A new report by the healthcare safety watchdog, Health Services Safety Investigations Body (HSSIB), has highlighted the risks to patient safety from lack of ambulance crew paramedic competence in using and interpreting ECGs. HSSIB’s investigation report, 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence, found gaps and inconsistencies in the academic, practical and continuing education and training that paramedics receive in using and interpreting electrocardiograms (ECGs) that is necessary for them to provide safe care for patients with signs and symptoms of acute coronary disorders, such as myocardial infarction or 'heart attack'. HSSIB warned that the resulting lack of confidence and competence amongst ambulance paramedics in using ECGs is putting patients’ safety at risk. Meanwhile, there is an increasing expectation on ambulance paramedics to provide the patients they attend with specialist emergency cardiac care. How are patients harmed by ambulance paramedic ECG errors? HSSIB’s report highlights the severe harm that can be caused by paramedic mistakes involving ECGs and related decision-making through a number of cases in which ambulance crews were called to attend patients with life-threatening cardiac symptoms. In one case, HSSIB received a coroner’s prevention of future deaths (PFD) report after an ambulance crew attended a 29-year-old woman, who was vomiting, with chest and arm pain. The crew noted her blood pressure, pulse, respiratory rate and other ‘observations’ as ‘normal’. They carried out an ECG which, as signalled by the machine’s auto-diagnostic function, indicated that she was suffering from an anterior infarct (a heart attack caused by a blocked artery restricting the blood supply to her heart). However, the crew (a paramedic and an emergency medical technician (EMT), both with over 8 years’ experience), misinterpreted the ECG as normal. Having been told that her ECG was normal, the patient declined to attend hospital. A second ambulance crew was called out to attend her later the same day and found her suffering from cardiac arrest. They were unable to save her life. The ambulance trust’s incident report noted that the crew had felt reassured about her condition owing to her age and because she appeared well. They had also assumed that some of her symptoms related to another medical issue. The coroner’s PFD report raised concerns about the higher education training of paramedics, noting that interpretation of an ECG was a ‘fundamental part of the job of a paramedic’. The coroner noted that there was ‘no evidence at inquest of any qualitative assessment of the ECG aspect of [the paramedic’s] training’, and that ‘presented a risk to patient safety’. In addition, the coroner noted that the paramedic and the EMT had not received any further training from their employer following the patient’s death. Another case involved the death of an 85-year-old woman from myocardial infarction (heart attack) soon after an ambulance paramedic and EMT disregarded the abnormalities on her ECG. Despite her history of nausea and vomiting, the paramedic crew did not consider the ECG to be a true representation of her symptoms, as she had no chest pain at the time they assessed her and was moving around the house. The ambulance trust’s own investigation found that the patient had been unable to make an informed decision about going to hospital or receiving further care because she had not been informed of the ECG abnormalities and the associated risks. In addition, the trust found that the crew had not acted in accordance with guidance which advised that whilst women usually suffer from chest pain when experiencing a myocardial infarction, chest pain will not always be evident. The ambulance paramedics felt their ECG training from the trust had been limited, focussing mainly on obvious heart rhythms and rates. What is an electrocardiogram (ECG)? An electrocardiogram or ECG is a commonly-used test for heart disorders which measures and records on a trace the electrical activity (such as the rate and rhythm) of a patient’s heartbeat. During a 12-lead ECG, electrodes are placed onto specific areas of the patient’s body to record 12 different views of the heart’s electrical activity. Accurate placement of the leads and correct interpretation of the ECG trace are essential skills for paramedics, but some ECG machines also have an auto-interpretation or auto-diagnostics function to help clinicians interpret the ECG’s results. Ambulance crew and paramedics’ use of ECGs HSSIB found that ECG interpretation is seen as a ‘top five critical skill’ for paramedic staff. Newly qualified and experienced paramedics told HSSIB that they were typically required to carry out an ECG on every working shift. Guidance by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) identifies multiple indications for ECG use in clinical care, with an emphasis on the importance of early and accurate ECG interpretation. Paramedics must be registered with the Health and Care Professions Council (HCPC), which usually involves completing a bachelor’s degree with honours in paramedic science. Following qualification, all newly qualified paramedics undergo a