In this past week, many major news outlets have covered a story about a London Ambulance Service paramedic who refused to attend a 999 call on the grounds that he and his crewmate were dangerously tired after 11 hours overnight without a break.
Across the mainstream media, the tone of the headlines used invariably focused on the public perspective.
On 7 April 2015, The Guardian reported 'Paramedic refused to help sick woman as crew were tired, tribunal told'. As subsequent news outlets picked up on the story, the Evening Standard went with a more outrage-inducing 'London paramedic "refused to answer 999 call because he was about to finish shift"'. The Mirror chose 'Paramedic suspended after refusing to attend 999 call because he was '"tired"' and the Metro opted for 'Paramedic suspended for refusing to pick up patient because he hadn’t had a break on 11-hour shift'. ITV weighed in with 'Paramedic who refused to help sick woman because crew were 'too tired' is suspended' and even the Belfast Telegraph got involved with 'Paramedic suspended for 12 months over 999 call snub'.
It has most likely been covered elsewhere too, but I think the theme - and the bias - is clear.
The facts which were cherry-picked from the publicly available Health and Care Professions Council (HCPC) hearing documentation are mostly consistent throughout the coverage. Due to his actions on 29th May 2013, Edmund Daly, a paramedic and team leader of 30 years service, was found to have 'seriously undermine[d] public confidence in the profession' by refusing to attend a call to a 43-year-old woman who was 'feeling faint, dizzy and vomiting'.
The HCPC panel chairman, Julian Weinberg, is quoted as saying, 'As a paramedic and as a team leader, he failed to make service users his main concern. (Daly) has also not demonstrated any remorse for his actions and such misconduct seriously undermines public confidence in the profession. However, the panel has taken into account that this was an isolated incident in the registrant's 30-year unblemished history of service as a paramedic and that it occurred after an 11-hour shift without a rest break.'
According to the London Ambulance Service, Edmund Daly's contract had already been terminated following an internal investigation of the matter and the HCPC notes state that he was no longer working as a paramedic. The final outcome of the HCPC hearing was a 12-month Suspension Order. A Striking Off order was considered but thought disproportionate given Daly's 'otherwise unblemished 30-year career'.
Treating the Symptom, Not the Cause
I know I am not alone in thinking that the broader concern has been entirely missed here, hence the provocative choice of headline for this article.
Although we are not privy to the underlying history of this particular case or Edmund Daly's general working practises, it is safe to assume from repeated reference to his 'unblemished record' that he had conducted himself in an appropriately professional manner for the past 30 years. So what drove this veteran to engage in the kind of brinkmanship which was likely to have a poor outcome for him?
I think it's important to recognise that Daly’s actions gave his employers, control room staff and the HCPC little choice but to act in the manner they did, but a man of Edmund Daly's experience would have known this. Yet still he drew his line in the sand and said 'no more'. Whether it was a calculated decision or just the poor judgement of an exhausted mind is a matter of speculation.
Like many current ambulance crews, I empathise with Mr Daly, having many times in the past been exhausted and emotional myself after yet another gruelling, endless shift. I know from first-hand experience how hard it is to think clearly through that haze of fatigue. I am still haunted by attendances gone awry due to fatigue-induced oversights and mistakes, near misses and lapses in professionalism both on the road and when dealing with patients or co-workers. The system forgets paramedics are still only human and it has no regard for the kind of pressure under which the current, brutally under-resourced emergency clinicians are expected to perform flawlessly.
Not one of the previously mentioned articles nor the HCPC panel addressed the implications of the fact that '[a]s a result of the Registrant’s refusal to attend the call, there was a delay of approximately 90 minutes before another crew was able to attend the service user.'
Surely this highlights a much bigger cause for concern than the actions of one clinician. Why such a dearth of ambulances? Was there really not a single other vehicle available for 90 minutes? Or perhaps the call wasn't deemed to be that much of a priority after all. In either case, resources were clearly stretched too thin to provide adequate cover given that the sudden unavailability of a single ambulance caused such an apparent failure. The existing system has no overlap, no redundancy, no buffer. The few ambulance crews available are endlessly bounced from attendance to attendance until they can take no more.
Compounding this is the cultural disregard for crew welfare best exemplified by ITV’s quote, purportedly from the controller called as a witness in Edmund Daly's final hearing, which shows that providing any respite for exhausted staff is given little value,
‘The crews all know getting off on time is a bonus. If it happens it happens, and if an emergency call comes in it's a late shift. It is not a guaranteed nine to five job.’
While it is accepted by all staff that responding to emergencies is the absolute priority, the comment is a bitter pill to swallow coming from a staff member whose role should also include protecting road crews. Considering that this is in the context of a crew who have already worked continuously overnight for longer than most people’s entire working days, the statement is a damning indictment of the emergency service culture and the prevailing attitude to road staff if ever there was one.
However, it’s not the fault of control room staff either. They too are under enormous pressure to perform in the ‘room of doom’. They cannot afford to see staff on the road as anything more than a vital mobile resource. If only dispatchers were provided adequate resources to distribute the calls in a manner that didn't dangerously overwork the few responding crews to hand, there would be far less acrimony and far more efficiency.
Bleeding Out?
But if the problem does not lie with operational staff, then where? Was anyone else’s competence called into question for the circumstances which drove an exasperated paramedic to willingly commit career suicide? Of course not, it's just business as usual. Targets to meet, et cetera, et cetera. Little wonder that sickness, recruitment and staff retention is such a huge problem for ambulance trusts. Edmund Daly, like every other emergency clinician, was expected to make up for the shortcomings of a collapsing, inadequate system being throttled by underfunding and misuse.
How many more staff need to physically or psychologically crumble before the problem is addressed? It is clearly a nationwide problem, with the Manchester Evening News reporting ‘Paramedics in Greater Manchester at breaking point due to stress, says union’. The article details the findings of a staff survey revealing ‘[m]ore than 90pc of the 153 staff surveyed reported suffering with stress with huge numbers of staff reportedly leaving the North West Ambulance Service.’ This summary of UNISON's national survey indicates the true scale of the problem.
Evidently, if more effort is not made to protect ambulance staff by providing them with tolerable working conditions, they can’t be expected to maintain the level of excellence demanded of them or even stay in their jobs.
There is some hope, at least. Parts of the establishment are aware of the problem and there is evidence that efforts are being made to address it. East of England Ambulance Service recently published a document focused on improving working conditions which identifies the need to tackle the problem. In it, the joint working group of EEAS managers and UNISON members identified key stressors impacting staff performance.
‘The group recognised that the existing policy around late finishes was not working. As new frontline staff continue to be recruited it will help ease the pressure on staff and reduce late finishes. There was joint agreement that implementing supportive changes over the issues identified will help retention, reduce sickness levels and make EEAST a more supportive, sustainable organisation.’ ~EEAS Trust update: improving working conditions
This is clearly a positive step and EEAS should be commended for attempting to stem the flow. But, as has long been the case, it will likely remain a well-intentioned dream until more deep-seated cultural changes - both within ambulance services nationwide and more broadly in government and the general public - take place.
Meanwhile, if the case of Edmund Daly is anything to go by, existing and future staff will continue to be wrung out, abused and discarded as organisational failings and public demand continue to brutally sacrifice the health and careers of those willing to prop it up until they can't - or won't - any more.
Edmund Daly, like every clinician and operative working to provide emergency care to the public, deserves better.
Addendum: In response to Edmund Daly's case, an iPetition has been set up.
Image credit: Daniel Sundahl, DansunPhotos.com via EMSworld
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