23. Mr S complains the Trust did not provide him with any help when he presented with chest pain and his condition deteriorated whilst he was in the ED waiting room.
24. Within his complaint we have considered the following issues: triage waiting time; the Trust’s actions while Mr S was in the waiting room; the Trust’s actions when triaging Mr S.
Triage waiting time
25. In its complaint responses, the Trust explained that although triage should occur within 15 minutes of arrival, this is not always possible during times of peak demand. This is because the triage team are not able to keep pace with patient arrivals.
26. The Trust explained that when Mr S presented at ED the department was working under peak demand pressures. It stated that when this happens, it continues to try to see patients in order of arrival but will also prioritise patients according to how time critical their presenting issue is and how unwell they are.
27. RCEM Initial Assessment guidance says that EDs should triage patients within 15 minutes of their arrival.
28. However, the Kings Fund ED waiting times article explains that due to increased demand for ED services, a lack of funding and growing staff shortages, nationally ED waiting times exceed the ideal times given in guidance.
29. The records show Mr S registered at ED at 7.13pm and the Trust completed triage at 7.43pm. This means it took the Trust 30 minutes to triage Mr S. This is not in line with RCEM Initial Assessment guidance as it exceeds the 15-minute triage time recommended.
30. We understand from our ED adviser that nationally, EDs were and still are under ongoing severe pressure as a result of poor recruitment and retention of staff, increasing attendances, a lack of hospital beds to move ED patients to (exit block) and the ongoing effects of the COVID pandemic. This is evidenced within the Kings Fund ED waiting times article.
31. The Trust has explained that at the time of Mr S’s ED attendance it was under significant pressure. This is reflective of the national situation regarding waiting times.
32. Given the documented national pressures on EDs, it is our view that a delay of 15 minutes in triage time does not fall so far short of the expected standard as to be a failing.
33. We appreciate the wait to be seen was very distressing for Mr S and are sorry for his experience.
The Trust’s actions while Mr S was in the waiting room
34. The Trust explained its receptionist informed the triage nurse how much pain Mr S was in and that he looked unwell. The Trust stated the receptionist did not recall Mr S’s daughter requesting a sick bowl or Mr S being on the floor in the recovery position. The Trust explained if the receptionist had seen this, they would have pulled the emergency bell.
35. NMC The Code paragraph 13.1 says nurses must accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care.
36. We can see from the Trust’s complaint response both Mr S and subsequently his daughter told the Trust receptionist he was experiencing increasing chest pain and nausea. The Trust receptionist stated she informed the triage nurse of Mr S’s pain on both occasions.
37. Our ED adviser explained chest pain is common presentation to ED, and a patient presenting with chest pain would not necessarily be considered a very high priority situation. They explained that if a patient is awake, alert and appears orientated, other patients who present with more urgent problems, for example, bleeding uncontrollably, loss of consciousness, or having a seizure, are necessarily of a higher priority to be seen.
38. At the time he and his daughter informed the Trust receptionist of his increased chest pain, we understand Mr S was awake, alert and orientated. Therefore, we cannot say the Trust should have moved his triage forwards at this point. This is because we cannot know what other patient priorities the Trust was managing at that point.
39. Mr S explained to us that he initially sat down in the main area of the waiting room. He was then sick and decided to move nearer to the doors of the ED treatment area. At this point he sat on the floor in the W position, which he had learnt in military first aid training. The idea of the W position is to assist in improving circulation and reducing the heart's workload. He says his condition then got so bad he felt the need to place himself in the recovery position.
40. We have considered whether the Trust should have noticed Mr S placing himself in the recovery position and provided care at this point.
41. We understand from our ED adviser there is no specific guidance on whether staff should notice an unwell person on the ED waiting room floor.
42. The Trust has told us that the triage nurse, and nurse in charge of minors have responsibility for patients in the waiting room. This means the most relevant guidance is NMC The Code paragraph 13.1.
43. Our ED adviser explained that although Trust staff should have noticed Mr S was lying on the floor and checked on him, this can be very hard to do in a busy ED waiting room. This is because in ED waiting rooms there are often too many people in not enough space. This makes it extremely challenging to identify which patients are unwell.
44. The Trust acknowledged in its complaint response that the ED waiting room requires work, and that had the receptionist seen Mr S in the recovery position they would have pulled the emergency bell. In its complaint responses the Trust also shared that at the time of Mr S’s presentation to ED the department was very busy.
45. It is our view that while we recognise the Trust should have noticed Mr S was on the floor, the fact it did not do so does not fall so far short of NMC The Code as to be a failing. We do not underestimate the distress Mr S suffered during this time and do not intend our decision to undermine the ongoing impact this experience still has on Mr S.
