) of three. It lists the provisional diagnosis of “cardiac arrest”.

A brief description of events leading to [Master B’s] collapse is included.

Vital signs are documented as being measured at 0946 hours (9.46 a.m.).

These are recorded as:

Pulse 0

Respirations 0

GCS 3

A section of the record, labelled “Primary” lists:

Airway “0”

Breathing “0”

Circulation “0”

LOC “0”

Colour “0”

The implication of the “PRIMARY” section of the report is that this is the primary survey — the very first assessment of [Master B] when [the private ambulance service] staff arrived at his side. The recording of “0” against each of these categories does not provide any meaningful information. While it might reasonably be assumed that = “Breathing 0” and “Circulation 0” mean that the rate of breathing and heart rate were both zero per minute; “airway 0”, “level of consciousness 0” and “colour 0” are meaningless. The Glasgow Coma Score is a scale from 3 (completely unconscious with no responses) to 15 (conscious, alert and orientated to time, place and events).

I note that in the absence of clinical records documenting assessments, procedures and findings, the assertion that these were undertaken cannot be substantiated. Paramedics are thoroughly taught about the legal implications of poor documentation.

If [Master B] was in cardiac arrest at the time that [the private ambulance service] staff arrived at his side, then the assessment documented was adequate and resuscitation should have commenced immediately (however, the 111 call and the venue’s security video demonstrate that this did not occur). Further assessment should have followed if/when time allowed.

The evidence does not support that [the private ambulance service] staff recognised that [Master B] was in cardiac arrest on their arrival. The first 111 call records the caller saying that he is being told to discontinue the call by the [private ambulance service] medics.

Pulse:

The clinical record states that [Master B] was pulseless. It records that his pulse was “0”.

Subsequent (retrospective) statements by [the private ambulance service] staff assert that [Master B’s] pulse was present and was neither fast nor slow; however, there is no evidence to support this claim. If [Master B’s] pulse was present, as claimed, this was not documented nor adequately assessed. Such an assessment would normally include the rate, rhythm and strength of the pulse.

Respirations:

The clinical record states that [Master B] was not breathing. It records that his respiration rate was “0”.

Subsequent (retrospective) statements by [the private ambulance service] staff assert that [Master B] was breathing. The rate was not calculated. A respiratory assessment was not conducted. This would normally include respiratory effort, accessory muscle use, chest wall symmetry, lung sounds and skin colour if hypoxic. The airway was not assessed.

Blood pressure was not measured.

[Master B’s] pupils were not assessed for size and reactivity to light. This can be an important indicator of a head injury. [The private ambulance service] staff had noted that [Master B] hit his head when he collapsed.

A pain assessment was not recorded. This is normal for an unconscious patient.

There is no documented evidence of attempts by [RN D] to measure [Master B’s] blood glucose level. If [Master B] was in cardiac arrest, per the clinical record, then measuring the blood glucose level is a very low priority. If [Master B] was not in cardiac arrest, then this is an appropriate assessment. It is an invasive procedure that should have been documented if it occurred.

There was no measurement of [Master B’s] blood oxygen level (O2 saturation).

[Master B’s] temperature was not measured. An assessment of [Master B’s] level of consciousness is documented. I note the ease with which it is possible to retrospectively conclude that a patient had a GCS of 3 when they have had CPR performed on them.

[Master B’s] skin was not assessed for colour and temperature.

There was no secondary survey, assessing for injury.

There was no information obtained about the seizure, such as how long [Master B] seized for, what his seizures looked like, and what he hit (if anything) as he collapsed.

There is minimal information about [Master B’s] background medical history.

The clinical record provided by [the private ambulance service] staff does not match statements later provided by the same [private ambulance service] staff, which describe that they were alerted to [Master B] having a seizure, approximately 15 minutes prior to the time stated on the clinical record. They assert that his pulse was checked and was present and that he was breathing and that his breathing was laboured. In this situation, it is then necessary and appropriate to conduct a detailed assessment of the patient. This will allow the clinician to determine what is wrong, and what treatments are required. A detailed assessment is not documented (nor detailed in the subsequent statements by [the private ambulance service] staff).

[The private ambulance service] describe on several occasions that detailed examinations were undertaken. This claim is unsupported by clinical records detailing the findings of such examinations.

Additional information from alternative sources

I have reviewed the transcription of the 111 call provided by [the emergency call centre]. It describes the call handler talking to a bystander and coaching that bystander through an assessment of the situation. The call taker asks if the patient is breathing and instructs the caller to say “yes” every time the patient takes a breath. The call then says “yes, he just breathed”. This is a single breath, observed by the caller who is not right at the patient’s side. [Private ambulance service] staff then inadvertently block the view of the caller, and she/he is unable to see when [Master B] takes his next breath (the timing of a second breath would have immediately established if [Master B’s] breathing was life-sustaining). The 111 call taker and a bystander did not complete the assessment because [the private ambulance service] staff indicated that the call to 111 should be cut.

Ambulance communications centres in New Zealand give a 111 caller immediate instructions to commence (or have someone commence) CPR for any patient who is unconscious with questionable breathing. This is because commencing CPR is time critical.

The detection of [Master B’s] breathing by the 111 caller shows that the [the private ambulance service] clinical record is incorrect.

I note that [the private ambulance service] also references this 111 call, using it to support their assertion that [Master B] was breathing when [the private ambulance service] staff first arrived at the scene (in conflict with the [the private ambulance service] clinical record).

Appendix two (a)

Interventions and treatments

Expected standard of care:

Cardiac arrest treatment: The standard of care/accepted practice (extracts from the national ambulance clinical procedures and guidelines) is:

• Perform continuous chest compressions while the defibrillator is being attached and charged

• Defibrillate immediately if the cardiac rhythm is VF or VT using a single shock and immediately recommence chest compressions

• Perform two-minute cycles of high-performance CPR between rhythm checks

• Place an LMA and gain IV access, but high-performance CPR takes priority

• Perform a rhythm check every two minutes and defibrillate using single shocks if the rhythm is VF or VT, immediately recommencing chest compressions after the shock

• Administer adrenaline every four minutes

• Administer amiodarone if the rhythm is VF or VT at any time after the first dose of adrenaline

• Back up from an ICP (Intensive Care Paramedic) must always be requested

• Use the cardiac arrest checklist once resuscitation is fully established

Cardiac arrest checklist

• Identify a team leader

• The team leader must ensure:

  • Roles allocated and confirmed

  • Space maximised and confirmed

  • Two-minute cycles, time on if available

  • Defibrillator screen visible to the team leader

Definitions

• A patient is in cardiac arrest when the patient is unconscious and has no signs of life. Agonal gasping is common during cardiac arrest, particularly in the presence of good CPR and is not considered a sign of life in this setting.

• A witnessed cardiac arrest is one where the patient is seen or heard to collapse, regardless of whether this is by a member of the public or by ambulance personnel.

The prognosis of cardiac arrest

There is no one factor that can be used to determine the prognosis of an individual patient in cardiac arrest. Multiple factors must be taken into account, noting that in most patients there will be a mixture of prognostic factors.

Better prognostic factors include:

• Primary cardiac arrest

• Witnessed

• Bystander CPR

• Response time less than eight minutes

• Initial rhythm VT or VF

• Time in Cardiac arrest less than thirty minutes

• No severe comorbidities present

Important aspects of high-performance CPR

• For an adult the CPR compression to ventilation ratio is 30:2 when ventilation is via a bag and mask. This ratio prioritises chest compressions on the basis that an adult is most likely to have had a primary cardiac arrest. If an adult has had a cardiac arrest secondary to asphyxiation or respiratory failure, alter the ratio to 15:2.