two-year preceptorship programme within the ambulance service, to integrate them into the ambulance service and give them time to apply their academic knowledge, skills and placement experience consistently to develop confident practice. HSSIB found that since the 1970s, the paramedic role has changed from ‘being a patient transport service to an increasingly professionalised and medicalised practice’. The College of Paramedics states that paramedics work autonomously as generalist clinicians across a range of healthcare settings. These can include complex and high-pressure situations in unfamiliar and unpredictable environments. In 2024, a report by the Association of Ambulance Chief Executives (AACE), in collaboration with NHS Providers and NHS Confederation, acknowledged that ambulance services can play a leading and co-ordinating role in urgent and emergency care, because they ‘already have highly skilled, increasingly multi-professional workforces, with a range of skill sets able to triage and operate autonomously in all environments’. The College of Paramedics’ (CoP) latest curriculum requires paramedics to have the skills to interpret and report 12-lead ECGs; correctly place the ECG leads relating to the different regions of the heart; recognise and interpret ECG changes that indicate cardiac and other non-cardiac medical conditions; and evaluate the significance of the ECG findings in the broader context of the patient’s diagnostic assessment. This means that paramedics must consider the patient’s ECG results alongside their signs, symptoms and medical history when deciding on the most appropriate action to take. HSSIB was told that despite the ‘generalist’ nature of the paramedic post, the specialist knowledge that paramedics are expected to have seems to be increasing. In the context of ECGs, this means that paramedics are expected to interpret more complex or nuanced heart rhythms and clinical presentations than the ‘obvious’ heart rhythms which are taught as part of their training. HSSIB found that paramedics faced challenges with carrying out ECGs, such as where patients have complex health conditions or comorbidities, or where the patient’s weight and body shape, disability, skin condition (clammy, hairy or fragile), religious beliefs, or inability to lie still in the correct position (such as from severe pain) made it difficult to place the leads correctly. The presence of electronic devices or other factors in the patient’s home or environment can affect the operation of the ECG machine. In addition, ECG results may differ depending on other factors including the patient’s age, gender and race. Paramedics need time and experience to develop their skills in ECG interpretation as well as the knowledge of what a ‘normal’ ECG reading looks like. HSSIB’s findings HSSIB found that paramedics’ education in ECGs was ‘hugely variable’ with a lack of consistency between different higher education institutions. Student and newly qualified paramedics often received very limited undergraduate teaching about ECGs, as well as limited exposure during their practical or placement training to patients with more complex presentations. Whilst a high level of competency was expected of student paramedics by the time they reached an ambulance service, HSSIB found that this was not realistically achievable given their current training and opportunities to practise. HSSIB found that in relation to assessment, there was no requirement setting out whether, how, or to what level of competency higher education institutions should assess students’ ECG set-up and interpretation skills. Whilst the College of Paramedics told HSSIB that in its view the minimum pass mark for any module assessing ECGs should be 70%, most higher education institutions only required a 40% pass mark at undergraduate degree level for paramedic science and ECG assessment modules, and students who failed these assessments were given multiple attempts to pass the assessment. Unsurprisingly, most of the paramedics who were interviewed told HSSIB that they lacked confidence in ECG interpretation. Medical negligence claims involving paramedics and ECGs Ambulance crew and paramedic negligence in the use and interpretation of ECGs can have life-threatening or life-changing consequences for the patient and their family. Medical negligence claims often arise from severe or fatal injuries caused by the failure to carry out or act on an ECG, or its misinterpretation. HSSIB’s investigation report, 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence, shines an invaluable light on the systemic failures in education, training and ongoing support which may contribute to these mistakes, and the increasingly complex environment which surrounds them. Given the clear, ongoing implications for patient safety, we welcome HSSIB’s call for improvements in ECG training and competence assessments for students and working paramedics. We await HSSIB’s related report into the role of paramedics in the diagnosis of patients with STEMI (ST elevation myocardial infarction, a type of heart attack), which is due to be published later this year. If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.
