Visits to the Emergency Department (ED)
22. Mr E says staff failed to identify and treat the cause of his left arm and chest pain when he attended ED between 21 and 28 October 2018. He says they did not consider his medical history and his previous visits to the ED that week and failed to provide him with appropriate treatment until 28 October 2018. We have looked at each presentation in turn below.
21 October 2018
23. Mr E reports having severe arm pain since 19 October which reminded him of angina pain that he had had previously. He said paramedics visited him on 19 October 2018 and were willing to take him to the ED but he suddenly began to feel better and his ECG reported as normal so after some discussion, he elected not to go to. However, the pain worsened again overnight and on 21 October 2018 he went to the ED. He says staff took an X-ray of his arm and says he saw a ENP who thought arthritic damage was the cause of his pain.
24. Mr E believes that more could have been done on this occasion in response to his symptoms. The Trust said in the absence of chest pain, shortness of breath or shoulder pain, the approach to the arm pain was reasonable.
25. Our emergency consultant adviser referred to NMC (The Code Oct 2018 - 13) guidance, which states that a nurse must:
‘Recognise and work within the limits of your competence. To achieve this, you must, as appropriate: • accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care • make a timely referral to another practitioner when any action, care or treatment is required; and • ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence.’
26. The records confirm the ENP considered Mr E’s presentation. The records detail the ENP understood Mr E presented with left elbow pain and documented that he had no chest pain, shortness of breath or shoulder pain. Mr E’s diary entry supports that elbow pain was his only complaint on this day. The records suggest staff were looking for signs of any worsening health. It also supports the Trust’s view that at this time the focus was elbow pain as opposed to any other symptoms suggesting this could be heart related. NHS choices outlines that elbow pain in itself is usually not a sign of anything serious but where there are associated chest pains, or the pain is triggered by exercise, or stops within a few minutes of resting that could signify more serious problems. We also note the records show that the ENP noted Mr E had a cardiac stent fitted in 2004 and so was aware of his clinical history.
27. Mr E says given his arm pain was getting steadily worse, staff should have considered angina as a possibility. However, his diary of events states that elbow pain was his only complaint on this day. We can see Mr E informed the ENP he had applied topical gel to his elbow, which had helped his pain. This would support a view of mechanical pain, which was relieved by the gel.
28. In line with the NMC guidelines above we would expect the ENP to identify and assess Mr E’s clinical presentation. It appears both accounts support Mr E reporting arm pain.
29. The ENP examined Mr E and ordered an X-ray of his elbow which showed no significant abnormalities. Our adviser confirmed that as this was his only complaint, there is no suggestion the ENP did not meet the requirements of the NMC guidance.
30. We are persuaded this assessment was in line with the NMC code guidance. We therefore found no failings in the Trust’s actions on this day.
22 October 2018
31. Mr E says by the following day, he had bad arm and shoulder pain, and an ambulance took him to the ED. He says the doctor said it was arthritic pain and saw no evidence of other problems. The Trust maintain their working diagnosis of an arm problem was appropriate, and there was no suggestion of this being cardiac in nature.
32. The Rapid Assessment Triage record confirms Mr E’s account and notes he presented on this occasion reporting left elbow pain radiating to his shoulder. The records confirm staff noted his previous heart problems and the results from tests carried out the previous day.
33. We appreciate that the arm pain he presented with could be considered indicative of muscle or arthritic pain (as the Trust has suggested) and as NHS choices indicates). However, in some circumstances, combined with other presenting symptoms, it can be indicative of heart problems as we have explained previously. Our adviser has pointed towards considering the possibility of acute coronary syndrome in light of Mr E’s overall presenting clinical condition. They referred to the national guidance from the GMC (Good Medical Practice 2014) which suggests the Trust should have taken account of his history, examined him and provided appropriate treatment if required.
