25 - 26 November
18. Mrs M complains the Trust did not appropriately act on her mother’s first episode of chest pain, or subsequently carry out the correct investigations.
19. We have carefully considered if the Trust managed this episode of chest pain in line with guidance.
20. The chest pain guidance says when a patient presents in hospital with chest pain to take a resting 12 lead ECG and a blood sample for high sensitivity troponin. The ECG is an initial diagnostic test that records the electrical activity of the heart, which helps diagnose various cardiac conditions and define the appropriate treatment. A troponin test is a blood test used to assess heart damage which can help diagnose heart attacks. The chest pain guidance also says to carry out a physical examination and take a detailed clinical history.
21. The GMC guidance says when assessing or diagnosing a patient, a doctor should take account of their history, and where necessary examine the patient. They should promptly arrange suitable advice, investigations, or treatment, and refer the patient to another practice if necessary.
22. Mrs B’s first episode of chest pain was documented on 26 November at 6.15pm. Records note the pain was sharp, across her whole chest and in both arms.
23. The junior doctor took a history and examined Mrs B after her chest pain. They prescribed her pain relief (oxycodone) which is an opioid. An opioid is a group of drugs which are often used for moderate to severe pain. The assessment was detailed, and our physician adviser told us it was in line with the GMC guidance.
24. The doctor also took a blood test to determine Mrs B’s troponin level and discussed this with a senior doctor. They carried out an ECG, although it is unclear which ECG this is in the records, as two of the ECGs are undated and untimed. The records do support an ECG was carried out at this time as they say no changes were noted on the ECG. This management was in line with the chest pain guidance.
25. Mrs B’s troponin level came back as 20.3, which is raised. The Trust says this was at 7.05pm. The Trust’s policy says based on a score of 20, this test should be repeated within three hours of the first sample. This is in keeping with the chest pain guidance, and based on this the Trust should have repeated the ECG and troponin test by 10.05pm. This would have determined if Mrs B was having an acute cardiac incident. An acute cardiac incident refers to sudden disruption in the hearts function or blood flow and refers to conditions like heart attacks.
26. There is no evidence of these tests being repeated. The Trust did not follow the chest pain guidance, or its own policy based on Mrs B’s troponin levels. This is a failing.
27. Our nursing adviser also considered the episode of chest pain on 26 November. The chest pain guidance is relevant from a nursing perspective, alongside the NEWS guidance.
28. Nursing records show Mrs B complained of chest pain, described like indigestion. Indigestion is an issue that causes discomfort in the upper abdomen. It says tramadol was given with good effect, and Mrs B slept in the chair as she was short of breath. Tramadol is also an opioid medication. The entry is untimed.
29. The paper and electronic observations within the medical records are in three different places (paper early warning score (EWS) chart, electronic NEWS chart and narrative notes). The early warning scoring system is a guide used to determine the degree of illness in a patient. It relies on vital signs to identify acutely ill patients.
30. A patient’s NEWS sets out how frequently a patient should be monitored and the urgency of a clinical review. There are trigger levels for a clinical alert requiring clinician assessment.
31. A NEW score of one to four is low and should prompt assessment by a nurse, to decide if a patient needs further clinical monitoring or if escalation is required. A score of five or six is a key threshold indicative of a potential serious deterioration and the need for an urgent clinical review from the medical team. A score of seven or more is high and should prompt an emergency assessment by the medical team.
32. Our nursing adviser explains that all observations should be recorded in the same place, to enable an overall assessment and identify any deterioration in the patient’s condition. The Trust did not use the nationally recommended NEWS charts, designed to highlight triggers for the appropriate clinical response.
33. Our nursing adviser has considered all available evidence about the observations taken.
34. At 8.17pm, Mrs B’s NEWS was recorded as two. Her oxygen saturation level was 93% which is slightly low, she reported feeling short of breath and had a nine out of ten score for chest pain. In hospital patients are asked to rate their pain intensity out of ten. Zero indicates no pain, where ten is the worst pain. The observations also show at 8.20pm on 26 November Mrs B’s blood glucose was 21.9. This was very high.
35. As set out above, a NEWS of four or less, requires a ward-based response, with repeat observations every four to six hours. This did not take place. Our nursing adviser explains as Mrs B had shortness of breath and chest pain, she should have been assessed and monitored more promptly, to alert to any deterioration, as well as escalation to the medical team.
36. Mrs B’s observations were not taken until the next day at 3.24am. This is over seven hours later. This was not in line with the NEWS guidance. In line with the Trust’s own policy, this indicated escalation to a specialist nurse and/or doctor for further treatment, and for the blood glucose test to be repeated. The evidence does not suggest any action was taken here. The Trust did not follow up on Mrs B’s observations, and there is a failing here.
