14. Mrs E told us that her father had significant heart issues and was under the care of a cardiologist as an outpatient at the Trust, with input from cardiologists at another Trust. On 7 June 2023, Mr A underwent an unsuccessful transcatheter aortic valve implantation (TAVI, a procedure where a new aortic valve is inserted into the heart to treat the narrowing of the aorta). Instead, a successful balloon aortic valvuloplasty (BAV, a balloon is inserted through a blood vessel and inflated in the affected valve to improve blood flow) was performed.
15. On 14 July, Mr A was reviewed by his cardiologist at the Trust who took an ECG and discussed attempting the TAVI again in 4 weeks’ time.
16. Mrs E said that despite her father’s past medical history and symptoms on both 18 and 19 July, this did not seem to ‘ring alarm bells’ when he was admitted into the ED. There was no urgency to get to the bottom of his symptoms, refer him to cardiology or later move him to the CCU. Instead, she feels her father was essentially put to one side with paracetamol and Gaviscon.
17. We considered, with the input of our adviser, the actions of the Trust during Mr A’s admission to the ED.
18. NHSE guidance sets out how patients ‘flow’ into the ED. It says that ‘handover of non-pre-alerted patients (patients who do need to be received by a clinical team), should be completed following local agreed processes within 15 minutes of arrival. Responsibility for patient clinical assessment and treatment lies with the hospital from the point the ambulance arrives at the department’.
19. Mr A’s medical records show that he arrived at the ED at 8:54am and was triaged at 8:56am. The triage indicated that Mr A reported chest pain radiating to his jaw the night before, pain when taking a deep breath, heartburn, nausea and dizziness. Our adviser confirmed that Mr A’s triage was in line with the national standard of 15 minutes.
20. We can see from the medical records that the Trust performed an ECG which showed no acute changes that would indicate an acute coronary event such as a heart attack. We do not know what time this test was performed. Blood tests were taken at 9:08am.
21. Mr A’s medical records say that he had mild pain. The Manchester Triage System (a clinical risk management tool used to prioritise ED patients) says the appropriate triage category would be ‘yellow’ which had a target time for a clinical assessment of 60 minutes. Our adviser explained that the records suggest that Mr A was not seen by a clinician until 11:21am. Which would be outside of the recommended timescale.
22. Our adviser set out that in a busy ED this can occur with otherwise stable patients. Mr A’s records were recorded electronically and show that they were started at 11:21am. Electronic records are often completed after the assessment as they are not completed simultaneously with the assessment. Our adviser said that if the assessment was within 2 hours of the triage time, they would consider this reasonable.
23. The GMC’s Good Medical Practice sets out how clinician should apply knowledge and experience to practice. Point 15b says ‘if you assess diagnose or treat patients, you must:
• promptly provide or arrange suitable advice, investigations or treatment where necessary.
24. We can see that tests started in the time between triage and the recording of the electronic notes. It is likely that Mr A was seen before 11:21am and staff started the notes at this time. Therefore, we are of the view that the Trust acted reasonably in line with the guidance during the early part of Mr A’s admission.
25. The records show that a Paramedic Trainee Advanced Clinical Practitioner (PtACP) reviewed Mr A and started to record the notes at 11:21am. The PtACP took Mr A’s past medical history. He was diagnosed with:
• Critical aortic stenosis (the narrowing of the aortic valve which is at a critical level) • Severe left ventricle systolic dysfunction (the heart’s left ventricle is not able to pump blood effectively) • Thromboembolic stroke (a blood clot in the brain)– following the attempted TAVI and BAV procedure • Hypertension (high blood pressure) • Hyperlipidaemia (high levels of fats such as cholesterol) • Deep vein thrombosis (a blood clot in the leg) in 2005 • Vascular Dementia (a type of dementia caused by reduced blood flow to the brain).
26. The PtACP also took a medication history and completed a medical review of Mr A.
27. Point 15a, 15b (as mentioned above in paragraph 23) and 15c of the GMC Good Medical Practice says:
• Adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient.
• Refer a patient to another practitioner when this serves the patient’s needs.
