12. Miss L says the Trust failed to investigate and treat her mother appropriately when she attended A&E on 7 September 2023. She says clinicians did not seek correct input from cardiologists at the appropriate time and as a result, her mother very sadly died.
13. The Trust explains Ms R had a significant cardiac history, having had quadruple heart bypass, as well as other significant co-morbidities including several kidney transplants. It says Ms R was appropriately treated for acute coronary syndrome but had a sudden deterioration in the A&E department and despite all attempts to resuscitate her, she sadly died in the department.
14. The Trust says most cardiac conditions can be managed safely and effectively by the medical team and the cardiology team does not necessarily need to be contacted. It says clinicians discussed Ms R’s case with the specialist cardiology team at hospital B.
15. Acute coronary syndrome encompasses a range of conditions resulting from a sudden reduction of blood flow to the heart, including myocardial infarction (heart attack) and unstable angina (reduced blood flow to the heart). NICE Guideline NG185 on acute coronary syndromes says:
STEMI:
1.1.1 Immediately assess eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy (either primary percutaneous coronary intervention [PCI] or fibrinolysis) in people with acute ST-segment elevation myocardial infarction (STEMI).
1.1.3 Deliver coronary reperfusion therapy (either primary PCI or fibrinolysis) as quickly as possible for eligible people with acute STEMI
NSTEMI:
1.2.2 Offer people with unstable angina or NSTEMI a single loading dose of 300-mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.
1.2.3 Offer fondaparinux to people with unstable angina or NSTEMI who do not have a high bleeding risk, unless they are undergoing immediate coronary angiography.
1.2.7 As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6‑month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]). [2010]
1.2.8 Include in the formal risk assessment:
• a full clinical history (including age, previous myocardial infarction [MI] and previous PCI or coronary artery bypass grafting [CABG]) • a physical examination (including measurement of blood pressure and heart rate) • a resting 12‑lead ECG, looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin)
16. The notes show Ms R arrived in A&E by ambulance at approximately 10:35am on 7 September 2023. Her presenting complaint was central chest pain radiating to her neck and head, breathlessness and vomiting. We can see from the notes, a doctor assessed Ms R promptly shortly after her arrival in A&E and noted her past medical and cardiac history.
17. An electrocardiogram (ECG) records the electrical activity of the heart, including the rate and rhythm. ST elevation is a finding on an ECG. A ST segment elevation myocardial infarction (STEMI) is usually caused by complete and persistent blockage of the artery and can cause extensive damage to the heart. A non- ST elevation myocardial infarction (NSTEMI) occurs when there is partial or intermittent blockage of the artery. The notes show clinicians arranged for Ms R to have an ECG when she attended A&E, which did not indicate she had a STEMI and her recorded observations at triage were within normal range. The ambulance crew had already given Ms R aspirin before she arrived at hospital, which can be used as an antithrombotic to help to stop blood from clotting.
18. Clinicians also arranged for Ms R to have a chest X-ray and a high sensitivity troponin blood test. Troponin is a protein found in the muscles, including the heart. When the heart is injured or damaged, troponin is released into the blood and the levels rise. Ms R’s result was high which suggested some damage to her heart. Her chest X-ray showed no acute changes to her previous one. The clinical impression was unstable angina and following discussion with the medical registrar, the plan was to admit Ms R to hospital and repeat the troponin test at 2pm. Our adviser tells us this was appropriate management in line with the NICE guidance NG185 on treating NSTEMI and unstable angina set out above.
19. At around 3:45pm, clinicians transferred Ms R to the resuscitation area as she reported feeling dizzy, clammy and cold. Our adviser tells us the ECG showed ST elevation. We cannot say when this exact ECG was done as they are not time stamped, but this was a new change compared with the previous ECG’s taken that day. Clinicians attached Ms R to monitors, repeated the troponin test, and gave her intravenous (IV) fluids.
20. The treating clinician noted they discussed Ms R’s condition and whether she would be suitable for percutaneous coronary intervention (PCI) with the cardiology team at hospital B at around 4:08pm. PCI is a minimally invasive procedure to open blocked coronary (heart) arteries and as per NICE guidelines above, patients with ST elevation should be assessed for this. The treating clinician noted the cardiology registrar at hospital B advised that Ms R was not for PCI transfer now and to treat her locally for acute coronary syndrome, and to call them call back post-cardiology review.
21. The cardiology registrar at hospital B also made a note of this conversation in their records. They noted Ms R did not meet the criteria for urgent PCI based on the ECG findings alone. The cardiology registrar noted they discussed this with their consultant who advised ACS treatment, additional blood gases, local cardiology review and a bedside echocardiogram (scan of the heart). They then recorded they had a further telephone conversation with an A&E consultant at the Trust who had since reviewed Ms R. The cardiology registrar noted they advised the A&E consultant to call back if more information on the above is available and ‘the patient remains unwell or if things deteriorate’.
22. The A&E consultant prescribed fondaparinux as advised by the cardiology team at hospital B. Fondaparinux is an anticoagulant medication used to prevent or treat blood clots. As per 1.2.3 of the NICE guidance above, fondaparinux should be offered to people with unstable angina or NSTEMI who do not have a high bleeding risk. Fondaparinux has Increased risk of bleeding for patients with renal impairment. Our adviser says ideally clinicians should have prescribed fondaparinux to Ms R earlier in the admission but on the balance of probabilities, considering the risk of bleeding, it would not have altered the outcome.
23. At around 5pm, the notes say Ms R became clammy and sweaty again and her blood pressure and oxygen saturations dropped. Ms R became unresponsive, and her breathing was laboured. She went into cardiac arrest and clinicians started cardiopulmonary resuscitation (CPR). Very sadly, CPR was not successful, and Ms R died at 6:48pm.
24. We find that clinicians arranged appropriate tests and investigations for Ms R when she attended the A&E department and they sought cardiology appropriately and in a timely way, when her condition deteriorated, and she had new ECG changes. This management is in line with the NICE guidelines above. Overall, we do not see the Trust got something wrong and we do not uphold this complaint. We fully recognise how important this complaint is to Miss L and how incredibly distressing this experience was for her. We hope our decision provides her with some reassurance.