LUCAS device
14. Mrs R says there was no Lund University Cardiopulmonary Assist System (LUCAS) device in the resuscitation area, and it took 45 minutes to retrieve an alternative device. The LUCAS device provides mechanical chest compressions to patients in cardiac arrest, instead of human- performed manual compressions.
15. The Trust say the LUCAS device was missing from the resuscitation room. This meant chest compressions were delivered manually. It says rescuers are trained to give effective manual chest compressions and a team leader ensures staff are rotated with minimal interruption to prevent fatigue.
16. The Resuscitation Council UK: Adult advanced life support guidelines 2021 say ‘consider mechanical chest compressions only if high-quality manual chest compression is not practical or compromises provider safety. When a mechanical chest compression device is used, minimise interruptions to chest compression during device use by using only trained teams familiar with the device’.
17. The notes show Mr U arrived in A&E at around 8:15pm. He sadly went into cardiac arrest at 8:21pm and clinicians started CPR. The notes say there was no LUCAS in the resuscitation room and all CPR was done manually. A LUCAS device came from the critical care unit (CCU) at 9pm and it was used for compressions from then on.
18. Our ED adviser explains there is no specific national guidance that says a LUCAS device should be available in the resuscitation room. If there is a prolonged cardiac arrest, clinicians can consider using a LUCAS device as per the resuscitation council guidelines above, but it is not mandatory. It was therefore not a requirement this should have been used in Mr U’s case.
19. Large randomised controlled trials of the routine use of mechanical devices in the out-of-hospital setting have found no evidence of improved patient outcome in patients treated with mechanical CPR, compared with manual CPR. Our ED adviser explains there is conflicting evidence around the benefits of using a LUCAS device, and it does not always achieve a better outcome.
20. We appreciate Mrs R’s concerns with the lack of a LUCAS device, and we understand this caused her additional worry. We have not found any indication the Trust got something wrong here.
Intubation
21. Mrs R says there was a delay in intubating her husband following his cardiac arrest. Intubation is a medical technique that involves having a tube inserted into the trachea (the tube that carries air to and from the lungs) through the mouth or nose to keep the airway open.
22. The Trust says the cardiologist asked A&E clinicians to intubate Mr U to secure his airway before he could be transferred. It says clinicians intubated Mr U at 8:50pm and attempts to intubate were interrupted by the need to deliver shocks.
23. The Resuscitation Council UK: Adult advanced life support guidelines say:
• during CPR, start with basic airway techniques and progress stepwise according to the skills of the rescuer until effective ventilation is achieved.
iIf an advanced airway is required, only rescuers with a high tracheal intubation success rate should use tracheal intubation.
• the expert consensus is that a high success rate is over 95% within two attempts at intubation.
• aim for less than a 5 second interruption in chest compression for tracheal intubation.
• use direct or video laryngoscopy for tracheal intubation according to local protocols and rescuer experience.
• high-quality chest compressions with minimal interruption and early defibrillation remain priorities.
24. The notes say the emergency department doctor spoke with a cardiologist at 8:30pm for advice on Mr U’s suitability for primary percutaneous coronary intervention (PPCI). PPCI is a procedure to unblock a coronary artery. The cardiologist requested Mr U be intubated before he could be transferred to the catheterisation lab, and this was completed by the ICU team at 8:50pm. The ED doctor then called the cardiologist back and they advised to do further arterial blood gases.
25. Our ED adviser tells us there is no guidance that sets out a specific time when a patient in cardiac arrest should be intubated. As set out in the resuscitation guidelines, the initial focus would be on CPR with minimal interruption. Mr U was intubated prior to his transfer to the catheterisation lab. Our ED adviser says it was sensible and pragmatic to intubate Mr U before transfer. There was no indication clinicians should have intubated Mr U before this.
26. Our ED adviser also explains there is also no overwhelming evidence early intubation improves outcomes. A study looking at airway management during cardiac arrest concluded that the current evidence does not indicate a substantial improvement in outcome from any single airway strategy.
27. We are truly sorry to hear about Mrs R’s concerns that delays with intubation may have had an impact on her husband’s condition. Having considered the available evidence, we cannot see there is an indication something went wrong here.
Blood gases:
28. Mrs R says there was a delay in clinicians requesting additional blood gases when her husband was in cardiac arrest.
29. A blood gas test measures the oxygen and carbon dioxide levels in the blood as well the blood's pH balance. The notes show clinician’s performed blood gas tests for Mr U at 8:26pm 8:36pm 8:54pm, 9:38pm and 9:43pm.