34. We can see the Trust were presented with arm pain but are also conscious they say they knew ambulance staff from another Trust had asked Mr E screening questions which covered breathing and heart problems and all were negative, and the 12 lead ECG showed right bundle branch block (a delay or blockage along the pathway that electrical impulses travel to make your heart beat). It is accepted he was known to have this on his ECG, as well occasional ectopic beats (extra heart beats). The Trust says this ECG shows no evidence of ischaemia (when the blood flow and oxygen is restricted or reduced), which would support a conclusion of a heart problem.
35. We have also noted the ED consultant who assessed Mr E considered whether his presentation could be related to his heart. In addition, staff took blood tests which included specific tests for a possible heart attack, and which later came back as normal. The records show that Mr E was then reviewed by an ED registrar who noted his elbow pain with no other symptoms such as breathlessness, sweating and nausea, which are often seen with heart-related pain. It says routine bloods were requested for inflammatory markers and that the working diagnosis was that this was an arm problem, with no evidence that it was cardiac in nature.
36. Our adviser confirmed that this assessment was in line with the guidance. They explained that given Mr E’s singular complaint of left elbow pain with no other symptoms, the ED registrar’s diagnosis of possible arthritis in the elbow was reasonable on this occasion.
37. We can see staff considered Mr E’s presenting condition, noted his medical history including his previous heart problems, and that the ED consultant who looked at him considered whether it would be related to his heart. We can also see they did an ECG, indicating he had a right bundle branch block and then excluded this, and that his blood test came back as normal.
38. With this in mind, we are satisfied that the Trust adequately assessed Mr E on this date, and we found no failing here.
24 October 2018
39. Mr E says he was still feeling unwell a couple of days later and had some arm pain, so went to see his GP. He says his GP was unhappy with the Trust’s diagnosis of arthritis, so called the Trust and spoke to a registrar who instructed Mr E to go to the ED. Mr E says that on this date, or at least by 25 October 2018, he should have been examined by the cardiology team and given treatment for angina.
40. The Trust says they did not consider there was a basis to suggest a heart attack on this occasion, but they gave Mr E a nitrate tablet for angina and referred him to the rapid access chest pain clinic. They maintain they acted appropriately in line with his presentation.
41. We understand that during this attendance Mr E was not seen by an ED doctor at any stage and that the decision regarding Mr E’s admission or discharge on this date was made by a cardiologist. We therefore sought some advice from a cardiologist about this admission.
42. The adviser referred to the NICE guidance pathways – ‘Tests in hospital for people with a suspected acute coronary syndrome, chest pain, early management of unstable angina and nstemi’. The guidance explains the expectation is that an ECG would have been done, and a blood sample taken for troponin along with a physical examination and a detailed clinical history. Specifically considering the characteristics of the pain, associated symptoms, history of cardiovascular disease and any previous investigations or treatment for similar symptoms of chest pain.
43. Our cardiology adviser highlighted that Mr E had an abnormal ECG (multiple extra heartbeats), slightly elevated troponin levels (proteins released in to the bloodstream that can indicate heart damage), was getting pain regularly at rest and had presented at A&E multiple times. Our adviser said this was an indication that Mr E could have acute coronary syndrome. Where this is the case the expectation is that the patient would be monitored until a firm diagnosis is made. Given this, we consider the cardiology team should have reviewed him and admitted him at this point for observation, subsequent investigations, and management (including an angiogram and treatment if necessary).
44. We note the previous diagnosis of osteoarthritis and appreciate this may have clouded the clinical decision. We also note that there was only a small increase of increased protein levels in Mr E’s blood. However, our adviser highlighted that he had been stented previously and had extra heart beats, and that this could be a sign of a decrease in blood flow to the heart. They said that the cardiology team should have considered all of these factors, and the fact he had been complaining of arm pain for a week as the whole picture.
45. Our adviser suggested Mr E’s presentation fitted the criteria for immediate assessment for acute coronary syndrome. In line with the guidance, we would therefore have expected for Mr E to have been admitted for observation, subsequent investigations, and management (including an angiogram and treatment if necessary).
46. The records show that Mr E was regularly taking aspirin which is the first step for anyone with suspected acute coronary syndrome, or unstable angina. However, staff did not follow the rest of the guidance as they did not admit and treat him for acute coronary syndrome or acute angina on this admission.