• For a child the CPR compression to ventilation ration is 15:2 when ventilation is via a bag and mask (exception — the ratio is 3:1 for neonates). The 15:2 ratio reduces the priority of chest compressions on the basis that a child is most likely to have had a cardiac arrest secondary to respiratory failure. If a child has had a primary cardiac arrest, alter the ratio to 30:2.

• Perform continuous chest compressions if an LMA (or other supraglottic airway) is present and this does not obviously impair ventilation via the LMA. If however, continuous chest compressions obviously impair ventilation via the LMA, interrupt the chest compressions to provide ventilation. If there is uncertainty, perform continuous chest compressions.

• Ventilation has a low priority during the first few minutes of resuscitation if the patient has had a primary cardiac arrest. During continuous chest compressions ventilate adults and children with ten breaths per minute, preferably using a ventilation timing light. Ventilation rates higher than this reduce the blood flow achieved during CPR, as a result of increased intrathoracic pressure and reduced venous return.

IV access and drugs

• Gaining IV access and administering IV drugs has a lower priority than providing high performance CPR.

3.15 Treatment following return of spontaneous circulation

• Gain IV access if not already gained

If [Master B] had suffered a seizure, as an [the private ambulance service] statement suggests, then the standard care following the seizure is:

• position the patient on their side

• maintain airway and breathing

• monitor pulse oximetry and administer oxygen if required

Appendix two (b)

[The private ambulance service] provided a copy of its resuscitation guidelines. These appear to be extracts from a document. I note that these “guidelines” do not meet the NZS 8156 standard. Nor do they provide adequate guidance for resuscitation.

The guidelines recommend to assess whether an attempt at resuscitation is feasible. The guidelines advocate to follow current international CPR procedures (eg, 30 compressions, 2 breaths) appropriate to the level of training, including defibrillation. The guideline gives guidance on when resuscitation should not be attempted. It discusses “Do not resuscitate” orders. The guidelines also discuss oxygen administration (but not oxygen administration during cardiac arrest) and oxygen flow rates. These guidelines (with the exception of the references to oxygen) do not provide any care above the level of first aid.

Appendix two (c) Image one: A non-rebreather mask

[Please refer to PDF version of this report to view image]

By ICU nurses — Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=34392119

…[75]

…[76]

Appendix three (a)

Decision-making for patient transport and clinical assistance

The standard of care/accepted practice for decisions about transporting patients:

5.8 Seizures

Referral and transport

• The patient must receive a clear recommendation to be transported to an ED by ambulance if this is the first time they have had a seizure, unless the cause is clearly recreational drug use and the patient has recovered to be able to mobilise safely.

• The patient may receive a clear recommendation not to be transported to a medical facility by ambulance, even if midazolam has been administered, provided the patient:

1. has known epilepsy with no significant change in their usual pattern of seizures, or has recreational drug poisoning, and

2. has not been injured, and

3. has recovered to a safe postictal state

Additional requirements for a determination to transport the patient are inability to confidently exclude serious injury, or obvious need for ongoing care in hospital. [The private ambulance service] staff documented that on their arrival [Master B] was on the ground, unresponsive and gasping. A detailed, time-consuming examination of the patient was not required to determine that he needed urgent transport to hospital. Therefore, delaying the call for an emergency ambulance was absolutely inappropriate.

The decision to request clinical assistance should be made as soon as it is recognised that the patient urgently requires clinical interventions that are outside the scope of the clinicians on scene.

…[77]

Appendix four (b)

The clinical record provided by [the private ambulance service] staff is neither fully legible nor accurate.

The clinical record documents a time at the top of the form. This is 9:45 a.m. The form does not state what this time refers to. I note that this time does not correlate with other evidence provided by [the private ambulance service] that describes them being alerted to [Master B] seizing at about 9:30 a.m. to 9:40 a.m.

The section “Time of incident/onset” is not completed. This is vital information that needs to be documented as none of the clinicians initially treating [Master B] accompanied him to hospital.

The History section contains a brief description of what happened. It does not say how long [Master B] seized for.

There is no past medical history (PmHx) listed.

The sections for On Arrival (of [private ambulance service] personnel) and On Examination contain a very brief description of [Master B] being on the ground, unresponsive, gasping, pulseless. The retrospective statement provided by [the private ambulance service] personnel contradict this information.

The examination section includes comments that there is no previous medical history. Mother in attendance hysterical, previous to today no prior (indecipherable) or injury. Patient on autism spectrum. Takes antihistamine for hay fever.

The treatment section (Tx) describes CPR, two defibrillations, and some illegible words [the emergency call centre] called (indecipherable text).

The outcome of the shocks is not recorded, nor was the ventilation via a bag/mask.

The section detailing Medications/Shocks/IV details that there were two shocks delivered from an AED at 9:50 a.m. and 9:52 a.m.

The provisional diagnosis is listed as cardiac arrest. This is in conflict to statements from [the private ambulance service] who describe the initial working diagnosis as post ictal (unconscious following a seizure).

The next section of the report details oxygen therapy options. This section has a line scrawled through it. This is the deliberate recording that no oxygen was administered, which is consistent with the observations by [Ms A]. Additionally, there is no record of oxygen being administered to [Master B] anywhere on the report. The contention that oxygen was administered, and the timing thereof, is discussed elsewhere in this report.

The [private ambulance service] paramedic on scene has provided a statement that she inserted an oropharyngeal airway. This is not recorded on the clinical record. She also stated that she was asked by [emergency call centre] personnel to insert an IV and had begun to do so. This is not recorded.

There is no record of attempts by […] to obtain a blood glucose recording. This is an invasive procedure that should have been documented. Again, I note that in the absence of clinical records documenting the procedures and findings, the assertion that various assessments were undertaken cannot be substantiated.

There are no recorded treatments, or assessments of vital signs, from 0952 hours until the arrival of [emergency call centre] personnel at 1007 hours. This is the period of time that concerned [Dr F]. I note that during the 111 call recording, voices in the background talk about [Master B] beginning to breathe again. There is no audible dialogue suggesting that anyone has checked his pulse. The AED can be heard advising that no shock is advised. This means that [Master B] is in a non-shockable rhythm but does not mean that his heart is beating, nor, if it is, that it is beating sufficiently strongly to produce a life-sustaining pulse. CPR may still have been required.

The [a]mbulance that transported [Master B] to hospital departed the [venue] at 10.41 a.m. This allowed [the private ambulance service] staff about 30 minutes to complete accurate, legible documentation.

…[78]

The author has been asked to provide a supplementary opinion to this initial report to the Commissioner on case number C21HDC00192 and has read, and agrees to follow, the Commissioner’s Guidelines for Independent Advisors. This follows the provision of additional information.

Qualifications, training and experience relevant to the area of expertise

…[79] Meteorological Technical Support Officer, NZ Meteorological Service

Guest presenter: Resuscitation of patients in cardiac arrest, Wellington School of Medicine

The Commissioner is seeking an opinion on the care provided by [the private ambulance service] to [Master B] (now deceased) in October 2020.

Additional advice requested

Whether any of the information provided subsequently changes any aspects of the initial advice (in relation to the departures initially identified in the standard of care provided to [Master B], and in particular when taking into account the information that the [private ambulance service] staff had at the time of the events.

Supplementary information reviewed

The following information was provided and has been reviewed.

1. Response from [the private ambulance service], dated 17 May 2022.

2. Response from RN [D], dated 23 June 2022.

3. Statement from [RN D], dated June 2022.

4. Statement from [Miss C], dated 23 May 2023.

Resources consulted

• NZS 8156:2019 Ambulance, paramedicine and patient transfer services

• St John Clinical Procedures and Guidelines, Comprehensive Edition 2019–2022

Pertinent points from the supplementary information

I have provided opinion on relevant portions of the supplementary information. These are copied below.