28. Point 16b of the GMC Good Medical Practice says:
• Provide effective treatments based on the best available evidence.
29. The PtACP discussed Mr A with the ED consultant at 11:56am. On the advice of the consultant, the Trust confirmed investigations for chest pain, which included the ECG and blood tests, he was prescribed paracetamol for pain relief and Gaviscon for his indigestion-like symptoms. This is in line with the guidance.
30. Our adviser explained that the ECG results did not show any acute changes that would suggest a coronary event such as a heart attack or a reduced blood flow to Mr A’s heart. Mr A was not complaining of acute severe chest pain, which can also indicate heart problems.
31. The blood tests also checked Mr A’s troponin levels (troponin is a protein which is released when the heart muscle is damaged. High levels indicate a heart attack or other heart related issues).
32. The first blood test taken by ED staff at 9:08am and received by pathology at 9:50am. The troponin level was 28 nanograms per litre (ng/L). This result was in a borderline range of between 5-120 ng/L. When a result falls within this range, the result comments say that a second blood test is required.
33. The second blood test was taken at 12:46pm and received by pathology at 1:06pm. The level was 35 ng/L. This level was again in the borderline range. A positive troponin result is above 120 ng/L.
34. The result comments say that if there is a change in troponin level of less than 12, a senior review is required. The level change between Mr A’s two tests was 7 ng/L. Once the results of all its investigations were received by ED staff, it referred Mr A to cardiology at 2:28pm. A cardiologist reviewed Mr A at 2:48pm.
35. Our adviser said that as Mr A was not reporting acute severe chest pain, it was reasonable to wait for the wait for the troponin test results before making a cardiology referral.
36. Based on Mr A’s medical records, we can see that the ED staff assessed Mr A symptoms and considered his past medical history, performed the necessary tests and promptly referred him to the cardiologist. We can see no evidence to say that the Trust delayed in referring Mr A to the cardiologist and its actions were in line with the guidance.
37. Following its review, the cardiologist decided to admit Mr A for inpatient management and treatment, and it booked a bed on the CCU at 2:42pm. Mr A waited in the ED for a bed to come available.
38. Our adviser explained that CCU beds in all Trusts are limited. In a busy acute Trust, it would be unusual for a CCU bed to be immediately available. Patients who need to be admitted to the CCU are unsuitable to be moved on other wards and will wait in the ED. An ED ward has reasonably high staff numbers and immediately available staff if needed.
39. The medical records do not tell us when a CCU bed became available therefore we cannot determine if there was a delay in moving Mr A from the ED to the CCU. We can say that the decision for Mr A to wait in the ED for the CCU bed was appropriate.
40. We can see that Mr A was regularly reviewed while in the ED. At 3:09pm the PtACP discussed Mr A’s further neck and abdominal pain with the ED consultant. Further Gaviscon was prescribed. At 5:11pm, staff further observed Mr A, and his blood pressure was elevated. A cardiologist registrar requested a third troponin test. This was taken at 5:56pm. We can see that although Mr A waited in the ED for the CCU bed to become available, his needs were being met by ED staff during this time.
41. We know that Mrs E is concerned that delays in the ED led to her father’s sad death which has caused all the family an immense amount of shock. We have seen no evidence to suggest that there were any delays to Mr A’s treatment, the cardiology review or transferring Mr A to the CCU.
42. For the reasons set out, we have seen no indication that something went wrong while Mr A was being cared for in the ED. Mr A had a significant history of cardiac issues and we can see that despite staff providing treatment to manage his presentation at the time, his condition unfortunately deteriorated very quickly.
43. In its complaint response dated 21 March 2024, the Trust said that Mr A’s cardiologist had seen Mr A on a few occasions after the BAV and his case was discussed several times in the cardiology multidisciplinary meetings. The cardiologist explained that Mr A’s situation was ‘extremely high risk’, and they had ‘reiterated to both Mr and Mrs A that deterioration in his condition would be ‘sudden’’. Sadly, we can see that this happened.
44. We understand how important this complaint is to Mrs E, and we thank her for sharing her concerns with us. We hope she will be reassured that we have not found anything to make us think that we need to ask the Trust to take further action in relation to the issues considered.