14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something seriously wrong. We do this by comparing what should have happened with what did happen. If we see signs something went wrong, we look at whether this had any negative impact. If there are no signs that something had a serious or lasting clinical impact, we will not consider it further.
Complaint about the timing of the doctor’s assessment
15. The RCEM assessment guidelines say initial triage should usually take place within 15 minutes of arrival at the ED. After this, an early assessment by a senior doctor (which was the purpose of the pitstop area) would involve seeing the patient as soon as possible. No set timeframe is specified in the guidelines.
16. In Dr F’s case triage took place within 15 minutes, and this found his physiological observations were normal and he was clinically stable. A doctor then saw Dr F 13 minutes later, which was within 30 minutes of his arrival to the ED. In the context of Dr F’s history and current presentation, our adviser said this early assessment was timely.
17. We have not seen anything to suggest the doctor’s assessment was delayed or should have taken place sooner. In our view, they acted in line with the guidelines and therefore we see no indications anything went seriously wrong here.
Complaint about the adequacy of the doctor’s assessment and documentation, and that the Trust did not suspect or diagnose aortic dissection.
18. The GMC guidelines say doctors need to record their work accurately and document the relevant clinical findings and any action taken or agreed.
19. The RCEM assessment guidelines explain the purpose of an early senior assessment (in an area such as the pitstop area) is to identify time-critical conditions within an appropriate timeframe. Our adviser explained this is not a full clinical assessment but rather a brief assessment for the purpose of triage and to ensure relevant clinical input is identified. A full examination would be done by the relevant clinician, once identified.
20. It is difficult to establish what was included in the assessment because there is very limited documentation. The doctor has completed one line of notes and this does not include any explanation of what history and symptoms were considered or what the examination consisted of. We know history taking and examination took place as the complainants describe this happening, although they say it was only limited.
21. The Trust says doctors are only expected to complete brief records in the pitstop area due to the purpose of the assessments done there. We recognise there was no need for a full assessment at this time, but the records completed do not appear to reflect the extent of the clinical input that was provided. We therefore think it is likely the doctor did not fully document everything that took place.
22. In terms of the quality of the assessment, is it difficult for us to say whether this was detailed enough or not because the record is brief. However, as we go on to explain below, the evidence in the entirety of the records supports an early working diagnosis of ACS and there was no indication to suspect aortic dissection.
23. Although the RCEM diagnosis guidelines are from 2025 and post date events, we have used them to inform this part of our decision as they explain how aortic dissection presents and the challenges of diagnosing it in the ED. We have not used them to say whether or not the Trust got something wrong as we cannot expect the Trust to have followed guidance that did not exist at the time of events.
24. The RCEM diagnosis guidelines say it is often difficult to diagnose aortic dissection in the ED. It is a relatively uncommon cause of chest pain, and of the patients who have symptoms suggestive of aortic dissection, only 0.3% actually have it.
25. The main symptom of aortic dissection is sudden chest pain which is worst at onset and feels like a tearing or ripping sensation. Other symptoms can occur, such as problems with blood pressure and pulse, neurological deficits such as confusion, weakness or loss of consciousness. However, these symptoms are often the same as other heart conditions. Commonly there are no other specific clinical signs.
26. Our adviser says Dr F did not present with the classic symptoms of aortic dissection described above. The doctor who assessed him felt ACS was the most likely diagnosis. Our adviser says this was an appropriate working diagnosis based on Dr F’s presentation. We explain this below.
27. The NICE guidelines say a diagnosis of ACS is indicated if someone has new onset chest pain lasting over 15 minutes that is associated with any of the following: pain in the arms and jaw, nausea and vomiting, sweating, breathlessness, or symptoms from reduced blood flow like low blood pressure, fast heart rate or altered mental state.
28. Dr F presented with many of these symptoms, and therefore we consider a working diagnosis of ACS in the absence of classic aortic dissection symptoms was appropriate and in line with the NICE guidance. We cannot see any indications the Trust got something seriously wrong here.
29. Despite this, we would like to offer some further explanation to the complainants. Dr F’s cardiac arrest occurred within two hours of his arrival in the ED. Our adviser says the onset of his cardiac arrest was rapid and, even if Dr F had classic signs to cause suspicion of aortic dissection, there would have been no opportunity for the Trust to diagnose or treat it in this time. We hope this provides them with some reassurance about the timing of their father’s sad death.
30. Although we have seen there was a potential issue with record keeping, we would like to reassure the complainants this did not have any impact on Dr F. The evidence elsewhere in the records supports the doctor’s working diagnosis, despite the limited documentation of their assessment. As there are no signs of any serious clinical impact arising from the limited record keeping, we will not consider the issue further.
