Paramedic Incident Responsibility Flowchart

● Mandatory

Legal duty — no consent required, cannot be waived Preserve life where the patient lacks capacity and there is immediate risk of death or serious harm (MCA s5 best interests). Protect children and vulnerable adults from significant harm (Children Act s47, Care Act 2014) — consent not required and sometimes must not be sought. Respond to a 999 dispatch as directed (contractual / employer duty). These obligations exist regardless of patient wishes or any other factor. Failure here = potential criminal liability, inquest finding, or fitness-to-practise referral.

● Prof. Expectation

HCPC / employer standard — expected but conditional on consent Complete a PRF, conduct a capacity assessment, offer referral pathways, provide safety netting, follow JRCALC guidance, escalate to EOC when uncertain. These are professional and employer obligations that a capacitous patient cannot entirely override — but they describe how you practise, not whether you can compel action. If a patient refuses a referral you offered and documented, you have met the standard. Failure here = complaints, disciplinary proceedings, or fitness-to-practise risk — not usually criminal.

● Discretionary

Best practice — requires consent from a capacitous adult GP referral, Early Help, community team signposting, social care referral, follow-up arrangements, sharing information with third parties. All good clinical practice. None of it can be done without patient consent (or a lawful basis under GDPR) if the patient is a capacitous adult. You can offer, explain the benefit, and document the refusal — but you cannot proceed without agreement. Doing this without consent = potential data protection breach, even if clinically well-intentioned.

⚠

The grey zone Most prehospital decisions sit between professional expectation and discretionary. Capacity is often partial or uncertain. Risk is rarely clear-cut. The law uses words like "reasonable" and "appropriate" deliberately — because it cannot anticipate every scenario. Your protection in the grey is: structured assessment, documented reasoning, escalation when unsure, and a PRF that shows you thought it through.

Initiation

Person rings 999

Call handled by NWAS Emergency Operations Centre. Triaged via AMPDS. Category assigned (C1–C4 or hear & treat).

Dispatch

Ambulance deployed

At this point: Contractual obligation to employer begins. No direct legal duty of care to patient yet — you are not yet in a patient-clinician relationship. However, you must respond as directed.

⚖ Duty of Care attaches — patient contact

Once you make contact with a patient, a legal duty of care crystallises under the common law Donoghue v Stevenson neighbour principle and is reinforced by HPC/HCPC registration standards. You are now bound to act with reasonable skill and care. Abandonment without handoff or adequate safety netting from this point may constitute negligence or a fitness-to-practise matter.

Clinical Assessment

Attend patient — primary & secondary survey

Determine: capacity (MCA 2005), clinical condition, acuity, social context. Establish whether patient can consent, refuse, or lacks capacity.

Decision Point

Determine pathway & patient wishes

Consider: acuity · consent / refusal · capacity · risk to self or others · available alternatives to conveyance · safeguarding triggers

— Outcome pathways —

● Prof. Expectation Convey

Transport required — choose destination & method

Patient consents, clinically requires further assessment or intervention
Multiple destination and transport options available — expand below

Responsibility: match patient need to most appropriate destination. Not all conveyances go to ED. Document rationale for chosen pathway.

● Prof. Expectation Discharge on scene

Treat & leave — patient has capacity & declines conveyance

Minor injury / illness, low acuity
Mental health — mild, no immediate risk, appropriate safety net
Falls — no injury, adequate support at home

Responsibility: capacity confirmed, safety netting given, JRCALC guidance followed. Robust documentation. Consider GP/111 referral. Signed refusal form where indicated.

● Prof. Expectation Refusal — Capacitous

Patient has capacity and refuses treatment or transport

Informed refusal — patient understands risks
Includes overdose, chest pain, serious injury
Patient not detainable under MHA s136

Responsibility: explore reasons, explain risks clearly, document capacity assessment, consider clinical supervisor / ED referral. Cannot physically compel. Escalate to NWAS EOC if concerned.