27 November
37. Mrs M complains the Trust did not act on her mother’s second episode of chest pain the following day. She says her mother was left alone and telephoned her and her brother in severe pain. Mrs M says her mother was not checked until her brother arrived at the ward to seek help later that evening.
38. The Trust says Mrs B pressed her call bell at 5.45pm and was given GTN spray. The nurse did not go back to check on Mrs B and the Trust says a nurse next saw her at 8pm, however this is not documented in the records. The Trust acknowledges there was a two-hour period where Mrs B was not checked.
39. The chest pain guidance referred to above is also applicable here.
40. Mrs B was seen on the ward round by a consultant at 11.40am. The doctor recorded her troponin was 20. This is raised, and as highlighted previously means the troponin test needed to be repeated in three hours in line with the Trust’s policy and chest pain guidance. This was not done.
41. Records of the assessment say Mrs B’s ECG was normal. Our physician adviser has looked at the ECG and has confirmed it was abnormal, as it shows left bundle branch block. This is a specific pattern seen on an ECG that indicates an abnormality in the heart. The ECG also should have been repeated in line with the chest pain guidance, and this too was not done.
42. The records then show Mrs B reported experiencing chest pain at 5.30pm. A nurse gave her GTN spray twice, which did not resolve the pain. As Mrs B had a new episode of chest pain, in line with the chest pain guidance, the Trust should have carried out another ECG and troponin test. The Trust did not do this, and so did not act in line with guidance. This is a failing.
43. We have also considered the nursing care provided and obtained advice from our nursing adviser. From a nursing perspective, the chest pain guidance and NEWS guidance are applicable here.
44. Records show Mrs B’s observations were taken at 10.05am and 4.30pm. These were normal and her NEWS score was zero. Mrs B then rang her call bell at 5.30pm as she was experiencing chest pain.
45. No observations were recorded after Mrs B reported chest pain. Our nursing adviser says in line with the chest pain guidance, a fresh set of observations were indicated. There is no record of any observations after 4.30pm and no evidence of any care between 5.30pm and 8pm, 8pm to 8.30pm and 8.30pm to 8.50pm, until her condition significantly deteriorated.
46. Our nursing adviser says there was inadequate monitoring and assessment of Mrs B’s symptoms of chest pain, shortness of breath, and her oxygen saturation levels which were low, at 93%, noted at 4.30pm. Her chest pain at 5.30pm meant she should have been escalated to a specialist nurse, and the medical team. There is no evidence of any plan of care, reassessment, or escalation as there should have been, in line with the chest pain guidance and NEWS guidance. There was a missed opportunity to monitor and assess Mrs B when her condition was deteriorating. There is a failing here.
47. The next entries in the records were at 8.47pm, 9.24pm and 9.33pm, when ECGs were performed. The records show at 8.50pm, Mrs B was in cardiac arrest.
48. We recognise Mrs M has specific concerns about her mother being prescribed oxycodone and tramadol whilst having chest pain across both dates. There is no evidence in the prescription charts of either drug being administered. The Trust refers to giving the drug in the notes, so on balance it seems likely these were given.
49. The Trust says tramadol was part of Mrs B’s regular medications and the doctor had prescribed on an ‘as needed’ basis.
50. The GMC prescribing guidance says you must prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied the drugs or treatment serve the patient’s needs.
51. Our nursing and physician advisers have carefully considered if administering these drugs was appropriate in the context of chest pain. It is known that opioids can cause respiratory depression and shortness of breath. However, if a patient is reporting significant pain, as Mrs B was, appropriate analgesia should be given. Our advisers say these drugs were appropriate analgesia for chest pain, and this is in line with GMC prescribing guidance.
52. To summarise, we have identified failings in how the Trust managed Mrs B’s chest pain on 26 and 27 November. On 26 November, the Trust misreported the ECG as normal, when it was abnormal. On both dates, the Trust should have repeated Mrs B’s troponin tests and ECGs in line with the chest pain guidance. On both dates, the Trust should have monitored Mrs B and escalated her care in line with NEWS guidance.
Considering the impact
53. We know this will be extremely upsetting for Mrs M to read. We recognise she and her brother have serious concerns about whether their mother’s cardiac arrest could have been avoided with more timely intervention.
54. We have taken advice from a cardiology adviser to carefully consider how these failings impacted on Mrs B’s chances of recovery, and whether she could have survived if her care had been escalated sooner.
