21. Mr U says the doctors and nurses did not carry out the correct procedure and processes. They missed a red flag sign of chest pain during his mother’s care and failed to carry out further investigation, which could have changed the outcome. Mrs U died on 20 November 2019, following a heart attack.
22. NICE - Recent onset chest pain of suspected cardiac origin: assessment and diagnosis. CG95 24 March 2010, says:
‘1.2.1 Initial assessment and referral to hospital
1.2.1.2Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering: • the history of the chest pain
• the presence of cardiovascular risk factors
• history of ischaemic heart disease and any previous treatment
• previous investigations for chest pain. [2010]
1.2.4 Assessment in hospital for people with a suspected acute coronary syndrome
1.2.4.1 Take a resting 12 lead ECG and a blood sample for high-sensitivity troponin I or T measurement (see the section on use of biochemical markers for diagnosis of an acute coronary syndrome) on arrival in hospital. [2010, amended 2016]
1.2.4.2 Carry out a physical examination to determine: • haemodynamic status
• signs of complications, for example, pulmonary oedema, cardiogenic shock and
• signs of non-coronary causes of acute chest pain, such as aortic dissection.
1.2.4.3 Take a detailed clinical history unless a STEMI is confirmed from the resting 12 lead ECG (that is, regional ST segment elevation or presumed new LBBB).
Record: • the characteristics of the pain
• other associated symptoms
• any history of cardiovascular disease
• any cardiovascular risk factors and
• details of previous investigations or treatments for similar symptoms of chest pain.’
23. General Medical Council, Good Medical Practice says good clinical care must include an adequate assessment of the patient’s condition, based on the history and clinical signs and, if necessary, an appropriate examination.
24. Mrs U complained of right sided chest pain on 20 November 2019. An assessment was carried out by a doctor, and physician associate. From a review of the medical records, this included taking an appropriate history of the pain, its location, and a physical examination. The doctor noted the pain did not have the characteristics of typical cardiac pain. It was noted Mrs U’s early warning score (EWS) was 0, with a heart rate of 90, respiratory rate 19 and blood pressure 164/97. Mrs U’s temperature was 37.3˚C. There is an alternative diagnosis suggested in the medical records of gastric reflux symptoms, and for there to be re-assessment if the pain persisted.
25. Our physician adviser said throughout the episode of pain, Mrs U’s EWS remained low/normal. Mrs U subsequently suffered a cardiac arrest and died on the same day.
26. The Trust said, on Mrs U’s third day of admission, she was found unresponsive that afternoon. A cardiac arrest call was made. The Trust said Mrs U was at high risk of developing post operative cardiac complications, given her cardiac history, and an ECG should have been performed. The Trust’s own SJR concluded that an ECG should have been done and that symptom follow up should have been performed, with escalation to a more senior clinician.
27. Our physician adviser said chest pain in hospital inpatients is a common occurrence and there needs to be some clinical judgement regarding whether the pain sounds worrying. Most patients will not be having a cardiac event when seen and pain is due to other factors. However, an ECG and blood test are simple things to do in a secondary care setting. Especially in an elderly lady who was in the post operative period and at high risk of cardiac complications. These tests should have been done.
28. A thorough assessment of Mrs U on 20 November 2019 was undertaken in accordance with GMC and NICE guidance. However, we have decided that investigatory tests should have been performed to see if Mrs U had already had a heart attack. NICE guidance suggests an ECG should have been performed. We know from the Trust’s response letter that Mrs U was high risk of developing post operative cardiac complications given her cardiac history. She was also complaining of chest pain.
29. NICE- Hip fracture: management. CG124 22 June 2011 says:
“From admission, offer patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme that includes all of the following:
· orthogeriatric assessment
· rapid optimisation of fitness for surgery
· early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing
· continued, coordinated, orthogeriatric and multidisciplinary review”
30. From a review of the medical records, it is noted Mrs U was reviewed by an orthogeriatric consultant on day one post operation and was subsequently reviewed by a physician associate.
31. Our orthopaedic adviser said there was no pre-operative orthogeriatric assessment. It is not clear whether the physician associate was part of the orthogeriatric or orthopaedic team.
32. The GM, Geriatric Medicine Journal says:
‘Orthogeriatrics is defined as the care of elderly orthopaedic inpatients, most often following a fractured hip. It was developed as a subspeciality to address the poor outcomes of hip fracture patients by caring for patients alongside orthopaedic surgeons and with the support of a specialist multidisciplinary team.’
33. The Blue Book, the care of patients with fragility fracture, 2007 says there should be routine access to acute orthogeriatric support.
34. NICE does not specify how the orthogeriatric care is delivered but it is expected that there should be supervision by an orthogeriatric consultant of the post-operative care of all hip fracture patients.
35. From a review of the medical records, this did not happen. Our adviser said, on balance, it appears the orthogeriatric care of Mrs U was less than satisfactory. The Trust said nurses and doctors should have reviewed/followed up for symptom improvement after initial assessment and considered alternative investigation and diagnosis. Mrs U’s condition should have been escalated to a senior clinician for assessment.