The Trust’s actions when triaging Mr S
46. Mr S told us that when the triage nurse came to take him to the triage room, they did not check him or offer him any help despite being able to see he was in the recovery position. He says instead they forced him to self-mobilise to the triage room.
47. The Trust apologised that a member of the nursing team did not help Mr S off the floor and explained the triage nurse was an agency nurse. It initially stated this was due to Mr S being verbally aggressive but later acknowledged the nurse’s actions lacked care or compassion, and that when the nurse had realised Mr S was on the floor, they should have come to him immediately and acted on the situation.
48. NMC The Code paragraph 1.1 says nurses must treat people with kindness, respect and compassion. Paragraph 1.2 says nurses must deliver the fundamentals of care effectively. Paragraph 13.1 (see above) is also relevant.
49. The Trust complaint file confirms that when the triage nurse called Mr S for triage, they did not approach him whilst he was on the floor. Instead, they required him to get up and walk to the triage room without assistance.
50. Our ED adviser explained as soon as the triage nurse saw Mr S was on the floor, they should have completed a basic assessment prior to asking Mr S to move. This should have included assessing his conscious level, breathing and pulse to determine if it was appropriate for him to get up.
51. There is no evidence in the records the triage nurse did this. The Trust response also confirms the triage nurse did not assess Mr S prior to asking him to move. This is not in line with NMC the code, paragraph 1.2 and 13.1.
52. Additionally, we understand from our adviser the triage nurse’s approach was not in line with NMC The Code, paragraph 1.1 because they did not treat Mr S with kindness or compassion. The Trust have acknowledged this in its local resolution meeting.
53. Therefore, it is our view the Trust failed to act in line with NMC The Code paragraphs 1.1, 1.2 and 13.1 when taking Mr S for triage.
54. We consider the impact of this in paragraphs 73 to 81.
55. Mr S complained during triage the nurse did not allow him to lie down in the triage room. The Trust explained this is because triage beds do not have wheels, so it is quicker and safer to do a quick triage on a chair, before moving to a cubicle with a trolley to complete an ECG.
56. NICE NG185 1.1.1 says to immediately assess patients with acute coronary symptoms for eligibility for coronary reperfusion therapy. Coronary reperfusion therapy refers to medical treatments used to restore blood flow to the heart muscle following a blockage in one or more of the coronary arteries.
57. We understand from our ED adviser that although there is no specific guidance on whether a patient should sit or lie when triaged, the Trust’s explanation is clinically sound. Therefore, it is our view that the Trust acted in line with NMC The Code paragraph 13.1.
58. The records show on triaging Mr S the Trust immediately completed an ECG, recognised the results indicated Mr S was experiencing a cardiac event and transferred him to resus. This is in line with NICE NG185.
CCTV
59. Mr S also complains the Trust did not provide him with a copy of the CCTV footage he requested when he made his complaint.
60. In its complaint response the Trust stated it only keeps CCTV footage for two weeks. It explained that although Mr S sent his complaint and request for CCTV footage in under a week, due to severe workforce issues it was unable to process this before the CCTV footage was deleted.
61. The Trust went on to explain that it is updating its CCTV system to increase the memory size, which will enable it to store footage for longer than two weeks.
62. UK GDPR regulations state a person has the right to access any personal data an organisation holds about them.
63. Our ‘Principles of good administration’, ‘Getting it right’, state public bodies must comply with the law and have regard for the rights of those concerned. They also state public bodies should provide effective services with appropriately trained and competent staff.
64. Our ‘Principles of good administration’, ‘Being customer focused’, state public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits.
65. Government guidance on requesting CCTV footage states a person has the right to request CCTV footage of themselves under the data protection law, and that this can be done verbally or writing. It explains that if an organisation cannot release the footage due to other people being seen in it, then the organisation can invite the person to view the footage.
66. The Trust has stated at the time it kept CCTV footage for two weeks due to the capacity of its storage systems. The CCTV footage was taken on 22 April 2022 and was therefore deleted on 6 May.
67. Mr S verbally requested CCTV footage held of him on 28 April and contacted the Trust again on 4 May. The Trust processed his request for CCTV on 5 May and passed it to its security manager. This means the Trust processed Mr S’s complaint within five working days.
68. The security manager was unable to process the CCTV request immediately, and therefore the CCTV footage expired before the Trust could fulfil Mr S’s request. This is not in line with UK GDPR regulations or government guidance on requesting CCTV, as the Trust was unable to provide Mr S with personal data, which it possessed at the time he requested it.