From the response from [the private ambulance service], dated 17 May 2022, point:

(11) An Event stall holder came to the [private ambulance service’s] first aid base and advised [private ambulance service staff] that a young male ([Master B]) had collapsed and was possibly seizing or had hit his head in front of his stall. The [private ambulance service] cannot be precise about the time this occurred but estimates this would have been around 9.40am. All three [private ambulance service] staff were present in the first aid room as it was the start of the day.

Expected practice when presented with this information is to respond to the scene with sufficient equipment to assess and treat a patient who may be suffering (from the description provided) from seizure, head injury or cardiac arrest, or from other conditions that may present in this manner (i.e., hypoglycaemia).

(15) The cardiac monitor malfunctioned during the morning checks, and it would only work on power but not battery. The [private ambulance service] have a spare AED on back up and there is also an AED at reception near to the first aid room base set up.

It is expected practice to check all equipment (and replace any defective items) at the start of the shift, prior to leaving the ambulance base. It is unclear from the statement where the “morning checks” occurred and if replacement equipment was available.

It is accepted practice by emergency ambulance services to use combined monitor/defibrillators which always have multiple batteries. This allows ambulance personnel to:

—    avoid situations where flat batteries interfere with clinical treatment

—    carry less items (because the monitor/defibrillator is a single unit)

—    have access to additional functions such as pulse oximetry and capnography (which are usually included in the combined monitor/defibrillator devices.

I am not familiar with devices that are cardiac monitors only and not able to also perform defibrillation, therefore I am not qualified to comment on the suitability of using these in the context of an event ambulance service.

(19) [RN D] commenced a primary and secondary assessment of [Master B] as the cause of his collapse was not immediately apparent and noted his colour was of a bluish nature and he was gasping breathing. [RN D] also twice attempted to determine [Master B]’s blood glucose levels (BGL) but was unable to do so. She then put a 100% non-rebreather mask at 10L per minute onto [Master B] (they address Mr Bailey’s comments about this below).

Expected practice when approaching a patient with a presenting history of witnessed collapse with short duration seizure, who is unconscious and whose breathing is gasping and skin is blue, is to presume that the patient is in cardiac arrest until proven otherwise.

It is expected practice in this situation to immediately perform a thorough primary and secondary survey.

It would be a significant departure from the expected standard of care if an adequate primary and secondary survey were not immediately conducted.

Expected practice is to perform the blood glucose measurement after the primary survey.

Key information that should be obtained from a secondary survey, that has not been presented, includes a respiratory assessment, vital signs including blood pressure, capillary refill test, and detailed level of consciousness. The information related to a secondary survey that has been provided is the attempted measurement of a blood glucose level. This should be obtained while measuring the vital signs. In this incident it was reported as unable to be obtained despite two attempts (noting only one lancet and measuring strip were recorded as being used).

In the circumstance where the patient presents with a pulse that is regular and neither fast nor slow, but the breathing is gasping and the patient is blue in the face, then expected practice is to thoroughly assess the breathing.

Expected practice for this is checking the rate, rhythm and depth of the respirations, assessing if the chest is expanding equally, and if the trachea is situated in the midline. Lung sounds should be listened to, if the environment allows.

In this scenario it would be a significant departure from expected practice for a thorough assessment of the unconscious, blue and gasping patient’s respirations not to be conducted (and documented).

It would be a significant departure from expected practice to measure (or attempt to measure) the blood glucose level before administering oxygen to a hypoxic (blue) patient that has gasping respirations.

(21) While [RN D] was assessing [Master B], [Miss C] asked the member of the public on the phone to 111 to ask [the emergency call centre] to wait until [RN D]’s assessment of [Master B] was complete. This was to ensure that [the emergency call centre] could be fully appraised of the situation and ensure that resources were best utilised.

Accepted practice in this situation (an unconscious patient who is blue and has gasping breathing) would be either to allow the call to continue (the easiest option), or to instruct the caller to convey that the ambulance was required urgently.

It would also be accepted practice by a number of emergency ambulance service personnel, if they were still unsure of the patient’s condition and considered that it were possible the condition might be minor or easily reversible, to ask that [the emergency call centre] stay on the line while they completed the primary survey.

Note: while emergency ambulance personnel normally utilise ambulance communications infrastructure (i.e., a portable radio), it is not unusual to arrive at a scene and find bystanders on a 111 call.

(22) Ms [E] immediately moved the ambulance and backed into the open rear doors at Hall 4, which was approximately 5 meters from [Master B]. Ms [E] is unsure of the precise time that she arrived but notes that security footage could confirm this. Mr Bailey estimates this occurred at 9.53am, but it is unclear what Mr Bailey has used as a reference for this time. When she approached the scene, she could see that [Master B] was in a poor condition and got the stretcher out. She had a brief handover with [RN D]. Ms [E] confirms that she also confirmed that he had a steady pulse but did not carry out a pulse count.

Accepted practice when a patient is identified as being in a poor condition is to confirm the primary survey (repeat a previous primary survey if required) and then continue the assessment looking for treatable causes. This includes obtaining a full set of vital signs (which includes a pulse count, respiration count, blood pressure and blood glucose level, thorough level of consciousness assessment amongst other vital signs).

It would be a severe departure from expected practice to not thoroughly assess a patient that appeared to be in a poor condition, who was unconscious, gasping and blue in the face.

(23) [Master B]’s mother arrived at this time. She was understandably very upset and distressed. Ms [E] spoke to her briefly and calmly and explained what was occurring. Security also arrived at the same time. [Miss C], at the direction of [RN D], advised Ms [E] that [Master B] had stopped breathing.

Accepted practice, — particularly when the patient has already been identified as “in a poor condition” is for the senior clinician to focus on assessing and treating the patient. This is particularly the case when the junior clinicians are unable to provide the treatments potentially needed. Any relatives or friends will be attended to once the patient has been stabilised, or by a junior clinician if they are not tasked to other more important duties.

It would be a severe departure from accepted practice to not immediately and thoroughly assess a patient that appeared to be in a poor condition, who was unconscious, gasping and blue in the face.

In the scenario where the patient had adequate breathing and an adequate pulse, and was blue and unconscious, and whose primary survey did not necessitate urgent intervention (such as opening an airway or providing manual ventilation) it would be accepted practice for a member of the team to speak to the family and solicit relevant information as to a possible cause. This would be in addition to a sufficiently skilled team member continuing to assess and treat the patient.

(24) Ms [E] determined that [Master B] had a clear airway and was blue in colour around his lips and face. She then performed a rapid extraction and loaded [Master B] on the stretcher (with [Miss C]), which was set up and approximately 5 meters away. She chose to do this so that they could perform CPR outside with good lighting and away from a significant and growing crowd. She estimates this process would have only taken one minute.

Accepted practice is to perform resuscitation in the location the patient is found.

In circumstances where it is difficult to perform effective resuscitation in the location the patient is found, the desire to move the patient needs to be balanced against the time taken to do so. Every minute that CPR is delayed decreases the chance of survival by about 10%.

It is accepted practice that in circumstances when resuscitation cannot commence in the location that the patient is found (typically because the space is too small or there are dangers present), the patient be moved so that resuscitation can be commenced.

It is accepted practice that if the patient is not already on a stretcher, the quickest method for achieving the move is usually to drag the patient, and this occurs without chest compressions being performed during the move. This approach requires that the patient be moved as fast as is possible, as every second without chest compressions decreases the patient’s chance of survival. In this scenario, chest compressions are commenced (or recommenced) as fast as possible once moving the patient is complete. The distance moved should be the minimum distance possible that then allows for an effective resuscitation to commence.

Expected practice when moving a patient by stretcher (particularly if doing so is urgent) is to have the stretcher right beside the patient prior to moving the patient. This ensures that the ambulance personnel are at least risk of injuring themselves or the patient during the move, and that the move — if urgent — is as quick as possible. If the patient is in cardiac arrest, CPR should be performed prior to commencing to load the patient, and recommenced immediately that the patient is on the stretcher.

