What makes a non-conveyance decision safe?
Many ambulance responses in the UK end without a trip to the emergency department. Some patients are treated and discharged on scene. Others are referred to their GP, an urgent treatment centre, a falls service, a mental health team or a community team. Done well, this keeps people at home and frees ambulances for the sickest patients.
It is also one of the highest-risk decisions a paramedic makes, often alone or with one colleague, without tests, with limited time and calls waiting. When a patient left at home deteriorates or dies, the decision will be examined by the ambulance service and the coroner, and sometimes the HCPC.
How should you assess a patient before deciding not to convey?
Under pressure it is tempting to assess only the presenting complaint. Many missed problems sit in the parts of the assessment that were skipped.
- Scene and context: Safety, the home environment, who is present, how the person is coping, medicines, mobility aids, and any signs of self-neglect or safeguarding concerns.
- Primary survey: A structured approach such as <C>ABCDE, treating life-threatening problems as you find them.
- Full observations: Respiratory rate, saturations, blood pressure, pulse, consciousness, temperature and blood glucose where relevant, with NEWS2 for adults where appropriate and a 12-lead ECG where indicated.
- History: Onset and course, past history, all medicines including anticoagulants, allergies, social situation and the person's own concerns. Talk to carers, who may notice changes first.
- Examination: Examine the relevant systems and look for anything that does not fit. After a fall, check head to toe and ask why the person fell.
- Repeat observations: Repeat them before deciding and before leaving, so you can see a trend.
- Working impression: Name your most likely diagnosis and the serious conditions you considered and why you think they are less likely.
An 84-year-old man is found on the floor by his carer. He says he slipped and is not hurt. Observations are normal except a pulse of 44. A paramedic focused only on injury might help him up and leave a falls referral. One who asks why he fell, records an ECG and reviews his medicines might find complete heart block or beta-blocker toxicity. A long lie also raises the risk of pressure damage, dehydration and muscle breakdown.
Even when the medical problem is minor, ask whether the person is safe at home. Can they get to the toilet? Do they have food, heating and someone to check on them? Do they understand the plan?
Which patients are high risk for non-conveyance?
These situations do not mean a patient must always be conveyed. They should lower your threshold for conveyance, prompt a discussion with a senior clinician, and call for especially careful safety-netting and records.
| Situation | Why it carries extra risk |
|---|---|
| Older people, especially with frailty or dementia | Sepsis, heart attack and fractures can present atypically; delirium can be mistaken for usual confusion |
| Head injury in someone taking anticoagulants | Higher risk of bleeding inside the skull, which may show itself later. NICE head injury guidance (NG232) and JRCALC treat anticoagulant use as an important risk factor |
| Infants and young children | Can deteriorate quickly; parental concern matters; always consider safeguarding |
| Abnormal or worsening observations | A raised NEWS2 or a worsening trend is a strong signal of risk |
| Repeat calls for the same problem | Suggests the earlier plan has not worked or the diagnosis was wrong |
| Intoxication, mental health crisis or learning disability | Physical causes may be missed and capacity may be affected |
| Chest, head, abdominal or back pain without a clear benign cause | Serious conditions can present subtly |
| People living alone or without support | Less able to call for help if they deteriorate |
Use your service's clinical support desk or senior clinician line, and direct pathways to GPs or community teams. Give a structured summary and say what you are unsure about. Record who you spoke to and what was agreed.
Can a patient refuse to go to hospital?
Yes, if they have capacity. An adult with capacity can refuse, even if you think the decision is unwise. But a refusal from someone who lacks capacity for that decision is not a valid refusal, and leaving them at home may expose them to serious harm.
- Presume capacity, but assess when in doubt: Under the Mental Capacity Act 2005, assess capacity for the specific decision when there are signs of confusion, head injury, hypoxia, low blood glucose, intoxication or severe pain.
- Explain the risks: Say what you think may be wrong, what could happen if they stay at home including the worst outcome, and what the alternatives are. Check understanding.
- Apply the functional test: Can they understand, retain, use or weigh the information, and communicate a decision? If not, is that because of an impairment or disturbance of the mind or brain?
- If they have capacity: Respect the decision, try to agree an alternative such as a GP visit, give clear safety-netting, involve family if they agree, and document carefully.
- If they lack capacity: Act in their best interests, consider their wishes and values, consult family or carers where you can, choose the least restrictive option and seek senior support. Involve the police only in line with your service's policy and the law.
Pt refused to travel. Capacity OK. Advised to call back if worse.
Pt declines conveyance. Explained in plain terms that his chest pain could be a heart attack, which could cause cardiac arrest and death without hospital tests, and that the ECG cannot rule this out. He repeated the risk back accurately and said he will not leave his wife, who has dementia, alone overnight; he weighed this against the risk and chose to stay. No confusion, hypoxia or hypoglycaemia. Has capacity for this decision. Discussed with clinical support. Plan: GP to call in the morning; call 999 at once if pain returns or worsens, or he becomes breathless, sweaty or faint. Daughter will stay overnight. Written advice left.
What should safety-netting and referral include?
Safety-netting matters even more pre-hospital because you will not see the patient again. They and the people around them need to know exactly what to watch for and what to do.
- What you think is wrong, and that you cannot be certain.
- The specific symptoms that mean call 999 straight away.