55. The first missed opportunity to act on Mrs B’s chest pain was on 26 November, when a repeat troponin test and ECG should have taken place no later than 10.05pm.
56. Based on all the evidence made available to us, we think it is highly likely Mrs B’s troponin level would have remained high. Although it is not directly clear which ECG is which, the ECG’s showed abnormal results, and nothing happened in the intermediate period to tell us this was resolved. With a raised troponin level and the left bundle branch block seen on ECG, Mrs B would have had a coronary angiogram.
57. A coronary angiogram involves a tube being put into the wrist to take X-ray pictures of the heart by injecting radioactive dye. It is a straightforward test, which provides diagnostic findings which can be treated promptly as a result. It is used to identify the extent of any blockage, to then determine what treatment is needed.
58. We know the ECG that was taken shows a left bundle branch block. Because a coronary angiogram was not taken, we do not know the extent of the blockage in Mrs B’s case. There are varying levels of treatment that would all have been available for Mrs B, the choice of which being dependent upon the extent of the blockage shown on angiogram. The treatment options are set out in the acute coronary syndromes guidance.
59. The first is medication alone. It is very common for a patient to be successfully treated with medication. The standard medication is two drugs given to stop platelets clumping, and to reduce the risk of further events (for example statins and angiotensin converting enzyme inhibitors, or ACEIs). Statins are a group of medications which can be used to treat conditions like coronary heart disease, angina, heart attacks and strokes. ACEIs are a class of medications used to treat cardiovascular conditions, which helps the blood flow to the heart increase and improve heart function.
60. The second type of treatment would have been stenting. This is where a small tube, a stent, is put into the artery to prevent it from narrowing. Artery narrowing occurs when there is a buildup on the wall of arteries, and this can reduce blood flow. Stenting treats blockages and reduces the risk of heart attacks. This is a straightforward procedure.
61. The third treatment is surgery. Bypass surgery reduces the risk of heart attacks, and potentially in some patients increased the length of life. This is major surgery, with associated risks and a six-month recovery period.
62. The decision on whether to give Mrs B medication alone, or some form of revascularisation with either stents or bypass surgery would have been made once the angiogram had been undertaken.
63. It is very difficult to say which treatment option Mrs B would have needed, as this would depend on the results of the coronary angiogram where the heart artery lumen can be seen. A lumen is the opening or space inside the blood vessel. If there was mild disease in the coronary arteries, medication alone would have been sufficient.
64. If there were a couple of severe narrowings, these would have been treated with stents. If there was a lot of disease, or severe narrowing at the start of the arteries, bypass surgery would have been recommended.
65. The risk of complications depends on the clinical state and risk factors. The mortality rate is low from both stents and coronary artery bypass surgery, less than 5% in general.
66. Our cardiology adviser explains Mrs B would likely have been a candidate for all three of the above options. The above treatments are standard practice and there is nothing to suggest they would have been anything but successful in Mrs B’s case. Treatment with medication would have significantly reduced Mrs B’s risk of death. With a procedure such as stenting, generally patients can go home the next day. Surgery would have required approximately two weeks in hospital, depending on recovery time.
67. From their extensive clinical experience, our cardiology adviser says it is more likely than not Mrs B would have had her coronary angiogram and received treatment that evening.
68. On the evening of 26 November, when the angiogram should have been done, Mrs B’s Global Registry of Acute Coronary Events (GRACE) score indicated her risk of death was 3-5%. A GRACE score is a risk and mortality calculator for patients with acute coronary syndrome.
69. The GRACE score is used for both STEMI and NSTEMI patients. STEMI is an abbreviation used to describe the most severe type of heart attack which occurs due to the complete blockage of a coronary artery. NSTEMI an abbreviation used to describe another type of heart attack, resulting from a partial blockage.
70. This NICE approved risk calculator shows with treatment, it is likely Mrs B’s survival rate would have been 95-97% based on her data.
71. Because the angiogram was not done, we cannot know whether Mrs B had a STEMI or NSTEMI heart attack on 27 November. We explain this statistic, because our cardiology adviser says if it was STEMI, Mrs B’s Thrombolysis in Myocardial Infarction (TIMI) risk of death was 12.4% if she had been treated immediately. TIMI is a tool used to predict the chances of having or dying from a heart event, for people with STEMI.
72. We also find other missed opportunities for treatment to have been given to Mrs B the following day, 27 November. Firstly, following the ward round that morning where we have highlighted Mrs B’s troponin was still high and the test not repeated. Secondly, there was a much more immediate opportunity when Mrs B reported further chest pain. If the correct action had been taken here, it is highly likely further changes would have shown on the tests, giving another opportunity for her to have a coronary angiogram and subsequent treatment.