30. Paragraph 15 of GMC Good medical practice guidance says ‘you must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must… promptly provide or arrange suitable advice, investigations or treatment where necessary’.
31. From the notes we can see clinicians requested bloods gases for Mr U early to identify if there were any reversible causes of his cardiac arrest (which they did not). Our ED adviser says there are no specific recommendations in any guidance about how many times blood gases should be requested. Clinicians requested blood gases three times during the time Mr U was in the ED, which our ED adviser says was clinically appropriate. We consider this is in line with paragraph 15 of the GMC guidelines on promptly providing investigations and we cannot see any indication of a failing.
Cardiology input:
32. Mrs R says the ED clinicians delayed seeking specialist input from the cardiology team and the cardiology team was slow to mobilise. The Trust say the team recognised at around 8:30pm the likelihood that Mr U had a heart attack and contacted the on-call cardiology consultant.
33. Paragraph 16 of GMC Good medical practice guidance says ‘in providing clinical care you must… consult colleagues where appropriate’
34. The notes show the A&E doctor called the cardiology consultant about possible PPCI at around 8:30pm, around nine minutes after he went into cardiac arrest. The cardiologist said Mr U should be intubated, and once this was done to call back and to take to the catheterisation lab. The A&E doctor called the cardiologist back at 8:50pm, and they requested additional blood gases. Following this, the cardiologist advised the team had been activated and Mr U was transferred to the catheterisation lab with CPR still ongoing. When he arrived in the catheterisation lab, clinicians performed a scan on Mr U’s heart and sadly no cardiac activity was seen. The team therefore made the decision to stop CPR at 9:45pm.
35. Our ED adviser explains there is no specific guidance on when A&E should seek input from cardiology in this scenario. Our A&E and our cardiology advisers both say the ED clinicians requested input from cardiology early on and sought advice from them at the appropriate time. The cardiologists advised Mr U should be intubated, and blood gases should be done.
36. Our ED adviser says there was no obvious signs of a heart attack on Mr U’s ECG. A perfusing rhythm is a heart rhythm that allows the heart to effectively pump blood. Our cardiology adviser says the only clear indication to arrange cardiac intervention would be to restore a stable perfusing rhythm with evidence of ST elevation myocardial infarction (heart attack). As this was not the case for Mr U, there was no requirement to involve the cardiac team. It was appropriate for the A&E clinicians to seek cardiac advice and for PCI to be considered.
37. Our cardiology adviser explains there is no clear evidence base that PPCI would have improved Mr U’s condition. The role of PPCI in patients where resuscitation is being performed for ventricular fibrillation (a type of irregular heart rhythm) is controversial with conflicting results from studies. In patients where cardiopulmonary resuscitation is ongoing, the evidence on the effectiveness of PPCI is even less clear.
38. There are no guidelines to guide decision making around when to arrange PPCI in cases such as Mr U’s. The UK Resus Council guidelines make it clear the priority should be restoring a perfusing rhythm (through defibrillation), supporting a non-perfusing rhythm through CPR and providing and delivering oxygen to the tissues in the body through ventilation, which is what the treating clinicians focussed on. We therefore consider the treating clinicians acted appropriately and we cannot see any indication something went wrong.
Mortuary arrangements:
39. Mrs R says staff allowed other people to visit her husband in the bereavement centre after she and her daughter had expressly said she did not want this. She says she was physically removed from the building in order that this person could visit without time constraints.
40. In their statement provided as part of the Trust investigation, the mortuary member of staff says Mrs R informed them that another individual wanted to see her husband, and that she did not want any contact with them. The mortuary assistant says Mrs R did not instruct her that this individual should not see her husband and when the viewing concluded she suggested Mrs R leave via the visitor’s external entrance to avoid contact with the other individual and she walked her out and the interaction concluded amicably.
41. It is clear Mrs R’s version of events about what she said about no visitors and what happened after the viewing conflicts from what the mortuary assistant recalls. We recognise the way in which things are said are open to interpretation and each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception of the same comment.
42. Whilst we do not dispute Mrs R’s recollection, unfortunately, we were not present at the time to independently know what, and how, things were said. We accept there could have been some miscommunication and misunderstanding about what Mrs R’s wishes were regarding visiting. We are left without independent supporting evidence that would indicate to us that a service failure took place.
Phone access/ communication:
43. Mrs R says staff accessed and used her husband’s phone when he was unconscious and did not call her as her husband’s emergency contact and next of kin, to inform her of his death first.
44. The Trust say ED staff acted staff acted in the best interest of Mr U and once they were informed about Mrs R, the mobile telephone was used to gain access to her contact number.
