No record of discharge rationale
20. Mr C complains the Trust did not complete contemporaneous records for the rationale to discharge him on 10 August. The Trust have admitted the lack of appropriate record keeping is a failing.
21. The Trust said the junior doctor was unable to recall the details of the consultation before discharging Mr C. This is due to the passage of time and the number of patients they had seen since Mr C’s attendance.
22. The Trust said while it has notes from the paramedics, initial nursing, ECG, and the laboratory blood test results, the junior doctor did not make any contemporaneous notes of the assessment findings. They also did not document the rationale for discharging Mr C.
23. We can see the ED hospital admission records documented that Mr C had intermittent chest pain which was worse on exertion. He had chest pain for a few weeks, but it got worse on 9 August. It recorded that all worsening symptoms coincided with exertion and his last episode was after climbing the stairs.
24. Mr C’s recorded pain score was mild on 10 August, before the Trust discharged him. However, we agree we could see no assessment findings and rationale before the Trust discharged Mr C on 10 August.
25. Our ED adviser said the Trust did not act in line with paragraphs 19 and 21 of the GMC guidance in not documenting its discharge rationale. These paragraphs state that clinicians should record work clearly, accurately, and legibly.
26. Paragraph 19 says clinicians should: ‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.’
27. Paragraph 21 says clinicians should: ‘Clinical records should include a) relevant clinical findings, b) the decisions made, and actions agreed, and who is making the decisions and agreeing the actions, c) the information given to patients, d) any drugs prescribed or other investigations or treatment, e) who is making the record and when.
28. In line with the above guidance, before discharging Mr C, the Trust should have documented Mr C’s medical history, examination, diagnosis, plan of action, and discharge rationale.
29. As we can see no record of assessment findings or rationale before the Trust discharged Mr C on 10 August, in line with the above GMC guidance, this is a failing. When we find failings, we next look to see the impact. We shall consider this later in this report.
Discharge 10 August 2019
30. Mr C said the Hospital discharged him too soon. We can see it discharged him in the early hours of 10 August.
31. The Trust said, without any contemporaneous documentation by the doctor, it cannot say whether there was a reasonable rationale to discharge Mr C.
32. The Trust said the ECG’s (heart monitoring tracing) taken in ED on 9 August 2019, did not show evidence Mr C had a heart attack.
33. The Trust said it took blood samples to look for troponin T. Both blood samples at Mr C’s ED attendance, and the first taken upon his re-attendance the next day, were unsuitable for analysis. This is because the blood samples haemolysed (red blood cells burst).
34. The Trust said without a blood result to confirm diagnosis, the doctor would have needed to make a clinical judgement, in discussion with Mr C, about whether to take a further sample.
35. The Trust said it would have erred on the side of caution and recommended taking another blood sample. This is because troponin T would have been the only way to determine whether Mr C suffered a heart attack.
36. The Trust also said the doctor appeared to have not waited for the second blood test result before making the judgement whether to discharge Mr C. When the second blood sample reported as unsuitable for analysis, this was a couple of hours after the Trust discharged Mr C. We can see the records reflect what the Trust said about the blood test results.
37. Our ED adviser said it is not possible to determine whether the Trust’s decision to discharge Mr C on 10 August was in line with any guidance or standards. This is because the Trust’s doctor did not document their rationale for discharging Mr C, in line with paragraphs 19 and 21 of the GMC Guidance (as stated above). As stated, we shall consider the impact of this later in this report.
38. The Trust discharged Mr C with stable angina on 10 August. NHS guidance for chest pain says there are many different causes of it. This can include chest pain symptoms after chest injury or chest exercise, triggered by worries or a stressful situation, and feeling full or bloated. In most cases, chest pain is not caused by a heart problem.
39. Our adviser said it is not known if the ED doctor determined whether Mr C’s chest pain was cardiac (relating to the heart) to know whether they should have followed the Trust’s Chest Pain Pathway. This is because the Trust’s Chest Pain Pathway is guidance for patients presenting with cardiac chest pain and STEMI (type of heart attack).
40. Our adviser agreed the two blood samples taken before the Trust discharged Mr C on 10 August were inconclusive as they haemolysed. They confirmed the ED doctor should have waited for the troponin T results, or undertaken another blood test, before discharging Mr C. This is because the Trust had already started the process of taking blood tests to rule out whether Mr C was developing a heart attack. The British Heart Foundation Guidance supports this and states the following: ‘Troponin is a protein that’s released into the bloodstream during a heart attack. Detecting troponin in the blood can help doctors diagnose a heart attack and give you the treatment you need as soon as possible.’
