Background Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen.

Methods During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out.

Results The interviews revealed a similar assessment and decision-making process among participants:

• Prearrival: forming an early opinion from information from the emergency call.

• Initial contact: assessing the need for any immediate action and establishing a rapport.

• Continuing assessment: gathering and assimilating medical and social information.

• Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct.

Conclusions An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.