47. We therefore found that the Trust failed to admit and appropriately treat Mr E on 24 October 2018. We shall consider the impact of this in the ‘Impact’ section of this report.
25 October 2018
48. Mr E says he was experiencing bad pain, so again called NHS 111 who sent an ambulance to take him to the ED late on 25 October 2018. He says he saw the same emergency doctor as the day before. He says they reported ‘cardio says do not meet criteria’ and gave him a prescription for isosorbide mononitrate (a medication used to help manage chest pain). Mr E believes the cardiology team should have examined him by this date, if not sooner.
49. The Trust accepted Mr E’s troponin levels had risen on this occasion but said it was not a sufficient rise to confirm a heart attack. It says staff gave Mr E ranolazine for angina and omeprazole, and that the plan was to expedite his chest pain clinic appointment. They maintain the action taken on this occasion was appropriate.
50. Our emergency department consultant adviser explained that Mr E was seen and assessed on the 26 October 2018 at 1am by a junior ED doctor. They explained that following assessment, ECG and blood tests, the ED doctor discussed Mr E’s case with the on-call cardiology registrar who recommended that Mr E be discharged home with additional treatment for his angina. The emergency consultant adviser confirmed that the decision regarding Mr E’s admission or discharge on this date was made by a cardiologist.
51. As explained above, we would have expected that by this point, Mr E should have been admitted for monitoring and treated. However further to the above, we can see on this occasion the presenting condition had worsened suggesting this should have been even clearer. Our cardiology adviser said Mr E’s presentation on this admission showed a clear red flag (warning sign). They confirmed his troponin levels had increased to 27 and 23ng/l, he had had repeated admissions, continuing symptoms, and previous stents.
52. The adviser also highlighted that ranolazine was prescribed. They said that usually, a nitrate is given initially, then a beta blocker, then ranolazine as a third treatment. They explained that given the nitrate did not work, this was a clear sign that there was cause for concern. Our adviser said it did not meet the guidelines to send Mr E home at this point, but also expressed concern that they had provided a third line medication, and still came to that view. He explained that looking at the wider picture it was clear that Mr E required some intervention and should not have been discharged.
53. The records show that on this date, staff did not admit Mr E or provide him with appropriate treatment, and therefore acted outside of the guidelines. Taking this into consideration, we found a failing here.
Complaint handling
54. Mr E complains the Trust only considered his admissions on 24, 25 and 28 October 2018 in its initial complaint response, and did not consider the earlier visits, which he says caused him frustration. The Trust’s initial complaint response did only consider his admissions on 24, 25 and 28 October 2018 and we note that he raised concerns about this via email on 15 April 2018.
55. The Ombudsman’s Principles for good complaint handling say that organisations should listen to and consider the complainant’s views, asking them to clarify where necessary, to make sure the public body understands clearly what the complaint is about and the outcome the complainant wants.
56. Mr E’s complaint form dated 23 November 2018 attached his history of his treatment at the Trust from 19 October 2018 to 2 November 2018. He wrote ‘my complaint is that by Wednesday 24th October, or Thursday 25th at latest, I should have been examined by a member of the cardiology team and given some treatment for angina (e.g. GTN spray). This would have been a clear indication of my condition and I might have been spared the heart attack which was presumably in the small hours of Sunday 28th.’
57. Mr E’s initial complaint clearly asks the Trust to consider his history during this period, but the Trust only looked at his attendances on 24 and 25 October 2018. The Trust should have considered his attendances on 21 and 22 October 2018 in its initial response, and it did not do so. The Trust did not fully understand Mr E’s concerns and we have seen no evidence that it explored this further with him to gain a better understanding. Taking this into consideration, we found a failing here.
58. However, we note that when Mr E highlighted this to the Trust on 15 April 2019, the Trust apologised that it did not previously address his concerns about his attendances on these dates and took all dates into consideration in its second response. As such, whilst we saw a failing here, we are persuaded that when this point was highlighted, the Trust took steps to put this right. This action is in line with The Ombudsman’s Principles of good complaint handling.