69. Our ‘Principles of good administration’, ‘Getting it right’ mean that Trust staff should have been aware of how long CCTV footage was kept and the relevant UK GDPR regulations in relation to a person’s right to access their own data.
70. It is our view that the Trust did not act within a reasonable timescale when processing Mr S’s request for access to the CCTV footage.
71. This is because Trust complaints staff should have been aware CCTV footage was only kept for two weeks and immediately communicated Mr S’s request to the security manager. Additionally, the security manager should have been aware of the need to act promptly to ensure they complied with Mr S’s request before the footage was automatically deleted.
72. Overall, it is our view that the Trust failed to act in line with guidance when actioning Mr S’s request for CCTV footage. This is because it did not act in line with our ‘Principles of administration’, and it did not have the necessary systems in place to allow it to comply with UK GDPR regulations or government guidance on requesting CCTV.
73. We next consider the impact of this in paragraphs 82 to 89.
Impact - Triage
74. Here we consider the impact of the Trust triage nurse not assessing Mr S before asking him to self-mobilise to the triage room.
75. Mr S explained the Trust’s failure to provide him with immediate help when he deteriorated means he will never know whether his outcome could have been different. He reports that he now only has 30 to 35% heart function, which has caused him to lose his license to drive coaches, which in turn has led to him losing his job. Due to the impact of his heart health on his overall health Mr S has not been able to return to work in a different career, despite his attempts to do so.
76. He also explained the Trust’s actions have left him with no faith in the Trust or in any treatment it may offer him in the future. He says this has caused him to become fretful when going out.
77. The records evidence that Mr S did not suffer any immediate deterioration on standing or mobilising. Our cardiology adviser explained this makes it unlikely that mobilising the short distance to the triage room would have caused his heart attack to progress. Therefore, we cannot say the Triage nurses actions impacted Mr S’s physical health.
78. However, we feel the experience would have been highly distressing for Mr S, compounding what was already a traumatic experience for him.
79. Although we cannot attribute the entirety of Mr S’s loss of faith in the Trust to this incident, we recognise that the Trust’s initial response to his complaint is likely to have exacerbated his loss of trust.
80. This is because the Trust initially blamed Mr S for the nurse’s decision not to help him, stating ‘the nurse involved has mentioned that you were verbally aggressive and did not assist you for the sake of her personal safety. Whilst […] understands this could have been caused due to your panic and pain; the nurse felt threatened and intimidated; hence possibly the reason why she did not want to come too close.’
81. During a later local resolution meeting the Trust changed its position and stated that when the triage nurse realised Mr S was on the floor, she should have come to him immediately and acted on the situation.
82. Overall, it is our view the Trust’s actions caused Mr S to suffer a highly distressing experience, which could have been avoided, and contributed to his current lack of faith in the Trust’s ability to care for him.
Impact - CCTV
83. Mr S told us that not being able to access CCTV of the event caused him continuing stress, as every time he had to complain about the Trust failing to provide the CCTV, he was forced to explain and relive the traumatic events that occurred when he had his heart attack.
84. He explained that he had to go over the issues with the hospital, ICO, PHSO, hospital solicitors, then again with PHSO. Had he had access to the CCTV he would have been able to prove what happened to him at the time and not have to repeatedly relive it.
85. Mr S first complained to the Trust in April 2022. He then followed the complaints process through the Trust, ICO, Trust solicitors and PHSO, finally reaching the point of a detailed investigation with us in May 2024.
86. We cannot say that had Mr S had a copy of the CCTV footage, he would not have had to go over his complaint with the hospital, hospital solicitors, or with us.
87. This is because even with CCTV he would have initially needed to explain his complaint to the Trust and its solicitors. We also cannot say the Trust solicitor’s decision may have been different with CCTV. This is because its conclusion was based on expert advice that on the balance of probabilities it cannot say Mr S would have had a better outcome had the Trust triaged him earlier. Having access to CCTV would not have changed this decision.
88. Therefore, on the balance of probabilities, it is likely Mr S would still have brought his complaint to PHSO. While we could have considered the information from the CCTV footage as part of our evidence gathering, Mr S would still have needed to explain his complaint to us. Therefore, we cannot say having the CCTV footage would have meant he did not need to repeat his complaint to us.
89. We can say that had the Trust provided the CCTV Mr S would not have had to approach the ICO, which would have reduced the overall time and number of contact points involved in resolving his complaint. We understand this added step would have been stressful for Mr S.
90. Overall, it is our view the Trust’s actions regarding CCTV caused Mr S a short period of avoidable stress.