Accepted practice, if it is necessary to extricate a cardiac arrest patient by stretcher, is to perform chest compressions (and normally also ventilations via a bag/valve/ mask (BVM)) once the patient is on the stretcher. The stretcher is wheeled in a slow, controlled manner, allowing effective chest compressions to continue. This ensures that any oxygen can be circulated to the brain and other vital organs, keeping them alive. Note: that while the patient is being moved, the resuscitation efforts are compromised.

In the scenario where it is necessary to move a patient that is in cardiac arrest by stretcher, and it is possible to perform chest compressions while moving the stretcher slowly, would be a significant departure from practice to not start chest compressions once the patient was on the stretcher.

(25) The primary survey suggests that the first priority should be the patient’s airway, followed by breathing and circulation. Ms [E] carried out quick assessments including, checking [Master B’s] airway was clear and performing a jaw thrust. [Master B] was not breathing and had no pulse and Ms [E] considered that other airway manoeuvres were not appropriate at that stage, until CPR had begun.

Accepted practice in these circumstances would be to begin chest compressions immediately unless it is not possible to do so (in which case, the patient must be rapidly moved to a place where chest compressions can commence).

If the patient is not breathing — as has been described in the statements – and is not being artificially ventilated, then there would be no benefit derived by continuing to perform a jaw thrust if doing so did not allow breathing to spontaneously begin. In this scenario, an open airway will only be useful once chest compressions are commenced (when an inherent tidal flow will be generated by the chest being compressed).

It would be a significant departure from the expected standard of practice to not immediately commence chest compressions if it is possible to do so.

[RN D] commenced CPR on [Master B] on the stretcher outside the venue by the ambulance at the direction of Ms [E]. CPR would have commenced very shortly (perhaps one to two minutes) after [RN D] noted [Master B] was not breathing. [Miss C] set up the AED and Ms [E] set up an OP airway and got the bag mask ready. [Miss C] then placed the AED pads underneath the patient’s clothes as she had difficulty cutting them off and ascertained the patient’s heart rhythm. The AED displayed “shock” and [Miss C] gave the patient a shock. Ms [E] intended to continue jaw thrusting [Master B] and maintain his airway and ventilations during this time but switched with [Miss C] who was not as familiar with the equipment placement. [Miss C] then took over monitoring [Master B’s] airway and continued jaw thrust.

Expected practice for resuscitation in cardiac arrest (per the emergency ambulance clinical practice guidelines) is:

—     Continuous chest compressions

—     Attach the AED and follow the prompts

—     Immediately continue CPR after the shock is delivered and continue to follow the AED prompts

—     Place a laryngeal mask airway (LMA) or similar supraglottic airway device

Established practice [for] emergency ambulance personnel in the circumstances described, where one of the team members is not familiar with equipment placement, would be to talk them through finding the specific piece of equipment that is required (an airway kit or LMA in this instance), then to give instructions on where best to lay out the equipment.

Accepted practice for equipment layout in the scenario of treating a patient for cardiac arrest in an area where there is sufficient space is to have the airway equipment (including suction device) and oxygen at the patient’s head.

The defibrillator would be on one side of the patient, as would the equipment required for placing an IV cannula and administering drugs.

(27) Ms [E] supervised the work on [Master B], continued to manage the scene and called 111 to request further support. During the call, she placed the phone on the ground next to the AED so CPR could continue. [Miss C] then took over the call. Ms [E’s] phone shows the call was made at 9.58am and lasted for 8 minutes and 9 seconds. [The emergency call centre’s] records show that the call was made at 9.59am.

Expected practice in the scenario where the initial defibrillation has occurred and a call for help been initiated (without interfering with treatment), is to secure the airway (if not already secured) by LMA and to place an IV cannula.

Established practice for scene management and personnel supervision in the above scenario is that this role is performed by the person who is ventilating the patient. This is because if either of the other personnel (who would be performing chest compressions, defibrillating or initiating IV access and drug therapy) are distracted they can easily lose track of timings and/or drug sequences.

In the above scenario, it would be a moderate departure from established practice for the least clinically capable team member to take over a clinical handover, noting that it is not normal practice to provide a “handover” to a 111 call taker.

(28) Ms [E] also again spoke to [Master B’s] mother to obtain his medical history so they were able to determine what may be occurring. She reported he had no real medical history but did take antihistamines and was unusually grumpy for the last few days.

Accepted practice is that the least clinically qualified member of the team speak to the family/bystanders.

Accepted practice is that the senior clinician on scene goes to speak to the family once all treatment has been initiated and the scene is well managed (i.e., those performing chest compressions have established a good rhythm) and there are no outstanding clinical tasks. Prioritisation of tasks is detailed in the ambulance CPGs (and is second to last on the checklist).

(29) The AED displayed that a second shock was needed, and [Miss C] gave [Master B] a second shock. Ms [E] then assessed [Master B] and the AED displayed that a third shock was not needed. Ms [E] directed that [RN D] check [Master B] for a carotid pulse. [RN D] found a carotid pulse and Ms [E] double-checked this and confirmed the presence of his carotid pulse along with a weak radial pulse. [Master B] started to show signs of return of spontaneous circulation (ROSC). [Master B] sustained ROSC for 2–3 minutes before emergency services (ambulance and fire service) arrived at 10.06–10.07am.

Expected practice is to document the signs of ROSC that start to show (in addition to the detection of a pulse). These signs (other than the pulse and a breath) were not documented on the patient report form and have not been described in any of the subsequent statements.

In the above scenario, accepted practice is to place an IV cannula (if not already in place) immediately after ROSC has occurred. This is in case the patient suffers a subsequent cardiac arrest (as occurred with Master B).

In the scenario of ROSC occurring in a patient that remained unconscious, without the airway being secured and IV access being obtained, it is a significant departure from accepted practice not to ensure that the airway is secured (via an LMA) and not to cannulate the patient immediately after ROSC has occurred.

In the scenario of ROSC occurring and the patient showing evidence of gagging, it is expected practice to continue supporting the patient’s respirations while needed (while the patient is not breathing adequately for themselves), and to assist in maintaining the patient’s airway with jaw thrusts and suction as required.

(31) Ms [E] wrote the initial details such as job number and personal details on the paperwork but passed this to [Miss C] to complete while Ms [E] continued to carry out care for [Master B]. After [emergency call centre staff] took over [Master B]’s care, [Miss C] completed the paperwork but required help from Ms [E]. They accept that their paperwork was inadequate.

In the scenario of a busy incident, such as cardiac arrest, it is accepted practice that one team member might start filling out the clinical record, and then other members of the team complete (or contribute information related to) the assessments and treatments that each performed. In this scenario it is the responsibility of the treating (or senior) clinician to ensure that documentation is adequately completed.

(34) HDC’s investigation into the Complaint must consider whether the [private ambulance service’s] response and care of [Master B] was appropriate in the circumstances based on information known to the [private ambulance service] at the time.

Expected practice is for the clinical staff, on arrival at the patient’s side, to fully assess the patient in order to determine if the patient is experiencing a life-threatening condition.

It would be a significant departure from expected practice standards for ambulance personnel not to fully assess a patient presenting as unconscious, gasping and blue. The exception to this occurs if partway through the assessment a life-threatening condition is found (such as non-breathing) which requires immediate intervention.

(38.2) The [private ambulance service] needed to assess [Master B] and determine the cause of his collapse prior to commencing CPR. For example, if he had collapsed because he had fainted, had sustained a head injury or suffered a seizure (as reported by the member of the public to 111), then it would have been inappropriate for them to immediately commence CPR.

