Paramedic Non-Conveyance Decision: Kolb

Concrete experience

I attended an elderly woman who had fallen in her kitchen without injury. Observations were within normal limits, she had capacity, mobilised with her frame, and was adamant she did not want hospital. Her daughter, visiting daily, agreed to stay the night. I completed a falls assessment, safety-netted verbally and in writing, made a referral to the community falls team, and discharged her on scene. Driving to the next job I felt a specific unease I could not attach to any finding. Two days later I learned through a colleague that she had been admitted after a second fall the following evening - no serious injury, but the unease had been pointing at something.

Reflective observation

Reviewing my own documentation, the clinical picture genuinely supported discharge, and a second fall does not by itself mean the first decision was wrong. But reconstructing the scene honestly, I could name what the unease had been: the kitchen had been rearranged to keep everything within reach of one chair, and she deflected - twice, with charm - my question about how often she had fallen before. Neither observation made it into my assessment or my paperwork. My structured tools captured her physiology and that day's event; the environmental story, which suggested a pattern of decline being managed around rather than reported, lived only in my peripheral vision. I had felt it and filed it as niceness about a proud woman rather than as data.

Abstract conceptualisation

The general principle I take from this is that in non-conveyance decisions, the scene is a clinical finding. Frailty and falls risk are often legible in the home - adaptations, arrangements, worn paths - before they are legible in observations, and a discharge decision built only on the numbers systematically underweights exactly the evidence that distinguishes a one-off fall from a trajectory. Unease, in this framing, is not intuition to be trusted or dismissed; it is usually an observation that has not yet been articulated, and the professional move is to force it into words before leaving the scene. If it cannot survive being written down, it was noise; if it can, it belongs in the decision.

Active experimentation

I have changed my non-conveyance routine in two ways. First, every discharge-at-home now includes a deliberate environmental scan that I document in a sentence or two - what the home says about function and trajectory, not just hazards. Second, I apply a personal rule: if I notice unease, I must either write down what it points to or explicitly record that I could not identify a cause - naming it is now part of my decision, not an alternative to one. I tested this on a similar job last week: the written scan surfaced a concern about medication management that upgraded my referral from routine to urgent. I have also asked our clinical team leader to consider environmental observation as a topic for our next falls CPD session.