Refusal to discuss concerns further
59. Mr E considers the Trust’s second complaint response was ‘unsatisfactory’ and on 26 September 2019, he asked the PALS team for a meeting with the Trust to discuss his concerns further.
60. His email stated that if his history was looked at as a continuous narrative, it stands out like a sore thumb that something was wrong in the process. He said that he was ‘bewildered’ that the Trust appeared unable to see this. He said that he would simply like an acknowledgement that things in the end turned out to be different from what was initially thought, and some reassurance that that something was learned from his ‘unfortunate’ experience from which future patients might benefit. Mr E said the Trust did not contact him as he requested, to discuss this further. Instead, they signposted him to us.
61. We can see that Mr E requested a local resolution meeting on 15 April 2019 when he raised his outstanding concerns with the Trust. The Trust responded on 19 July 2019 with a further response which did address his concerns but did not offer a local resolution meeting as he had requested. The Trust’s response concluded with ‘should you have any further questions or require more information, please do not hesitate to contact’ the complaints team staff member he had been liaising with.
62. When Mr E received this letter, he emailed the Trust on 26 September 2019 and asked why the possibility of angina had not been considered before he had a heart attack, given his age and history. He also explained that on the penultimate occasion he attended A&E he was feeling very unwell, and suggested that by this point if not sooner, it would have been sensible to admit the possibility of a cardiac problem. The Trust declined to comment further, advising staff did not believe they could answer his concerns any differently than they had to date. They then signposted Mr E to us.
63. As stated above, the Ombudsman’s Principles for good complaint handling state that organisations are expected to listen to and consider the complainant’s views. If organisations do this, they may where necessary, offer a local resolution meeting to address any outstanding concerns. However, there is no obligation for the organisation to do so and this depends on the specifics of the complaint and the organisation’s view. In this case, the Trust did not consider that a local resolution meeting was appropriate. The Trust’s response to Mr E’s email on 30 September 2019 was that they had discussed his outstanding concerns with the staff involved in supplying information for the responses, and that they did not believe they could answer his concerns any differently than they had done at that stage.
64. We can appreciate that Mr E remained unhappy with the Trust’s response to his concerns, and that he was disappointed that there was no option for further discussion. However, if the Trust discussed this with the staff responsible for responding to the complaint, and they did not feel they could add anything further, we could not say that not offering Mr E a local resolution meeting amounts to a failing.
Impact
65. We found that the Trust failed to admit and appropriately treat Mr E when he presented on 24 October 2018. We also found that they failed to admit and appropriately treat him on 25 October 2018. He says this caused both him and his wife to worry, and he had a small heart attack, which he believes could have been prevented.
66. Our cardiology adviser suggest it is more than likely that Mr E’s heart attack would have been prevented, had he been admitted and managed as in-patient on either 24 or 25 October 2018.
67. In order to consider this more fully we looked at what was likely to happen if Mr E had been admitted. We note that staff were already aware Mr E was taking aspirin, in line with the NICE guidance pathway for ACS. Therefore, there would have been no change in that.
68. We also note staff assessed Mr E’s condition by taking his clinical history, examining him, carrying out an ECG and blood tests, in line with the guidance. There would also have been no change in that.
69. Given this assessment had indicated Mr E’s condition was clinically unstable by this point, if he had been admitted, staff would likely have gone on to give do some further tests, such as an angiogram. It is likely staff would then have then gone on to give him dual antiplatelet therapy along with the aspirin he was already taking and would have fitted a stent, as they did when he was admitted on 29 October 2018. It is likely the stent would have increased the blood flow to Mr E’s heart, which in turn would likely have prevented him from having a heart attack.
70. We can therefore say that had the Trust’s failure to follow the guidelines by not giving him an angiogram or treating him for acute coronary syndrome or angina led to a missed opportunity to prevent him from having a heart attack.
71. We can appreciate that this would have been an incredibly distressing time for Mr E and his wife and have seen no evidence that the Trust has acknowledged this. We therefore consider the Trust needs to take action to put this right.
72. We identified that the failing in complaint handling has been put right as above and therefore we have not considered the impact here.