73. This does not change the fact we think further action should have been taken and treatment started on 26 November. Our view is that the Trust then missed two further opportunities to act.
74. We think on the balance of probabilities these opportunities are likely to have saved Mrs B’s life. She had a very abnormal ECG and chest pain but was otherwise quite well. If the Trust had carried out the appropriate monitoring and treatment, it is more likely than not the outcome would have been avoided.
75. When Mrs B was later found after 8pm, she was hypoxic (low oxygen levels in tissues and cells in the body) with oxygen saturations of 60% on air. This is very low. She went on to have a major cardiac event and sadly died. The resuscitation guidelines state the reversible causes of a cardiac arrest include hypoxia, hypovolaemia (low fluid in the body), and thrombosis (formation of a blood clot). They say to treat the cause of asphyxia/hypoxameia as the highest priority, because this is a potentially reversible cause of cardiac arrest.
76. As explained, her GRACE score, setting out her risk of death from a future cardiac event at the earliest opportunity for treatment, was 3-5%. Without any treatment, this understandably increased.
77. Our cardiology adviser explains if Mrs B was seen at the time of hypoxia, her likelihood of death was estimated at between 27 and 35% using the TIMI score. This is clearly raised yet supports that is still more likely than not she would have survived had the Trust taken action at the third opportunity.
78. Mrs B was likely a candidate for all three treatment options, and we have seen no evidence to suggest she would not have made a full recovery from all three options.
79. Based on Mrs B’s clinical condition and history, and the known mortality risk percentages that applied in her case, if her chest pain had been picked up sooner, we think it is more likely than not she would have avoided her later fatal heart attack. Our cardiology adviser explains angiography significantly reduces the risk of acute myocardial infarction, which was Mrs B’s cause of death. This is supported in the ESC guidelines and NSTEMI guidance.
80. Overall, we conclude we think Mrs B would have survived if she had been treated sooner. We acknowledge how distressing this will be for Mrs M and her brother to learn, and do not underestimate the impact of this devastating information.
81. We also recognise the distress Mrs M and her brother experienced in the hours leading up to their mother’s death. Mrs M says her mother was calling them to explain she was in pain, and nobody was coming to see her. We know Mrs M’s brother was so worried, he attended the hospital to seek help as he was concerned for their mother. This was during the pandemic, so he was not able to go onto the ward.
82. We acknowledge what a difficult time this must have been for Mrs B whilst she was alone and in pain, and the worry this caused Mrs M and her brother. We recognise how distressing this time was, and only exacerbated by the events that followed. It is understandable the family suffered shock, and this affected the grieving process at what was already such a difficult time. Mrs M and her bother have since had to deal with the impact of feeling their mother would not have died if action had been taken sooner, and this has been incredibly distressing.
83. We have looked to see what the Trust has done so far to put things right.
84. The Trust says there was no evidence Mrs B was complaining of chest pain on 26 November, so it has not taken any action around this incident of chest pain.
85. The Trust has acknowledged that a nurse did not come back to check on Mrs B when she reported chest pain on 27 November. It says it has spoken to staff as a result, the nurse has reflected on the incident and expresses her apologies.
86. The Trust carried out a structured judgement review to look at the strengths and weaknesses in care. The outcome of the review was that some improvement was needed with regards to the nursing care, but the medical management was good, and the outcome would not have changed.
87. The complaints standards say organisations should give meaningful and severe apologies and explanations that openly reflect the impact on the people concerns. They also say they should take action to make sure any learning is identified and used to improve services.
88. We have identified failings in the Trust’s care and treatment of Mrs B, and explained the outcome we think resulted. We are yet to see the Trust has acknowledged this or taken action to remedy this. We do not think the Trust has recognised the significance of where things have gone wrong or taking learning as a result.
Complaint handling
89. We recognise Mrs M also has concerns around how the Trust handled her complaint and that is has not recognised where things went wrong.
90. The complaints standards say wherever possible to explain why things went wrong and identify suitable and appropriate ways to put things right for people.
91. In its complaint response the Trust has not recognised the action it should have taken following Mrs B’s chest pain on 26 and 27 November. It explained there was no signs of clinical deterioration, and as a result Mrs B’s death was not avoidable.
92. As set out earlier in report, we have identified failings in the care and treatment, and the impact of this.
93. We therefore consider the Trust’s explanation to be inaccurate. This is not line with the complaints standards and is a failing in complaint handling.
94. We have considered the impact of this. Mrs M explains this compounded the distress she was already experiencing. It is understandable this made what was already an incredibly difficult time worse. We have asked the Trust to take action as a result.