Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

3. Miss D complains the Trust should have taken an electrocardiogram (ECG) and troponin test much sooner from the time of her father’s arrival in the emergency department (ED) on 1 January 2024.

4. Sadly, Mr D had a heart attack and died that evening. Miss D says if the correct tests had been taken without any delay, her father’s death could have been prevented. She says this has had a massive mental, emotional and even physical effect on her. Miss D says she is left traumatised and has needed to seek counselling.

5. To resolve her complaint, Miss D seeks service improvements and a financial remedy.

6. Mr D was 58 years old at the time of these events. After calling 999 on the morning of 1 January 2024, an ambulance was with Mr D at 6.18am. Ambulance records document Mr D’s presenting complaint as: ‘Abdominal pain/generally unwell’.

7. Ambulance records contain information gained from speaking with Mr D. This includes note that his illness started around 4am to 5am, that he had ‘upper gastric pain’ and had been vomiting. It notes his abdomen was more distended than normal, and he had been having trouble opening his bowels on a regular basis. It notes Mr D had ongoing problems with urinary tract infection (UTI) and he was on a second course of antibiotic treatment.

8. Paramedics examined Mr D, finding upper abdominal pain and no chest pain. Mr D’s previous medical history is documented. This includes note of congestive heart failure, two previous heart attacks and having had five stents fitted. Paramedics put an ECG monitor in place and took Mr D to hospital.

9. Trust records note Mr D arrived at 6.57am, and ambulance records note the ECG was checked by a consultant on arrival. Care was given to Mr D in the ambulance whilst queuing outside the hospital building, awaiting space inside. Ambulance records show that observations were taken, and Mr D’s ECG was being monitored.

10. Mr D was handed over to ED staff at 9.10am. When first assessed in the ED, Mr D’s presenting complaint is documented as abdominal pain. Trust records also note his ‘extensive cardiac history’, documenting the five stents previously fitted.

11. An ED clinician assessed Mr D at 9.44am, noting Mr D had epigastric pain (below the ribs in the upper abdominal area) that was dull and non-radiating (in that area only). The clinician notes: ‘like something is stuck in there’, suggesting this is how Mr D described his pain. The clinician notes Mr D had a fever and had vomited, finding no chest pain, no shortness of breath, no heart palpitations, no loss of consciousness and no dizziness.

12. The clinician notes that paramedics gave Mr D aspirin and fluids in the ambulance. It was thought Mr D’s symptoms may be due to his UTI and the clinician’s plan for Mr D’s management included a request for an ECG.

13. A chest X-ray was taken at 1.06pm. Miss D says when her father returned from X-ray, a machine was by the bedside and a nurse came and said she needed to take an ECG. Miss D says her father explained he did not need one, as he already had an ECG in the ambulance. The records note that Mr D refused the ECG and as a result, at 1.18pm it was cancelled.

14. Miss D says a doctor then arrived and explained they had lost the ambulance ECG so needed to take another. She says her father was fully compliant and agreed, yet the nurse and machine did not reappear. Records say the doctor ‘convinced’ Mr D to have the ECG, and this was re-requested at 1.54pm.

15. We acknowledge the difference between the records suggesting Mr D refused an ECG and Miss D explaining her father did not refuse, simply saying he did not need a second. Despite this variance, both Miss D’s account and recorded evidence confirm the same course of events, that the ECG was planned at this time and did not go ahead.

16. Miss D says she was with her father when he was changing his clothes and was suddenly unable to breathe. An emergency call was made, and Mr D was taken to the resus area.

17. The Trust first took an ECG at 5.41pm. A repeat ECG was taken at 6.35pm and this showed evidence of myocardial infarction (MI, commonly known as a heart attack). Mr D’s heart arrested at 6.47pm and resuscitation was started. Very sadly, Mr D could not be resuscitated and he sadly died. Remaining unhappy with the responses to her complaint, Miss D asked for our consideration.

ECG 21. We know how concerned Miss D is about the timing of the ECG, and about the location of her father’s pain. She acknowledges that in response to her complaint, the Trust said Mr D presented with abdominal pain and not chest pain. When we spoke with Miss D, she said her father was in so much pain, he was unable to know exactly where it was.

22. We carefully considered this concern by looking at all available evidence, including ambulance records. We find the paramedics’ records, the initial ED triage note and the ED doctor’s assessment all document either finding abdominal pain on examination, Mr D reporting abdominal pain, or both. They all separately record an absence of chest pain.

