Diagnosis of pericardial effusion/ echocardiogram:
15. Mrs A says clinicians failed to identify her husband had a pericardial effusion when he attended A&E on 22 September 2017. She says there is no evidence a ‘fast’ echocardiogram was done in A&E after her husband’s cardiac arrest.
16. A pericardial effusion is the buildup of excess fluid in the sac that surrounds the heart. An echocardiogram (echo) is a type of ultrasound scan used to look at the heart and nearby blood vessels.
17. The Trust says the A&E clinicians initially suspected Mr A had a pulmonary embolism based on his clinical presentation. A pulmonary embolism is a blockage in one of the blood vessels in the lungs, usually due to a blood clot.
18. The Trust says an A&E doctor did an echo after Mr A went into cardiac arrest, but the exact time is unknown. It says this did not identify the pericardial effusion and the images were not stored as it was in the middle of a cardiac arrest. The Trust says the cardiologist then did a second echo which identified the pericardial effusion.
19. The notes show Mr A presented to A&E at approximately 12:05pm and a doctor assessed him at 12:34pm. He had worsening shortness of breath and was in a fast and irregular heart rhythm (atrial fibrillation) which was being treated as a priority before the cardiac arrest.
20. Paragraph 1.7.2 of NICE guideline CG180 says patients with atrial fibrillation should be offered either rate or rhythm control if there is no haemodynamic instability (insufficient blood flow).
21. Mr A’s heart rate was very high, and his oxygen levels were initially low and came up to a normal level with oxygen. Electrical cardioversion uses a machine to shock the heart into a regular rhythm. Chemical cardioversion uses medicine to try and reset the heart rhythm. The records show the treating clinicians opted to chemically try to convert Mr A’s rhythm into a normal rhythm with betablockers (medicine to slow the heart rate). Clinicians also gave Mr A given intravenous (IV) fluids for dehydration.
22. There is nothing in the guidelines to say an echo should form part of the initial management plan for fast atrial fibrillation, which was the predominant finding when Mr A arrived in A&E. We therefore cannot see there was a requirement for clinicians to have carried out an echo before Mr A went into cardiac arrest. Our adviser explains pericardial effusion is a rare diagnosis and other causes of Mr A’s shortness of breath including heart failure from fast atrial fibrillation were more likely.
23. Mr A went into cardiac arrest at around 1:05pm. During the local resolution meeting, the consultant who was leading CPR explained a doctor performed echo at his request as part of the ‘fast scan process’ but they did not see pericardial effusion. The consultant says the images would not have been saved and the result was fed back verbally. There is no evidence of this echo in the notes. The cardiology team arrived later and performed another echo which identified the pericardial effusion.
24. The resuscitation council guidelines (ALS) say ‘when available for use by trained clinicians, focused echocardiography/ ultrasound may be useful with assisting diagnosis and treatment of potentially reversible causes of cardiac arrest’. This should take place in between chest compressions (less than 10 seconds).
25. The events of this complaint took place in 2017. Our adviser explains ultrasound is still an emerging tool used in emergency medicine and trainees are becoming more skilled in this as time goes on. It would not be reasonable to expect a trainee to have 100% accuracy in identifying a pericardial effusion during a cardiac arrest based on one look during the window in chest compressions. They are not experts in ultrasound or cardiac ultrasound.
26. Mr A’s pericardial effusion diagnosis was eventually made by a cardiology consultant whose presence at a cardiac arrest is not routine. The cardiologist would have had much more skill and experience in heart ultrasound than the emergency medicine and medical team who lead cardiac arrests.
27. Paragraph 19 of GMC Good Medical Practice guidance says ‘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’.
28. Our adviser says the results of the first echo should have ideally been communicated to the scribe or documented later. It is however not unusual for this information to not be documented and lost, especially when there is prolonged resuscitation such as in Mr A’s case. Mr A had almost two hours of resuscitation and the team were involved in his complex care throughout.
29. Our clinical adviser says there are no national guidelines that say the treating team should done anything differently, which could have led to the diagnosis of Mr A’s pericardial effusion any sooner. At the point Mr A had the cardiac arrest he was sadly already extremely unwell. He was in asystole which means his heart was not beating at all in any meaningful way that could have led to an output resulting in circulation. Our adviser explains the outcome from patients who are in asystole at the time of the cardiac arrest is the poorest outcome for all patients in cardiac arrest and very sadly results in a very poor survival rate.