41. In addition, NHS guidance for diagnosing a heart attack says blood tests can be used to assess the state of a person’s heart and to check for related complications. It states the following: ‘Damage to your heart from a heart attack causes certain proteins to slowly leak into your blood…If doctors suspect you have had a suspected heart attack, a sample of your blood will be taken so it can be tested for these heart proteins (known as cardiac markers). The most common protein measurement is called cardiac troponin. Your troponin level will be measured through a series of blood tests done over the course of a few days. This will allow damage to your heart to be assessed, and also help determine how well you are responding to treatment.’
42. Our Principles also state that public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot. We can see the Trust started the process of taking blood tests to determine if Mr C had traces of troponin T on 10 August.
43. However, it did not follow through with completing a conclusive troponin T blood test before discharging him. We can see this is not in line with our Principles, the British Heart Foundation, or NHS Guidance for diagnosing a heart attack. Therefore, we find this a failing. We shall next look at the impact of the failings.
Impact of failings
44. Mr C said because of the Trust’s failing in discharging him on 10 August he had a heart attack that night. This led to a triple bypass operation. He says he developed pneumonia after the operation, and his GP diagnosed him with an underactive thyroid where the thyroid gland (small gland in the neck) does not produce enough hormones.
45. Mr C says he may have had less damage to his health, specifically, not had pneumonia or underactive thyroid if the Trust kept him in hospital on 10 August. He also said the lack of documentation caused him distress.
46. Our ED adviser said as there is no record of the discharge rationale, we do not know the Trust’s process in reaching it. As stated above, and agreed by the Trust, it is not possible to determine whether the Trust’s decision to discharge Mr C was appropriate. Our ED adviser also said without documentation of the ED doctor’s assessment and rationale for discharge, it is not possible to judge whether the discharge was safe.
47. The Trust said if Mr C had further episodes of chest pain, and if he had given a history that might otherwise have explained those symptoms, for example muscle strain, then there possibly would have been a clinical rationale for discharge. Therefore, it was essential for the Trust to document its assessment findings and discharge rationale.
48. Our ED adviser said, as the Trust did not document the assessment findings and rationale, this has caused a missed opportunity to know whether Mr C was developing a heart attack. We can also see it is a missed opportunity for the Trust to treat Mr C sooner, if indeed he was developing a heart attack.
49. Our cardiologist adviser said, in acute coronary syndrome, troponin levels tend to rise over 24 to 48 hours before plateauing and eventually falling, over a period of a couple of weeks. They said the records show, over a 36-hour period, from 10 August there was a gradual rise in Mr C’s troponin T levels.
50. However, as the Trust did not complete a conclusive troponin T blood test before discharging Mr C on 10 August, we do not know what the troponin T results would have been at that point. Because of this, we also do not know whether he was developing a heart attack at the time, or before he returned to ED later that day on 10 August.
51. Our cardiologist adviser said coronary artery disease can take many years to develop. Mr C’s coronary angiogram findings were in keeping with chronic coronary artery disease. This disease develops when the major blood vessels that supply the heart become damaged or diseased. This had built up over many months, or years, resulting in Mr C’s exertional angina symptoms. This is because there was the presence of coronary collaterals (tiny, specialised blood vessels) to occluded coronary artery vessels (partial or complete obstruction of blood flow of a coronary artery), which are typical features of a coronary artery chronic total occlusion (CTO).
52. Our cardiologist adviser referred to the Chronic Total Occlusions Guidance. This says: ‘Coronary CTOs are relatively common, observed in appropriately 15 to 25% of patients with coronary artery disease undergoing coronary angiography…. The CTO prevalence is much higher…among patients with prior coronary artery bypass grafting (a type of triple bypass operation) …’
53. This means it is common for patients with CTO, like Mr C, to undergo a triple bypass operation. Therefore, our cardiologist adviser said the hospital would have still referred Mr C for a triple bypass operation. This is even if the Trust had completed a conclusive troponin T test before discharging Mr C on 10 August.
54. Our cardiologist adviser said pneumonia is a type of chest infection. Infection is one of the main complications associated with triple bypass surgery, as stated in the NHS Guidance for Risks to Coronary Artery Bypass Graft.
55. Our cardiologist adviser also said underactive thyroid is a chemical abnormality in the body and is unrelated to acute coronary syndrome. We therefore cannot link the failing in the Trust not completing a conclusive troponin T result to Mr C’s GP diagnosing him with underactive thyroid.
56. We recognise how the lack of documentation, and a conclusive troponin T blood test result, would have caused some uncertainty and distress to Mr C as he will never know whether it was appropriate for the Trust to send him home. We also do not know whether he was developing a heart attack before the hospital discharged him or before he returned to ED on 10 August. If the Trust had done these it would have reassured Mr C it was doing all it could to care for him before it discharged him. We have made recommendations to put things right.