Complaint about cardiac monitoring and location
31. The complainants are concerned their father was not placed on continuous cardiac monitoring when he arrived in the emergency department and was not placed in resus. This is the part of the emergency department where people who are critically ill or need immediate life-saving treatment are closely monitored and cared for.
32. The records show when Dr F was triaged in the ED he was found to have normal physiological observations and was clinically stable. Our adviser says there was no clinical indication he needed to be in the resus area at this time. However, we acknowledge the Trust says in its complaint response it should have put Dr F on cardiac monitoring. This could be an indication something went wrong here.
33. We asked our adviser whether this had any negative impact on Dr F. They explained being on continuous monitoring would not have changed the outcome.
34. The purpose of cardiac monitoring would be to look at Dr F’s heart rate and rhythm. He had a normal ECG when he arrived in the ED indicating there were no problems with his heart rhythm at that time. It is possible this changed in the two hours before his cardiac arrest, but he was not on monitoring and there were no more ECGs, so we do not know.
35. Dr F’s presentation up until the point of cardiac arrest, such as being alert, as well as the type of heart rhythm found when he was in cardiac arrest, means it is likely cardiac monitoring would not have shown anything to make staff suspect aortic dissection.
36. Our adviser says, on balance, the outcome would not have been any different had cardiac monitoring been in place. We are also mindful of the Trust’s explanation that even if aortic dissection was suspected sooner, it would not have had time to facilitate the necessary tests and specialist surgical treatment in the short time that elapsed before Dr F went into cardiac arrest. We therefore cannot see any indications Dr F was negatively impacted here. We hope this reassures the complainants.
37. We recognise the complainant would have been more reassured had cardiac monitoring been in place. Our complaint standards say organisations should acknowledge and apologise for their mistakes, and we can see the Trust has done this in its final response to the complaint.
Complaint about delayed D-dimer test
38. The GMC guidelines say doctors must arrange suitable advice, investigations or treatment where necessary. The NMC code says nurses must make sure any treatment they are responsible for are delivered without undue delay.
39. D-dimer is a blood test used to help diagnose blood clots. It is not usually tested in cases of suspected ACS, and is not recommended in the NICE guideline, but can be carried out to rule out blood clots.
40. It looks like D-dimer was tested in Dr F’s case to check for a broad range of possibilities, following the doctor’s assessment. The records indicate the lab received all the blood samples at 10.08pm. This appears to be in line with the NMC and GMC guidance and we cannot see there was a delay in requesting this test.
41. Some test results were available at 10.54pm with all those relating to tests for blood clots available shortly after, at 11.36pm. This was after Dr F went into cardiac arrest.
42. It appears the results from blood clot tests took longer to come back than the other results. Although we do not know the reasons for this, we have not explored this further. This is because the working diagnosis was ACS and D-dimer is not needed to diagnose this. We would therefore not criticise the Trust for this result not being immediately available.
43. The D-dimer result was high, which can be a sign of a blood clot. When Dr F went into cardiac arrest the doctors did a test which also suggested he had a blood clot in his lung (called a pulmonary embolism). Doctors provided treatment for that suspected blood clot when they were resuscitating Dr F, but this was not successful. At post-mortem it was shown that he did not have a blood clot, but we note the complainants do not complain about this.
44. If the D-dimer result had come back sooner, we think Dr F would have received the same treatment at that point. This means that when Dr F went into cardiac arrest, the same earlier treatment would not have prevented the cardiac arrest. Additionally, we have seen that having the D-dimer result sooner would not have ruled out a blood clot or led to an aortic dissection diagnosis.
45. In summary, we think the care Dr F received, and the unfortunately unsuccessful attempts to resuscitate him, would not have been different had the D-dimer result been available sooner. We therefore see no indication anything went seriously wrong or had a negative impact on Dr F and will not consider this issue further.
Complaint about delayed pain relief
46. The GMC guidelines say doctors should take all possible steps to alleviate pain, and prescribe drugs or treatment that serves the patients needs. The NMC code says nurses must make sure any treatment they are responsible for are delivered without undue delay.
47. In line with the GMC guidelines the doctor who saw Dr F in the pitstop area identified he was in pain and prescribed intravenous morphine, a strong painkiller, at 9.35pm after they assessed him. It was the responsibility of the nursing staff to administer this promptly, but it was not given until 10.31pm.
48. In line with our complaint standards the Trust has already accepted there was a delay here and has offered an apology for this. We recognise it was difficult for the complainants at the time to know their father was left in pain when relief was available. We cannot see any indications this had any lasting or clinical impact, so we will not consider this issue further.