● Mandatory Capacity absent + Risk

No capacity — MCA best interests or MHA applies

Unconscious, severe intoxication, acute psychosis
Act in best interests under MCA s5
MHA s136 — remove to place of safety if risk to self/public
DNAR / ADRT — verify, document, respect

Responsibility: MCA two-stage test documented. Police liaison for s136. Least restrictive option always applied. Cannot use restraint beyond reasonable force in best interests.

● Mandatory Escalate

Situation beyond solo management — escalate

Overdose + refusal + high lethality (paracetamol, TCA)
Safeguarding concern — child or vulnerable adult
Domestic violence, scene safety
Clinical complexity requiring HEMS / specialist input

Responsibility: contact EOC, request senior clinician advice, involve police/social care as appropriate. Document all escalation attempts and outcomes.

● Discretionary Refer / Signpost

Refer to alternate pathway without conveyance

Mental health crisis — street triage, CRHTT
GP urgent same-day
Frailty / falls — community response team
Hear & treat — 111 clinical referral

Responsibility: pathway is confirmed before leaving scene. Patient or carer understands next steps. Referral is documented and handed off, not assumed.

Conveyance Options Select most appropriate for patient need — not always ED

Blue light / ED

Emergency Department

Immediate life threat, time-critical presentation, no alternative pathway available or appropriate.

Specialist sub-routes: PPCI centre (STEMI), Major Trauma Centre, Hyper-Acute Stroke Unit (HASU), Paediatric ED

Call Before Convey

CBC — ANP / Consultant pre-alert

Phone ED/MAU ahead of arrival. ANP or consultant agrees to receive directly, bypassing triage queue. Patient pre-clerked on arrival.

Avoids unnecessary AnE wait. Requires clinical confidence in your assessment and a receptive receiving clinician.

Same Day Emergency

SDEC — Same Day Emergency Care

Ambulatory patient requiring investigation or review but not acute resus. Referred directly to SDEC unit — bypasses ED entirely.

Typical: abdo pain, DVT query, chest pain low-risk, AKI, cellulitis. Must meet SDEC criteria and unit must have capacity.

Urgent Care

UTC / MIU / Walk-in Centre

Minor injury or illness not requiring ED-level resource. Urgent Treatment Centre or Minor Injuries Unit.

Laceration, soft tissue injury, minor fracture query, UTI, minor burns. Often reduced wait vs ED.

Mental Health

Mental Health Place of Safety / Crisis

S136 MHA detention — dedicated place of safety (not ED unless clinical need). CRHTT referral. Street triage if available.

ED is last resort for MH presentations. Liaison psychiatry, crisis hub, or home treatment team preferred where risk allows.

Taxi in 5 — NWAS

Alternative Transport — Taxi Booking

Use when patient needs A&E or WIC but does not require an ambulance for the journey. All 5 criteria must be met:

Needs face-to-face assessment within 3hrs at A&E or WIC (not suitable for GP referral)
Clear of COVID-19 or other infectious disease symptoms
Able to travel without intervention, medication, or monitoring en route
Fit to sit, fully mobile
No friends or family available to drive them

📞 Book: 0151 432 5577 State your call sign and destination. Navigator books taxi within minutes. Also inform EOC. Contact: Jack Watson (Senior Paramedic Team Leader) [email protected]

Elective / Planned

GP / Outpatient / Planned Admission

Condition suitable for same-day or next-day GP assessment. Or direct admission arranged via GP to ward (e.g. community hospital, frailty ward).

Requires GP availability confirmation. Patient must be safe to wait. Appropriate safety netting essential.

↑ To add a pathway: duplicate any co-card block inside id="convey-grid" and change the content. Colour classes: co-red · co-amber · co-blue · co-teal · co-purple · co-yellow · co-green

All pathways

Documentation & completion of duty

PRF completed — contemporaneous, accurate, signed.
Clinical handover — verbal + written where applicable.
Safeguarding referrals — submitted before end of shift if triggered.
Duty of care ends on adequate handover to appropriate receiving clinician, or on safe discharge with appropriate safety netting.

Failure to document = failure to defend. If it isn't written, it didn't happen.