36. We have decided that the process of care provided to Mrs U, within the orthopaedic department, was not in line with the NICE guidance. There was no consultant geriatric presence to ensure senior geriatric review of her care. Mrs U was over 80 years old with comorbidities and had undergone a hip hemiarthroplasty. She was in the post operative period and at high risk of cardiac complications. If the Trust had an orthogeriatric consultant available, then the physician associate could have asked for support when Mrs U complained of chest pain. This would have provided further specialist knowledge of the investigatory tests which were required, along with information on conservative treatment for her pain and discomfort. It is noted that Mrs U was suffering with chest pain throughout the day on 20 November 2019.
Impact
37. Mr U feels the Trust are being callous about the situation and desensitized about what happened. He says the final day of his mother’s admission was traumatic and his mother was in pain. Mr U said his mother was in a distressed state when he arrived at the hospital on 20 November 2019. He said the nurses were not aware of this until he told them. Mr U said there was a slow response from the crash team and his mother was left in full view of the ward while having a cardiac arrest because the curtains were left open. This was very upsetting for Mr U to witness.
38. The Trust sent two letters to Mr U in response to his complaint, dated 15 September, and 23 September. A meeting was also held on 22 September. The Trust’s SJR said pain relief using appropriate medications would have reduced the symptoms experienced by Mrs U. The Trust said if the ECG had diagnosed acute myocardial infarction (heart attack), the probable course of action would still likely have been to conservative treatment. Risk of mortality would have also been high given her post operative status. Mr U felt these comments desensitised the circumstances.
39. Our physician adviser said pain relief would have reduced the symptoms experienced by Mrs U. If the Trust were aware of a heart attack, Mrs U may have been put onto a cardiac monitor which might have marginally improved her chances of surviving, but overall, the outcome is likely to have been the same, a catastrophic event causing cardiac arrest and death.
40. Our cardiology adviser said an ECG may have helped to diagnose an acute ischaemic event such as acute myocardial infarction. However, the ECG could still be normal and would not exclude an acute coronary syndrome. The management in this case would probably continue to be conservative and medical given the frailty and the recent surgery.
41. Our cardiology adviser said they could not be certain the chain of events and the outcome would have been different based on Mrs U’s age, overall status, and comorbidities.
42. We are unable to say that the outcome would have been different if the Trust had performed an ECG. While we do not underestimate the impact of the events on Mrs U and Mr U, we can only reach a view that there was a missed opportunity for Mrs U to undergo investigatory tests. Mrs U was an elderly patient at over 80 years of age. If the Trust knew of the condition, we know the risk of mortality would have been high given her post-operative status. There was a short space of time between the complaint of chest pain and the cardiac event. It happened on the same day. We will never know what actually would have happened, this is why we cannot reach a view that the outcome would have been different. What we can say, is this is likely to have led to conservative treatment, which would have reduced the pain that Mrs U suffered.
43. We recognise this was a traumatic time for Mrs U, Mr U, and their family.
44. The medical records note that Mr U was with Mrs U at the time of the event. Mr U says the final day of his mother’s admission was traumatic and his mother was in pain. We appreciate this was a traumatic event to witness and remains upsetting for Mr U. Because of the missed opportunity to provide conservative treatment to reduce Mrs U’s pain, this has added to the upset caused to Mr U. We recognise this will cause Mr U to relive the trauma and distress suffered by his mother. We have decided that this is directly linked to the failings we have identified within this report.
45. Mr U would like his mother’s SJR score. He seeks an apology with some respect for him and his family. He would like the Trust to acknowledge what went wrong and the impact caused. He also seeks service improvement.
46. When considering the injustice, we have considered what actions the Trust has taken to put this right.
47. The Trust said the SJR concludes with a question and not a score. The question is ‘Was this death considered more likely than not due to problems in care?’ and in Mrs U’s case this was concluded as ‘no’. The rationale given for this conclusion was that the clinicians at the mortality and morbidity meeting felt that the ECG should have been performed. This may have impacted appropriate treatment, though more from a symptomatic perspective, and probably not altered the overall outcome. We are aware that Mr U has been provided with a copy of the SJR. There is nothing we can add to this information and the Trust has answered Mr U’s question about the SJR.
48. The Trust have apologised to Mr U within their response letter, although this could refer specifically to the impact caused to Mr U and his family.
49. The Trust said they have also agreed and implemented the following:
· the ward multidisciplinary team (MDT) includes nurses, doctors and physiotherapists now undertake a formal handover of all patients at 9am every morning
· a formal ward round is undertaken following the handover where all patients are clinically reviewed
· a second discussion then takes place with the MDT team
· medical teaching is now in place with orthopaedic doctors which includes post-operative complications for complex older people
· a consultant geriatrician is now present on Monday to Friday to ensure patients can receive senior review.
50. It is pleasing to see the Trust have accepted learning and improvements. However, we have not seen any evidence of these to satisfy ourselves that the injustice has been remedied.
51. We have considered the actions taken by the Trust further below when setting out our recommendations.