Expected practice in the scenario of the patient presenting with a potential cardiac arrest is to determine if the patient is in cardiac arrest and to immediately commence chest compressions if no pulse is detected.

Once cardiac arrest has been ruled out, any other life-threatening signs or symptoms should be immediately treated (such as life-threatening hypoxia (lack of oxygen, which is observable when the skin turns blue).

It would be a significant departure from expected practice standards for ambulance personnel not to fully assess a patient presenting as unconscious, gasping and blue following a short seizure.

(Table Row 7, Column 2) The [private ambulance service] agrees that high-performance CPR that is commenced immediately after a cardiac arrest can (but not always) prevent hypoxic brain injury. Further, for a patient to have the best chance of avoiding hypoxic brain injury following cardiac arrest it requires: 1. Immediate recognition that the patient has suffered cardiac arrest (which, as in this case, is not always possible) 2. Competent CPR to be performed immediately.

CPR can (but does not always) prevent hypoxic brain injury. Expected practice in the scenario of a patient presenting with possible cardiac arrest is for the immediate commencement of high-performance CPR, because a patient that is in cardiac arrest but that does not receive timely and appropriate treatment (chest compressions, defibrillation and ventilations) will suffer from hypoxic brain injury.

(Table Row 9, Column 2) The [private ambulance service] appropriately prioritises treating patients over completing paperwork. [Miss C] completed the [private ambulance service’s] clinical record after [Master B’s] care was transferred to [emergency call centre staff] and on the basis that [Master B] has suffered a cardiac arrest at some point — it does not reflect that the [private ambulance service] found [Master B] in cardiac arrest when they arrived. The [private ambulance service] accept that the clinical records are not adequate and they have made changes to their processes following this to ensure that this occurs going forward.

Accepted practice is to prioritise treatment over completing documentation.

Accepted practice when producing the clinical record is to state the condition that the patient was found in. This is entered into a section labelled by emergency ambulance service personnel as “On arrival” (or O/A).

It would be a moderate departure from the expected standard if the clinical record did not reflect key information such as the potential time that a patient was in cardiac arrest (i.e., whether the patient was found in cardiac arrest or whether it was witnessed by the ambulance personnel during their treatment of the patient).

Accepted practice for documenting care during a cardiac arrest (and on many other occasions) would be for ambulance personnel to make notes about treatment and timings on their gloves. These notes would then be transcribed to a clinical record as soon as appropriately possible afterwards.

As noted, the initial cause for [Master B’s] collapse was not clear at the time: He was 15 years old and did not have any known significant medical history. Therefore, these statements are based on information available to the [private ambulance service] based on their assessments and understanding. They fully accept that there may be better objective evidence that determines the cause of [Master B’s] collapse, and when he first suffered cardiac arrest. They are happy to accept that evidence as being “correct”. However, it does not necessarily follow that their understandings based on information known at the time were “incorrect”.

Expected practice in the scenario of approaching a patient where the diagnosis is not known, would be for ambulance personnel to determine all of the objective evidence that portrays the patient’s condition. From this a diagnosis and treatment plan would be determined.

It is expected practice when presented with an unconscious patient who is blue and gasping following a short seizure to assume the patient is in cardiac arrest until proven otherwise (by adequately assessing if the patient has life-sustaining breathing and an adequate pulse).

In a scenario where the unconscious patient’s breathing is irregular/inadequate, it is expected practice to commence chest compressions immediately; however, it is accepted practice for ambulance personnel to quickly check for a pulse if they think one might be present (such as if the breathing appears adequate, or if the patient begins moving while chest compressions are being performed (as can happen during cardiac arrest)).

It would be a significant departure from practice not to perform a full primary and secondary survey on an unconscious, blue, gasping patient in the scenario where the patient had an adequate pulse and breathing.

(43) The [private ambulance service] agrees with this statement. However, the presence of these symptoms can also reflect a range of medical conditions, so it is not appropriate to automatically treat a patient for cardiac arrest when they only present with these symptoms. For example, a patient who was suffering a different type of seizure may also present similar symptoms and they should not receive CPR and/or be shocked with an AED whilst their seizure is occurring as this can make the patient’s condition worse.

In the scenario where a patient’s presentation could result from one of several different conditions, it is expected practice to seek to eliminate the most serious potential causes. In the scenario where a patient presented as unconscious, gasping and blue, it would be expected practice to assume that the patient is in cardiac arrest until this is conclusively ruled out. This includes expected practice for 111 call takers.

When dealing with a 111 caller who describes an unconscious person who is not breathing adequately (i.e., gasping), established practice for the 111 call taker is to immediately coach the caller to start (or have someone start) chest compressions.

In the situation where it becomes apparent that the patient is not in cardiac arrest, chest compressions can be stopped with minimal likelihood of significant or lasting damage (particularly in a young person with more supple tissue, joints and bones).

The balance of risk means that commencing chest compressions is more important than preventing possible injury.

It is expected practice to not shock a patient with a pulse (except in specific clinical circumstances that are quite different from cardiac arrest), and an AED will not recommend (or allow) shocking a patient that is moving (such as during a seizure) and/or has a pulse.

(45) The [private ambulance service] agree that seizure-like activity can be a sign of cardiac arrest. However, it can also be a sign of multiple other conditions, and it is not by itself sufficient for the [private ambulance service] to have immediately determined that an otherwise healthy 15-year-old was in cardiac arrest. Expected practice is that seizure-like activity in the presence of an unconscious, gasping and blue patient is a cardiac arrest until proven otherwise.

(47) While it is now known that [Master B] suffered cardiac arrest(s), it is not reasonable to apply that knowledge retrospectively to determine whether the [private ambulance service] met the requisite standards of care. In other words, it is not reasonable to conclude that because [Master B] died, there must have been some shortcomings with the [private ambulance service’s] care.

In the scenario where the initial presentation indicates a differential diagnosis including cardiac arrest, accepted practice for ambulance staff is to adequately assess the patient. This includes noting information, observations and suggestions from bystanders (which can provide insight into the circumstances of the patient’s condition, but do not provide a diagnosis or treatment plan).

In the scenario of arriving at the side of a patient with an unknown history and unknown diagnosis, it would be a severe departure from accepted practice for ambulance personnel not to perform a thorough assessment of the patient.

(48) The [private ambulance service] is not sufficiently qualified to determine precisely when [Master B’s] cardiac arrest(s) commenced and accept that he may have been in cardiac arrest when they arrived. They say if he was, then it was not unreasonable for them to not identify this because the information available to them at the time was: [Master B] was an otherwise healthy 15-year-old who “fell backwards” after riding the mechanical bull; the event stallholder and the member of the public (on the phone to 111) reported that [Master B] had a seizure and knocked his head; [Master B] was unconscious when the [private ambulance service] attended; and [RN D] located a pulse on [Master B’s] neck, which Ms [E] confirmed on her initial arrival.

In the scenario where the cause of a patient’s presentation is unknown, and that presentation might be life threatening, expected practice for ambulance personnel is to adequately assess the patient, particularly when the initial presentation (short-duration seizure, unconscious, gasping, and blue) indicates a differential diagnosis, including cardiac arrest.

It would be a significant departure from accepted practice for a full set of vital signs not to be obtained in a scenario when a patient presents as unconscious, gasping, and blue, and has a carotid pulse (located at the neck) that is neither fast nor slow and is breathing adequately unless there is active treatment that is appropriately taking priority (such as the administration of high-flow oxygen, which normally takes up to a minute to begin administering).

(49) Further, the circumstances that the assessment was carried out in must also be considered. In this case, it was inside a venue during a show with dim lighting, flashing lights and blue lights with large crowds and noise. It is not possible to simply turn on a light switch and turn off the noise to make it easier to carry out the assessment. Therefore, when the [private ambulance service’s] care of [Master B] is being considered, all circumstances must be factored into the assessment of whether their care was appropriate. Mr Bailey does not appear to have done this.

