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 wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. We have set out our reasons for this below.
15. Mrs O complains the Trust should have done further tests on Mr R to establish the cause of his symptoms. Mrs O questioned why the Trust did not pursue a scan or use other diagnostic equipment to give the correct diagnosis.
16. The Trust said the ECGs and blood test it conducted on Mr R before the cardiac arrest were normal. It said given this, his normal observations, and that he did not have a cardiac history, this did not show any urgent cause for concern. The Trust said the ED triage was reasonable, and given the information available at the time, does not feel it would have been possible to predict what happened.
17. The records show on 3 January at 12.46am, Mr R presented to ED with chest pain. The records show at around 2.35am, Mr R collapsed in the ED waiting room and experienced a cardiac arrest at around 2.49am. The Trust conducted cardiopulmonary resuscitation (CPR) but sadly verified Mr R’s death at 3.15am.
18. As Mr R was in the ED for a relatively short period of time (less than two hours) before he collapsed, we have considered if the Trust carried out appropriate tests during that time and whether it should have done anything further, based on the evidence available. We discussed this with our clinical adviser.
19. RCEM guidelines help us understand what should happen. ‘Initial Assessment of Emergency Department Patients’ guidelines say staff should triage patients ideally within 15 minutes of their arrival.
20. This guideline explains the function of triage is to prioritise patients in a system where the demand for patient care exceeds the ability of the system to deliver it at the time of their arrival.
21. ‘Patient Care in the ED’ guidance says during triage, staff should consider if there is a process for early and appropriate investigations, for example, an early ECG.
22. NICE NG185 says patients with acute coronary syndromes (sudden trouble with the heart) should be risk assessed for future heart issues. This risk assessment should include a full clinical history (including age and previous heart conditions), a physical examination (blood pressure and heart rate), an ECG and blood tests.
23. The records indicate the Trust triaged Mr R at 1.09am, approximately 23 minutes after his arrival. This was 8 minutes over the 15-minute timeframe referred to in the RCEM guidance above.
24. However, the RCEM guidance states the 15-minute timeframe is an ‘ideal’ to aim for rather than a mandatory requirement. Our advisers view, which we agree with, is that this was not a significant delay. For this reason, we do not consider the Trust exceeding this ideal timeframe slightly, indicates a failing.
25. The records show during the triage, staff noted Mr R’s clinical history and took his observations, in line with NICE NG185 mentioned above. The observations showed his blood pressure was raised, and he was breathing fast. These observations generated an early warning score of three.
26. An early warning score (EWS) is a clinical tool used to detect early signs of deterioration in patients, allowing for timely medical intervention. The scores range from zero to seven or more. The lower the score, the lower the risk of deterioration. Our adviser explained an EWS of three indicates low risk of deterioration and concern.
27. During the triage, the records show staff requested blood tests and an ECG. The blood tests were to test for troponin. Troponin is a high sensitivity test used to diagnose heart muscle damage which indicates issues with the heart. As explained above, an ECG is used to assess the heart’s electrical activity to identify heart conditions and monitor heart health.
28. The records indicate staff collected the troponin blood test at 1.27am. The records indicate this was negative, meaning this did not indicate heart muscle damage at that time.
29. The records indicate the Trust conducted an ECG at 1.37am, which our adviser explained did not show any abnormal changes.
30. The notes show Mr R’s pain was not settling down, so staff conducted another ECG at 2am which also did not show any sudden change. Our adviser explained this means the ECGs did not show anything concerning which the Trust needed to treat immediately.
31. From the clinical advice we understand the Trust’s decision to conduct a blood test and ECGs at this early stage was in line with RCEM ‘Patient Care in the ED’. These tests were also appropriate, and in line with NICE NG185, to investigate the cause of Mr R’s chest pain.
32. The records indicate shortly after the second ECG, Mr R sadly collapsed, experienced cardiac arrest and the Trust attempted CPR, but he sadly died. As a result, the Trust did not have an opportunity to carry out further tests or investigations.
33. As the records and clinical advice indicates the test results were normal, we consider it was unlikely for the Trust to predict what happened to Mr R.
34. On this basis, we do not consider there is an indication anything went wrong here and will not consider it further.
35. We recognise Mrs O’s strength of concern the Trust should have done more tests or investigations on Mr R to establish the cause of his symptoms. We hope our consideration of this concern provides her with reassurances the Trust triaged Mr R promptly and conducted tests and investigations in line with NICE NG158 and RCEM guidelines during the short time he was in the ED for, before he sadly collapsed.