30. We appreciate the circumstances around Mr A’s cardiac arrest were incredibly traumatic for Mrs A and her family and the lack of evidence in the notes of the first echo left them with outstanding questions. We have seen the Trust’s management of Mr A was appropriate and in line with relevant guidelines. The result of the first echo should have been included in the notes. In the context of this happening during a lengthy resuscitation, we do not consider this omission is so serious it amounts to a failing.
Alteplase
31. Mrs A says clinicians gave her husband alteplase which was inappropriate for somebody with a pericardial effusion. The Trust explain clinicians thought the most likely diagnosis was pulmonary embolism and the alteplase was appropriate.
32. Alteplase a thrombolytic drug and it works by dissolving blood clots blocking blood flow. In is often used when a patient is suspected to have a pulmonary embolism or a stroke.
33. The ALS guidelines say clinicians should consider thrombolytic drug therapy when pulmonary embolus is the suspected or confirmed as the cause of cardiac arrest. The guidelines also say the resuscitation team should consider CPR for 60-90 minutes after administration of thrombolytic drugs.
34. Mr A presented with very low oxygen saturations and shortness of breath. Our adviser tells us the treating team made a reasonable assumption based on his symptoms there was a high probability he had a pulmonary embolism.
35. Pulmonary embolism is one of the reversible causes of asystole. Our adviser says in the absence of another cause being found, it was appropriate for the team to use alteplase and to continue CPR in line with the ALS guidance.
36. We acknowledge ultimately Mr A did not have a pulmonary embolism. He had pericardial effusion and alteplase is not indicated for this condition. As discussed in the section above, pericardial effusion is a rare diagnosis and pulmonary embolism was a reasonable diagnosis based on the evidence available to the treating team at that time. We are therefore not critical of the decision to administer alteplase in an attempt to treat this and reverse the cause of the cardiac arrest.
37. The postmortem report says Mr A’s pericardial effusion was due to invasion of the lung cancer into the pericardial space, which indicates this happened before the cardiac arrest. Our adviser explains we cannot know for certain if the alteplase led to the effusion becoming any larger during the cardiac arrest. Given over a litre of blood-stained (not blood) fluid was removed from the space, and Mr A’s symptoms had progressed over several days, our adviser says it seems unlikely the alteplase was a significant factor.
38. We fully understand Mrs A’s concerns around the administration of alteplase given he did not have a pulmonary embolism as first suspected, and we are sorry to hear about the additional distress this has caused. Although in retrospect this was not indicated for pericardial effusion; we are not critical of the Trust’s decision to give this in the context of a cardiac arrest where pulmonary embolism was a likely diagnosis.
Witnessed resuscitation
39. Mrs A says the family witnessed her husband’s failed resuscitation and were not given the opportunity to leave. The Trust says Mr A’s family chose to be present for the resuscitation but acknowledge a nurse who was not involved in CPR should have been present to accompany them and answer any questions.
40. Paragraph 33 of GMC good medical practice guidance says, ‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
41. The notes say Mr A’s family were asked if they wanted to attend the cardiac arrest and they chose to attend.
42. The Trust has acknowledged Mr A’s relatives were not offered the correct support when they attended his cardiac arrest. It identified there was not a medical member of staff there to support them, answer questions or escort them out if they wished to leave.
43. We recognise being present during attempted resuscitation without adequate support would have been an incredibly traumatic experience for Mrs A and her family. We are truly sorry they had to experience this.
44. NHS complaints standards say ‘an effective complaint handling system makes sure staff take a thorough, proportionate, and balanced look into the issues raised in a complaint. It gives people fair and open answers to their questions based on the facts, and takes full accountability for mistakes identified….wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’.
45. The Trust has apologised to Mr A’s family for not providing adequate support. It has also put a plan in place to improve training and staffing to try and prevent this from happening again. We are pleased to see the Trust have reflected on this and put measures in place to prevent a recurrence. We consider this enough to put this right, in line with the NHS complaints standards.
46. We recognise how important this complaint is to Mrs A and her family, and we do not doubt Mr A’s death has caused them immeasurable distress. We thank her for bringing her concerns to us for consideration. We hope she is reassured by our findings.