It is accepted practice for ambulance personnel presented with a patient that is unconscious and gasping to either work in the environment in which they find the patient or, if unable to do so (i.e., the environment is limiting the ability to adequately assess the patient), to immediately and rapidly extricate the patient to an environment where an assessment and treatment can take place.

In the scenario of an unconscious patient with circulatory compromise (apparent hypoxia, per the blue skin on his face and gasping respirations), it would be a significant departure from accepted practice to leave the patient inadequately assessed unless there were overriding circumstances. These circumstances would need to override the risk of death to the patient but might include a physical inability to move the patient, or danger to rescuers).

…[80]

(55.3) The [private ambulance service] had appropriate equipment in the ambulance and prioritised extracting [Master B] to the ambulance outside the venue (approximately 5 meters away) to ensure they had access to appropriate equipment to monitor him, and away from the crowds and lighting. [Master B] arrested before they were able to do this. As noted above, they proceeded with the rapid extraction to carry out CPR away from the crowds and poor lighting.

Established practice is for events staff and ambulance personnel who are responding to a person in a state of collapse to carry with them sufficient equipment to treat a cardiac arrest. Information provided by [the private ambulance service] staff describe that they responded with all the required equipment.

It would be a severe departure from accepted practice in the scenario of responding to an incident that might be a cardiac arrest (such as a collapse, seizure, or unconsciousness) to do so without a defibrillator (i.e., an AED), a suction device, a BVM and an airway kit (containing OPAs and LMAs).

In the scenario where a paramedic responds to such an incident, they should have available an IV starter kit and a drug kit.

https://www.resus.org.nz/assets/OHCA_All_NZ_March_2022_HQ.pdf

It is accepted practice to resuscitate a patient in a public place if necessary. Established practice in these circumstances is to ask personnel such as security personnel to keep members of the public back, affording as much privacy as possible.

It is accepted practice to move a patient into the back of an ambulance (providing doing so won’t compromise the patient) as quickly as possible if the conditions at the scene (such as poor lighting) are interfering with assessment and/or treatment.

(56) Mr Bailey goes on to state that Ms [E] initially spent her time “distracting” the mother and “much of her time on the phone, talking to [the emergency call centre]”. The [private ambulance service] is disappointed that Mr Bailey has characterised Ms [E]’s discussions with [Master B’s] mother as “distracting”, particularly as Mr Bailey ought to be aware that it is critical to obtain a comprehensive medical history to ensure that the patient received the correct treatment and care. Understandably [Ms A] was hysterical when she arrived, so she may have presented a safety risk to the [private ambulance service] and [Master B] if she was not able to be calmed. Ms [E] ought to be commended for calming her so quickly to enable the [private ambulance service] to continue to assess and treat [Master B].

In the scenario where information is required because it may alter the course of treatment, it is accepted practice for the most junior (but capable) team member to ask family or bystanders for relevant information.

In the scenario where the patient is obviously in a serious or critical condition (such as unconscious, blue and gasping), it would be a significant departure from accepted practice for the senior clinician on scene to leave the patient if a thorough primary survey has not been completed.

(57) Further, characterising her medical handover to [the emergency call centre] as talking on the phone is also misleading and disappointing. Ms [E] made the call to ensure that help could be summoned without having to go through the entire ProQA process and save critical time. Further, once through, Ms [E] handed the phone to [Miss C] who put the phone on the ground so she could treat [Master B] (this can be heard during the 111 call).

Expected practice is to prioritise applying treatment for the patient who is in cardiac arrest. This is particularly the case in the scenario where ROSC has not been achieved and/or while there are still procedures and treatments that have not been applied (such as securing the airway, establishing IV access and preparing and/or administering drug therapy).

In the scenario of a patient presenting with a shockable rhythm (i.e., the first rhythm check by an AED recommends that a shock be administered), there are no external reversible causes which take priority over the standardised expected treatment, and which cannot be determined by examining the patient.

The reversible causes for cardiac arrest are:

• Hypoxia

• Hypothermia

• Hypovolaemia

• Hyper/hypokalaemia

• Tension pneumothorax

• Tamponade (cardiac)

• Toxins (poisoning)

• Thrombosis

Note: Hypoglycaemia should be ruled out following ROSC.

The reversible causes which fall within the paramedic scope of practice to treat during cardiac arrest are hypoxia (expected practice during a hypoxic cardiac arrest is to secure the airway with an LMA or similar device and ventilate the patient), hypovolaemia (requires IV fluid administration) and toxins (a specific drug overdose which responds to the IV administration of normal saline).

Note: The cardiac arrest checklist prioritises “IV access secure, two sites if possible” above “Consider underlying and reversible causes”. “Communication with family/bystanders” is second to last on the checklist, above the formulation of “Extrication plan if ROSC occurs”.

When dispatching ambulance resources to a cardiac arrest, the ambulance communications centre only needs to know the address and the fact that the patient is in cardiac arrest.

Expected practice for a paramedic at the scene is to spend available time providing treatment to the patient. It is common for patients who regain a pulse to re-arrest. Therefore, it would be necessary to perform treatments such as intravenous cannulation and to prepare to administer drugs such as adrenaline and amiodarone (in case they are required) in circumstances where these had not been performed during the active resuscitation.

(58) Mr Bailey notes that it took the [private ambulance service] “about ten minutes, from their time of arrival at [Master B’s] side, to get him outside and begin resuscitation”. However, Mr Bailey does not have regard to the work that [the private ambulance service] were carrying out during these ten minutes, and [Master B’s] presentation at various points in time.

The evidence provided is that the [private ambulance service] provided the following treatment:

—    Pulse check

—    Breathing check

—    Attempted BGL reading x 2

—    Oxygen mask

In the scenario where the patient can be safely accessed, for ambulance personnel following accepted practice, including appropriate prioritisation of treatments and assessments, the above interventions and assessments would normally take about 2–3 minutes.

In the scenario where a patient that is unconscious, blue and gasping, expected practice is that the application of high-flow oxygen is prioritised above checking the blood sugar level.

(63) Further, it is not possible or advisable to insert an IV line while AED shocks are being carried out as these processes cause the body to move. These criticisms therefore have no basis.

It is inadvisable to touch a patient who is being defibrillated. This is because of the risk of electrocution which may cause the second person to have a cardiac arrest.

In the scenario of treating a patient for cardiac arrest, established practice is to use the two-minute periods between defibrillations to prepare for cannulation and to insert the cannula. This may take more than one two-minute period.

It is expected practice to use this approach (using the period between defibrillations) for the insertion of airway devices.

Note: while using an AED, the period available for IV cannulation is shorter because use of an AED requires that the patient is not touched/moved while the AED is assessing the patient’s cardiac rhythm. This rhythm assessment by an AED takes in the region of 5–15 seconds.

(64) Ms [E] confirms that IV lines can be inserted while CPR is being performed, but Ms [E] prioritised ensuring that [Master B] received adequate CPR and ventilation: High-performance CPR takes precedence over advanced skills (such as inserting IV lines), particularly when there are limited resources, such as the [private ambulance service] had on the day of the event (a nurse, a first responder’s first full resuscitation event and a paramedic). For example, when other emergency services provide a Code Purple response (such as for cardiac arrest) they usually respond with at least seven skilled resources: 1x ambulance (either two emergency medicine technicians, or an emergency medicine technician and paramedic), one Fire Emergency New Zealand fire truck (four crew members), one intensive care paramedic vehicle (sometimes two crew in vehicle), and sometimes a second ambulance also responds.