23. Whilst we understand it may have been difficult for Mr D to have identified the source of his pain, healthcare practitioners are trained and experienced to do so, via assessment and examination. GMC Guidance says clinicians must adequately assess the patient’s conditions, and where necessary, examine the patient. We are assured this was followed.

24. We know Miss D is concerned about whether the ED was aware of her father’s cardiac (heart) history. The records clearly document Mr D’s cardiac conditions and past events, indicating this was well-known and considered by the relevant medical teams. GMC Guidance says clinicians must take account of the patient’s conditions and history. We are assured this was followed.

25. Our adviser explains Mr D’s presenting symptoms did not immediately or directly indicate a current cardiac problem or cause. The ECG taken by paramedics reported slight abnormalities, yet nothing to show any acute cardiac concern, nor would this predict any future cardiac event. Our adviser confirms the ECG results did not clinically indicate that Mr D required any different management to the care and treatment given by paramedics and once he was in the ED.

26. Sadly, the records suggest Mr D deteriorated over the course of the day. The X-ray found some fluid in his chest, and his oxygen needs then began to increase. When the Trust took its first ECG at 5.41pm this reported slight abnormalities, yet nothing to show any acute cardiac concern, nor would this predict any future cardiac event.

27. Our adviser says there is no significant difference between the results of the ECG taken by paramedics that morning, and the ECG taken at 5.41pm. This further shows that there was no clinical indication that Mr D needed any additional or alternative management or action in the meantime.

28. When ECG was repeated at 6.35pm, this showed clear evidence of an acute MI. From the earlier result, we know that Mr D’s MI occurred sometime between these two ECGs. Considering the consistency of records reporting pain in the abdominal and epigastric area, and all clearly noting no chest pain, our adviser explains there was no immediate or urgent need for ECG.

29. There is no specific guidance that stipulates a need for ECG in any specific timeframe, in these circumstances. NICE Guidance does contain recommendations on timely ECG, however only once a cardiac event has already been identified or diagnosed. This was not the case for Mr D initially as he did not present with a clear cardiac cause for his symptoms. We are satisfied NICE Guidance was followed when Mr D’s symptoms changed and did indicate a cardiac event. In response, the Trust took a repeat ECG without delay.

30. We understand how strongly Miss D feels, that an earlier ECG may have changed the sad outcome. We hope to provide her some assurance that clinically, we do not find this would have been the case. Considering the results of the first ECG, our adviser explains that an ECG at any earlier time is very unlikely to have shown anything different or to have changed Mr D’s management. We do not see anything to indicate a service failure here.

Troponin 31. We also know how concerned Miss D is that a troponin test was not taken sooner.

32. Troponin is a protein within the heart’s muscle cells that leaks into the blood if those cells become damaged. This damage can occur, for example, at the time of or after heart attack. As troponin is only found in the blood once damage has occurred, it is not an indicator of any possible upcoming cardiac event. It is tested in order to aid the clinical management of a person once a cardiac event or cardiac damage has already happened.

33. NICE Guidance recommends troponin testing, yet only when a cardiac event is suspected. As Mr D’s presenting symptoms did not immediately or directly indicate a current cardiac problem or cause, there was no clinical indication or need for troponin testing.

34. Even had Mr D’s bloods been tested for troponin levels earlier, considering there was no evidence of a cardiac event prior to 5.41pm, our adviser says his troponin levels would not have been raised to any extent to warrant any change in his clinical management. We hope to assure Miss D we do not see anything to indicate a service failure here.

In conclusion 35. We were very sorry to have learned of the reasons for Miss D’s complaint, and in no way intend to diminish the incredible distress she has experienced following the death of her beloved father.

36. Our adviser explains that tragically, Mr D suffered a very quick, acute and unrecoverable deterioration, despite an appropriate response once this was clinically indicated. We hope to assure Miss D that we do not see anything to indicate service failure with the timing of the ECG and troponin testing, for the reasons we have explained.

1. We have considered the evidence carefully and we do not see any indications of failings on the part of the Trust. For this reason, we have decided not to investigate further.

2. We know how difficult this time has been for Miss D and how much she has been affected by her father’s sad death. We thank her for sharing the details of her experience with us and hope this statement clearly explains our decision.