- Symptoms that mean contact the GP or NHS 111, and when.
- What follow-up has been arranged, by whom and when they will hear.
- Written information or a copy of the record where your service provides it.
- Confirmation that the patient and any carer understand, for example by asking them to repeat the key points.
'See your GP' puts the work on the patient. Where possible, make the referral yourself through an agreed pathway, confirm it has been accepted, and tell the patient who will contact them and when.
How should you document a non-conveyance decision?
Your patient care record is often the only evidence of what you found and why you decided as you did. A list of observations with no reasoning is very hard to defend.
| Element | What to record |
|---|---|
| Assessment | Timed observations including repeat sets, examination findings and important negatives |
| Working impression | Most likely diagnosis and the serious differentials considered |
| Decision and rationale | Why non-conveyance is appropriate, including the patient's wishes and the safety of the home |
| Capacity | The decision assessed, how the functional test was applied and the outcome |
| Discussion and referral | Who you spoke to, what was agreed and the referral made and accepted |
| Safety-netting | The specific advice, to whom, and confirmation of understanding |
What happens if a non-conveyance decision is investigated?
The service will usually carry out a learning review. If the HCPC becomes involved, it considers whether your fitness to practise is currently impaired: do you understand what went wrong, have you addressed it, and is there a risk of repetition? Reflection, targeted learning, mentored practice and audited records are all relevant. If you are under investigation, get advice from your trade union, professional body or legal representative before writing statements.
She was alert with a GCS of 15 and it was her right to refuse. I gave safety-netting. Head injuries are unpredictable and the service was under huge pressure that day.
I assessed an older woman who had hit her head but did not check her medicines, so I missed that she took an anticoagulant. That is a recognised risk factor for bleeding and should have led me to recommend conveyance for imaging. When she declined, I did not explain that risk or assess and record her capacity, so I cannot be sure her refusal was informed. I left her alone with vague advice. I now review medicines with every patient, call clinical support for any high-risk patient I consider leaving, record capacity in full and arrange for someone to check on people who live alone. My team leader has audited my non-conveyance records over four months.
The strong reflection names each gap (medicines, risk recognition, capacity, safety-netting), recognises the potential harm, avoids blaming workload, and shows specific changes checked by someone else.
Further learning
Our course Paramedic Practice: Assessment and Non-Conveyance Decisions covers structured assessment, high-risk groups, capacity and refusal, safety-netting and documentation, with a worked case and a remediation plan for anyone who has had a concern raised. It is educational and does not replace your service's training or policies. Related courses on maternity care and restrictive practice may help colleagues who work in those areas.
Frequently asked questions
Can paramedics leave you at home?
Yes. Paramedics can treat and discharge patients at home or refer them to other services when a full assessment shows it is safe and appropriate, following their ambulance service's policy and JRCALC guidance. They should give clear safety-netting advice and document their reasoning, and convey or seek senior advice when in doubt.
What if a patient refuses to go to hospital but lacks capacity?
A refusal from someone who lacks capacity for that decision is not a valid refusal. The paramedic must act in the person's best interests under the Mental Capacity Act 2005, consider their wishes, consult family where possible, choose the least restrictive option and seek senior support, following service policy.
Can a paramedic be referred to the HCPC for leaving a patient at home?
It can happen, usually where a serious outcome followed and the assessment, capacity assessment, safety-netting or documentation fell short. The HCPC looks at whether the paramedic has insight, has addressed the gaps and poses a continuing risk. Anyone under investigation should seek advice from their union or legal representative.
Should every head injury patient on anticoagulants be conveyed?
Anticoagulant use is a recognised risk factor for bleeding after head injury, and national guidance sets out when imaging is needed. Follow NICE NG232, JRCALC and your service's head injury pathway, and discuss with clinical support if you are considering leaving such a patient at home.
What should I write when a patient declines conveyance?
Record what you explained about the possible diagnosis and risks, the patient's own words showing understanding and weighing, how you assessed capacity for that decision, any discussion with clinical support, the alternative plan agreed, and the specific safety-netting given and understood.
What does see and treat mean?
See and treat describes an ambulance response where the patient is assessed and treated at the scene and is not taken to hospital, sometimes with a referral to another service. It requires the same thorough assessment, safety-netting and documentation as any non-conveyance decision.
Related courses
Paramedic Practice: Assessment and Non-Conveyance Decisions
This course teaches a structured approach to assessment and safe decision-making when a paramedic considers discharging a patient on scene or…
Maternity Care and Fetal Monitoring Concerns
This course teaches safe fetal monitoring in labour, including intermittent auscultation, structured CTG review and escalation, using UK guidance and…
Restrictive Practice and Use of Force in Mental Health
This course explains the legal and professional framework for restrictive practices in mental health settings in England, including physical…
Sources and further reading
- Standards of proficiency: paramedics. Health and Care Professions Council.
- Standards of conduct, performance and ethics. Health and Care Professions Council.
- JRCALC Clinical Guidelines. Association of Ambulance Chief Executives and Joint Royal Colleges Ambulance Liaison Committee.
- Head injury: assessment and early management (NG232). National Institute for Health and Care Excellence.
- Mental Capacity Act 2005 Code of Practice. Office of the Public Guardian.
- National Early Warning Score (NEWS) 2. Royal College of Physicians.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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