In the scenario of treating for cardiac arrest, established practice is that once high-performance CPR is under way:

—    one person manages the airway and ventilation

—    one person (a paramedic or higher clinical qualification) cannulates and administers drugs as appropriate; and

—    two or more people continue the chest compressions (rotating every two minutes)

Note: In the above scenario, AED defibrillation can be performed by either the paramedic or the clinician assisting with CPR.

In the scenario where there is more than one clinician on scene, expected practice is that if the paramedic is the only clinician on scene able to secure the airway with an LMA, then this is performed prior to IV cannulation and the administration of drugs (adrenaline and amiodarone).

The additional resources listed are dispatched by the ambulance service after the 111 call and provide additional clinical skills (such as drug-assisted airway management).

(65) Mr Bailey also notes that the first recorded heartbeat was by [emergency call centre] paramedics shortly after they arrived at 10.06am but it ceased almost immediately. This statement is incorrect because [RN D] and Ms [E] located [Master B’s] pulse prior to [emergency call centre staff] arrival.

The [emergency call centre] patient report form notes the first recorded heartbeat at 10.06 a.m. The [private ambulance service] clinical record does not document a heartbeat (noting that subsequent statements report that a heartbeat was detected but do not state the rate).

(71.3) The [private ambulance service] confirm that they removed the mask when they placed [Master B] on the stretcher to carry out the rapid extrication to outside (including easily moving gear) and commence CPR. If [Ms A] saw [Master B] without a mask, then she may be recalling seeing him on the stretcher.

In the scenario of moving a hypoxic patient urgently, and where a team member is able to carry the oxygen bottle, it is expected practice to leave the oxygen mask on the patient.

It would be accepted practice to remove the mask from a non-breathing patient in the scenario where the oxygen bottle interfered with moving the patient.

In the scenario where the patient is known to be in cardiac arrest, it is accepted practice not to provide chest compressions during the move by stretcher, only if it were not physically possible to provide chest compressions — such as if needing to transition through a very small space.

It would be a significant departure from expected practice not to provide chest compressions if it is possible to do so while moving the patient on a stretcher.

(72) Mr Bailey also notes that if the [private ambulance service] had placed a non-rebreather mask on [Master B] with oxygen flowing at a rate of 10 litres per minute, then he would have been inhaling close to 100%. The [private ambulance service] note that the reservoir bag on the mask was full. Ordinarily, the [private ambulance service] would check for misting on the mask to confirm that the patient was breathing, but this was not possible in the dim/blue/flashing lighting.

Expected practice is to visualise the patient’s chest moving as the patient breathes and to count the cyclic movements for one minute.

It is accepted practice that in rushed circumstances, counting breaths by visualising the patient’s chest movement for 30 seconds and multiplying by a factor of two will provide a reasonable guide. Note: some paramedics will watch the chest movement for 15 seconds and multiply by four; however, this risks inaccurate assessments.

The reservoir bag on the mask will be full if the patient is not breathing. It will also be full if the patient is breathing with a tidal volume that is less than that of the oxygen flowing into the reservoir bag (which might result from a high oxygen flow rate or an inadequate tidal volume by the patient).

It would be a departure from accepted practice to rely on observing condensation forming on the inside of a mask. Such condensation often occurs as a patient exhales into the mask, but this is a function of air temperature, humidity and mask temperature. However, the inflowing oxygen actively displaces exhaled air via valves on each side of the mask, and condensation does not always form.

(75) The [private ambulance service] agree with these statements and note their practice is to change the CPR performer every two minutes (where possible) to ensure that the patient receives the best CPR.

Expected practice is to change the person performing chest compressions every two minutes (or less if the person is tiring or not performing high-quality chest compressions).

(79) Mr Bailey also does not speculate as to what drugs the [private ambulance service] should have inserted or when he says that Ms [E] should have done so. However, as already noted, there was insufficient time to do this as her priority was ensuring CPR commenced as soon as possible and best utilizing the team’s skillset.

Expected practice for drug administration to an adult patient ([Master B] is considered to be an adult in terms of drug dosages) in cardiac arrest is adrenaline one milligram every four minutes and amiodarone 300 milligrams, after the first dose of adrenaline, if the rhythm is shockable.

…[81]

Bag/valve/mask ventilation with an unsecured airway risks air being mis-directed into the stomach. This can cause regurgitation or vomiting which may, in turn, compromise the airway and be aspirated into the lungs and impair oxygenation.

(82) It is unclear when Mr Bailey says that the [private ambulance service] should have inserted the laryngeal mask given all of the circumstances at play.

Expected practice for emergency ambulance personnel is to insert an LMA immediately after the first defibrillation.

(86) The [private ambulance service] agrees that others could have phoned for an ambulance. However, the purpose of the call was not simply to telephone 111: Rather it was to ensure the fastest dispatch (as noted above she aimed to dispense with the ProQA) and commence a handover to [the emergency call centre] and seek additional medical advice. Ms [E] passed the phone to [Miss C], who placed it next to the defibrillator. This criticism is unfounded.

In the scenario where the patient remains in cardiac arrest and all expected treatments have not yet been performed, established practice would be that ambulance personnel treat a patient who is in cardiac arrest and provide any responding personnel a handover when they arrive on scene.

[2.] Clinical Procedures and Guidelines 2019–2022

Statement from [RN D], dated June 2022.

(10) When I arrived at the scene, I found that [Master B] had been put into the recovery position by a member of the public. He was breathing, but his breaths were laboured. His face was pale bluish in colour, which on reflection could have been attributed to the lighting effects in the venue. He was not responsive to voice. I unpacked the resuscitation kit and connected the non-rebreather oxygen mask to the tank and placed the mask on [Master B]. I asked the other people [Master B] was with whether he had any history of seizures, but they did not know.

Expected practice for a patient that is unconscious, gasping and blue in the face would be to first conclusively rule out cardiac arrest.

Accepted practice in the scenario where this cannot be done in situ would be that the patient be urgently moved (dragged if necessary) to a location where these checks can be adequately performed.

It is expected practice that when a patient is breathing and has a pulse and has a face that was pale bluish in colour, the ambulance personnel administer high-flow oxygen.

It is expected practice when assessing a patient’s breathing, that if the patient has a blue tinge to the skin, the ambulance personnel conducting the assessment note if the blueness is peripheral (most evident in the fingertips) or central (most evident in the lips).

(12) I attempted to take a blood glucose reading but was not able to complete this. I wanted to check this because hypo- and hyperglycaemia can cause collapse and seizures. As I say, at this point, the information we had was that [Master B] had collapsed and had a seizure.

In the scenario of an unconscious patient, expected practice would be to obtain a blood glucose level during the secondary survey. This is to ensure that the ambulance personnel are not distracted during the primary survey by tasks that would compromise a resuscitation (if resuscitation is needed).

Expected practice, if the blood glucose test is unsuccessful, is to redo the test with a fresh lancet and a fresh test strip.

Identifying the portion of the blood glucose test that failed can help narrow down the problem. For example, patients with poor blood flow to the peripheries are difficult to obtain a blood sample from. A fresh lancet, firmly applied — after first “milking” blood towards the end of the finger, can resolve this issue. Lack of blood to the peripheries is common when people are cold or have low blood flow states such as heart failure or cardiac arrest.

(13) [Ms E] arrived with the stretcher, she left [Master B’s] side as his mother arrived on scene. I requested [Miss C] to get [Ms E] as I needed support, I was already in the process of moving him to the stretcher when I noticed that he had stopped breathing. [Ms E] came back moments before he had stopped breathing. The decision was made by [Ms E] to get [Master B] onto the stretcher and outside into the service lane. There we commenced CPR and using the AED described in my initial report.

In the scenario of moving a patient urgently, it would be expected practice to place the stretcher as close to the patient as possible and to use four or more people to move the patient. This helps prevent injuries to the ambulance personnel and the patient. It also contributes to maintaining patient dignity (if time and circumstance allow; however, in an emergency this aspect is not prioritised).