45. GMC Confidentiality: good practice in handling patient information says:
'34. You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support, while respecting the patient’s right to confidentiality.
38. If a patient lacks capacity to make the decision, it is reasonable to assume the patient would want those closest to them to be kept informed of their general condition and prognosis, unless they indicate (or have previously indicated) otherwise.
44 You may disclose personal information if it is of overall benefit to patient who lacks the capacity to consent. When making the decision about whether to disclose information about a patient who lacks capacity to consent, you must:
• make the care of the patient your first concern • respect the patient’s dignity and privacy • support and encourage the patient to be involved, as far as they want and are able, in decisions about disclosure of their personal information.'
46. We appreciate this was a very difficult situation as Mr U very sadly collapsed shortly after arriving in the A&E department on his own, and before staff had a chance to complete a history. Our ED adviser says it does not appear clinical staff exhausted all options to find out who Mr U’s next of kin was before they accessed his phone and shared information with others and this was not in line with GMC guidance.
47. Our ED adviser explains Trust staff could have looked at Mr U’s patient records, contacted his GP or contacted the police. Often, people will also have the emergency contact function on their phone, and this gives access to the information the patient would want the clinicians to have. This meant Mrs R was not the first person to be notified of her husband’s death and we appreciate this was incredibly distressing for her and her family.
48. The Trust says it is looking into whether any training or guidance can be implemented for staff on how to access emergency contact information on Android or iPhone handsets. It says it will take the communication of accessing emergency contact information on mobile telephones as an action.
49. NHS complaints handling standards say ‘wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people and ‘organisations should take action to make sure any learning is identified and used to improve services’. We are very sorry to hear about the impact this had on Mrs R. We consider the actions the Trust has already taken are in line with the NHS standards and enough to remedy what went wrong here and we will not take any further action.
Complaint Handling:
50. Mrs R complains about how the Trust handled her complaint. She says staff refused to speak with her about her complaint until she provided her marriage certificate.
51. NHS complaints standards say ‘your duty of confidentiality to your patients and service users continues after their death. If the person has died, their ‘personal representative’ or the legal executor of their estate will control access to any personal information, including clinical records’.
52. We can see from the Trust complaints file Mrs R raised her formal complaint on 22 August 2022 and the Trust asked some documentation to ensure she was suitable to bring the complaint. Mrs R provided her and her husband’s marriage certificate. The Trust initially asked for bereavement consent but after taking some further advice, decided that would not be necessary. The Trust confirmed this to Mrs R in an email dated 8 September.
53. Complaints responses often contain very sensitive information about the patient and organisations are still bound by the duty of confidentiality even following a patient’s death. The Trust asked for information to check Mrs R was suitable to bring the complaint, which is line with NHS complaints standard. We fully recognise this was an incredibly upsetting time for Mrs R and her family and we are truly sorry to hear about the additional distress this caused them. Given the Trust has followed the relevant guidance, we cannot say there is an indication of failing here.
54. Mrs R also says the Trust sent its response letter to her the day before her husband’s inquest, so she had no time to process the information, and it avoided giving direct answers.
55. NHS complaints regulations say:
2) As soon as reasonably practicable after completing the investigation, the responsible body must send the complainant in writing a response, signed by the responsible person, which includes—(a)a report which includes the following matters (i) an explanation of how the complaint has been considered; and (ii) the conclusions reached in relation to the complaint, including any matters for which the complaint specifies, or the responsible body considers, that remedial action is needed; and (b) confirmation as to whether the responsible body is satisfied that any action needed in consequence of the complaint has been taken or is proposed to be taken;
56. The Trust responded to Mrs R’s complaint on 22 October 2022. We can see Mrs R raised further concerns to the Trust on 22 November 2022. The Trust’s further response letter is dated 26 January 2023. Mr U’s inquest took place at the end of January 2023.
57. We are very sorry to hear the letter arrived very shortly before the inquest, so Mrs R did not have the opportunity to digest the information. We appreciate this would have been difficult. We can see the Trust provided a lengthy response to Mrs R’s further concerns within a reasonable timeframe and shared it with her at the earliest opportunity, in line with NHS complaints regulations. We therefore cannot say this was an indication of a failing.
58. We appreciate Mrs R was not satisfied with the answers the Trust provided, We consider the Trust’s responses met the standard set out in the NHS regulations as they contained explanations of what happened and considered each of Mrs U’s questions in turn. It also identified where action could taken to improve services. We therefore cannot see it got something wrong.
59. We fully recognise how important this complaint is to Mrs R and thank her for bringing it to us. We hope she is reassured by our decision.