This is a fictional dilemma compiled from the MDU's files.
The scene
A junior doctor contacted the MDU after being told that because of capacity issues, she and her colleagues might be asked to assess patients waiting outside the emergency department in the back of queuing ambulances.
She was understandably cautious about this and asked if it might invalidate her indemnity cover.
The background
The scenario of patients queued outside UK emergency departments is not a new problem. In March 2022, the Royal College of Emergency Medicine and the College of Paramedics issued updated guidance on the topic.
This phenomenon is well recognised, along with the impact it has on the patients waiting in the ambulances, the unwell patients left in the community with no available ambulances, the ambulance crews, and the hospital staff.
The CQC, NHSE and HSSIB are some of the organisations that have published on this topic.
Our advice
Indemnity
The primary concern in our case study related to indemnity, so we'll begin with this aspect.
As an NHS hospital doctor in England, you would usually be indemnified against clinical negligence claims by the clinical negligence scheme for trusts (CNST). Similarly, hospital doctors in Wales, Scotland and Northern Ireland are protected by their own respective schemes.
Locums working for NHS or HSC trusts (NI) will normally be indemnified by the NHS or, in Northern Ireland, the Department of Health Social Services & Public Safety (DHSSPS) indemnity schemes.
To be clear, state indemnity only applies to clinical negligence claims. As such, in the event of an adverse outcome that triggered other types of investigations, you would contact your MDO.
The MDU provides access to support with many other medico-legal issues arising from clinical practice that aren't included in NHS indemnity - such as an ombudsman's investigation, a complaint to the GMC or a professional disciplinary or criminal investigation, as well as help with media enquiries.
Because of this, if your employing trust expects doctors to go out to ambulances to assess or treat patients, you should fall under the umbrella of NHS indemnity in the normal way for any claims for negligence arising from that work. However, you may want to clarify this with your trust.
If you need to ask for our help with other issues arising from a patient encounter in the back of an ambulance, as a member you can be reassured that you can do so in the usual manner.
The difficulty for a doctor faced with these circumstances is that regardless of allocation of organisational responsibility, they could be asked to explain a decision to attend, assess and implement treatment in a less than ideal setting.
Where does the clinical responsibility lie?
Another common question relates to where the clinical responsibility actually lies for these patients, given they are between the NHS hospital trust and the ambulance service.
Essentially, this is a matter for the two organisations to agree upon, and ideally should be set out in agreed operational procedure documents.
If you're informed that your organisation will be asking you to assess patients outside of the hospital building, you may want to ask the clinical director whether an express agreement has been reached on this point.
While an organisational-level agreement can be helpful in providing a framework for how to deliver care in these difficult circumstances, individual clinicians are sometimes called upon to justify their decisions retrospectively.
The difficulty for a doctor faced with these circumstances is that regardless of allocation of organisational responsibility, they could be asked to explain a decision to attend, assess and implement treatment in a less than ideal setting.
However, the flip side is that they may equally be asked to explain a decision not to do so, even where hospital policy did not mandate it.
Whether there were missed opportunities and who is responsible for these will therefore depend on the nuances of each case, and for each individual clinician there is no ideal solution.
With this in mind, the following approach may help to mitigate the risks involved in seeing patients in these unusual circumstances.
Working to policies
- Make sure that the trust's management supports patients being seen in waiting ambulances, and have stated that this is an acceptable practice in the extreme circumstances you face.
- Check if there is an operational policy in place for this model of care, so you can do your best to work in a way that's consistent with it.
Communication
- Good communication is paramount in medicine, but it's even more important in extreme circumstances. Make sure that any patient you see understands why they are being seen in the ambulance and what the plan is. If they have to undergo any treatment, make sure they're fully informed about any additional uncertainties or risks that flow from this taking place in the vehicle rather than in the hospital itself.
- Communication with colleagues is also key. It is important that the ambulance crews and hospital staff are clear about how these patients are managed and how any urgent concerns can be escalated. As part of this clear communication, there also needs to be oversight of the patients so no-one falls through the gaps.
- Clinicians on these front lines have described how in these very stressful environments, even the most measured professionals start to fray at the edges. Tempers can flare and usually supportive, calm colleagues can act out of character towards their colleagues and patients. While it might be easier said than done, it will stand you in good stead to ensure that your behaviour reflects the expectations outlined in the GMC's 'Good medical practice' (2024).
![E-learning: Duty of candour in England]()
Confidentiality
- Delivering care in the back of an ambulance while surrounded by others does create challenges to maintaining patient confidentiality and dignity, especially when the doors might need to stay open to allow access for several health care professionals. Be mindful of the potential for the patient's confidentiality to be breached and how best to maintain their dignity during any interaction with you.
Records
- Keep thorough, contemporaneous records. These should include the fact that the patient was seen in the ambulance, and ideally why this was deemed the safest option in the circumstances.
Raising concerns and delegation
- If, after you have assessed the patient, part of your management plan is that treatment be administered in the vehicle by the ambulance crew, you'll need to consider if you are delegating appropriately. You can find the GMC's delegation guidance here but the key point is:
- 4. You must be confident that the colleague you delegate to has the necessary knowledge, skills, and training to carry out the task, or that they will be adequately supervised to ensure safe care.
- While none of the relevant concerns will likely come as a surprise to the organisations involved, doctors are still obliged to raise concerns about patient safety. Doing so may seem futile in the circumstances, but it will stand you in good stead to be able to demonstrate that you responded appropriately to risks you encountered in your patient-facing role - especially if managers might need to be told in order to help take steps to address these at an organisational level.
You can find the GMC's raising and acting on concerns guidance here.
Unfortunately, there is no straightforward solution to the enduring issue of delays in ambulance services handing over patients when emergency departments are full. The problem is complex and requires a multi-faceted approach to resolve it.
However, as an individual clinician there are still some steps you can make to mitigate the risk to both patients and yourself in the event of an adverse incident.
Dr Ellie Mein
Medico-legal adviser
Dr Ellie Mein
Medico-legal adviser
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
See more by Dr Ellie Mein