(16) Mr Bailey is critical of the interventions I provided between arriving at [Master B’s] side and when CPR started. I have explained above that oxygen and assessment in relation to his collapse and seizure were my initial priorities. In terms of primary survey, I have explained that I assessed breathing and provided oxygen. In terms of level of consciousness, [Master B] was not responsive to voice or pain (when I applied the mask and attempted the BGL: test, for example). I have explained [Master B] was pale bluish in colour. I did not take his pulse at this point, but I did that once we had shifted him outside. The priority once we moved [Master B] outside was to commence CPR, and this is what occurred. As to oxygen saturation, I did not have the pulse oximeter with me, but I could see this was low based on colour. I did not check temperature, but [Master B] was not hot or cold to touch.

Expected practice when presented with a patient that is unconscious, gasping and blue, and with a history of witnessed collapse and short seizure would be to immediately check that the patient is not in cardiac arrest. This is achieved by assessing the airway, the breathing and the presence of a pulse.

It would be a significant departure from expected practice if the pulse of an unconscious, blue and gasping patient was not checked at this point.

(17) In terms of Mr Bailey’s comments about agonal breathing and life-sustaining breathing, the presenting complaint and provisional diagnosis was seizure, which often causes people to become cyanosed and have difficulty breathing. We did not consider these at this point. The report given to us was that he also hit his head, which could have indicated a potential head injury, which could also explain his laboured breathing.

Expected practice when evaluating the presenting history would be to remain open to all possible causes. Where possible, the potential causes should be ruled out in order of severity.

It would be a significant departure from expected practice to not assess for a life-threatening condition that fit the presentation (collapse, short seizure, unconsciousness, gasping, blue).

…[82]

Statement from [Miss C], dated 23 May 2023

…[83]

5) This was my first cardiac arrest and the most serious patient I have helped treat. I did what I could to help the more senior team members, including asking [Master B]'s friend about what happened while [RN D] was treating the patient. I contacted [Ms E], the most senior team member at the event to get her assistance with the patient. After we had gotten the patient on the stretcher and taken him outside, it was noticed that he had no pulse, so I took out the AED and put on the pads, while another [private ambulance service] member started CPR. I relayed instructions that the AED gave when a shock was advised and CPR needed to stop so no one was touching the patient when the patient was shocked. I assisted with writing up a PRF to give to [emergency call centre staff] when they arrived. There were some things I could not do due to my ATP level such as IVs or putting in an LMA. I was willing to assist with CPR, but some bystanders stepped in to help with compressions.

It would be accepted practice for ambulance personnel to document assessments and interventions that they performed and for the documentation to be checked by the senior clinician involved.

It would be accepted practice that ambulance personnel document a colleague’s assessments and interventions and have that colleague check the documentation.’

[1] Registration of paramedics with the Paramedic Council of New Zealand commenced in March 2021, meaning that no paramedics were registered at the time of these events. Since registration commenced, only those currently registered are permitted to use the title ‘paramedic’. Mr Bailey was registered with the Paramedic Council of New Zealand at the time of providing his initial advice, and at the time of providing his follow-up advice, he continued to work in the ambulance sector but was no longer registered. As Mr Bailey was no longer registered at the time of writing this report, he is referred to as a ‘former’ paramedic.

[2] Low oxygen levels in body tissue.

[3] These features were a witnessed cardiac arrest, the presence of medical staff, and immediate access to a defibrillator.

[4] The private ambulance service said that its base was located within the event venue, approximately 20 to 30 metres from the hall where Master B collapsed.

[5] Cardiopulmonary resuscitation — chest compressions and assisted breathing to help blood and oxygen flow after someone has stopped breathing or their heart has stopped beating.

[6] Under the private ambulance service scopes of practice, Miss C was a ‘first responder’ as she had undertaken a ‘Pre-Hospital Emergency Care’ first aid course. The authority to practise for a first responder can include providing supplemental oxygen, operating an automated external defibrillator (AED), airway management, vital sign recording, pulse oximetry, use of bag valve masks, and blood glucose level testing.

[7] At the time of the events, RN D had been a team member for the private ambulance service for 12 years, Miss C for 5 years, and Ms E for 3 years.

[8] Prior to completing these forms, the private ambulance service staff held a ‘hot debrief’ that same day while on site, and individual debriefs took place the next day over the phone. An in-person debrief could not take place until 4 November 2020, which is when the incident forms were completed.

[9] The resuscitation kit contained an oxygen tank, bag valve mask, airways, IV rolls, medications, manual suction, vital sign equipment, and trauma gear.

[10] An AED is an automated device used to monitor a heart rhythm and deliver an electric shock to the heart when an abnormal rhythm is detected.

[11] The national emergency response number.

[12] A rapid assessment performed by first responders to check for immediate threats to life. A primary survey includes checking the airway, breathing, circulation (including a pulse check), disability, and environmental factors. Although there is an order to the factors, immediate threats to life should be treated first. A primary survey takes approximately 30 to 60 seconds to complete.

[13] A mask connected to an oxygen tank that provides high-flow oxygen to a patient.

[14] A device that clips onto the finger to check oxygen levels and heart rate.

[15] GCS measures level of consciousness and is scored from 3 to 15, with 3 meaning that the patient is unresponsive.

[16] The secondary survey is a more extensive examination of the patient, which is performed if no significant issues are noted in the primary survey and includes taking vital signs. Usually, a secondary survey takes a few minutes to perform.

[17] The event venue had security cameras outside the hall. The original CCTV footage was deleted after eight weeks, as per the facility’s usual practice, and therefore HDC was unable to obtain this. However, the venue provided Ms A with a copy of the footage, as the private ambulance service had requested the footage prior to it being deleted. Ms A provided HDC with the CCTV footage she received.

[18] The CCTV recordings provided by Ms A were not timestamped and ran at a faster speed, meaning that although they could be used to show what was happening, they could not be used to provide the exact time of an event occurring. Each file showed the date and time at which the clip started, meaning that rough estimates of when certain events occurred could be calculated based on how long the clip ran for, and the starting time of the next clip.

[19] A medical device used to keep an airway open.

[20] A handheld device with a mask connected to a handheld pump. The pump is used to assist patients who are not breathing by pumping oxygen into their airway.

[21] The pulse felt in the neck, under the jaw.

[22] The pulse felt in the wrist.

[23] The return of a sustained heart rhythm.

[24] Placement of a tube inside a vein so that medication can be administered.

[25] Recorded as 90 beats per minute. The normal heart rate is between 60 and 100 beats per minute.

[26] The provision of care and support to optimise the quality of life and reduce the suffering of individuals facing life-threatening conditions.

[27] Brain damage caused by oxygen deprivation.

[28] Inflammation of the heart muscle.

[29] I note that it is the role of the Coroner to determine how and why a death happened, and the Coroner did not take jurisdiction over Master B’s death.

[30] https://www.standards.govt.nz/shop/nzs-8134-02008

[31] Agonal breathing is gasping breaths that usually are audible and visible and are not life-sustaining.

[32] Right 4(1) of the Code states: ‘Every consumer has the right to have services provided with reasonable care and skill.’

[33] A device that helps to hold the airway open.

[34] Into which the roller door fitted.

[35] Right 4(2) of the Code states: ‘Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.’

[36] The course content covers adult and child collapse, use of AED and manual defibrillation, airway management, initial approach to trauma and different scenarios involving collapse and medical emergencies.

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[71] Kenshi Murasaka et al. Seizure-like activity at the onset of emergency medical service-witnessed out-of-hospital cardiac arrest: An observational study. Resusc Plus. 2021;8:100168. doi: 10.1016/j.resplu.2021.100168

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