Source · Prevention of Future Deaths

Trevor Bailey

Ref: 2023-0419 Date: 20 Oct 2023 Coroner: Mary Hassell Area: Inner North London Responses identified: 2 / 2 View PDF

The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a rapid access chest pain clinic.

Date 20 Oct 2023

56-day deadline 1 Jan 2024 est.

Responses identified 2 of 2

Other related deaths

Coroner's concerns

AI summary

The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a rapid access chest pain clinic.

View full coroner's concerns

I heard evidence at inquest that Mr Bailey was a (very recently ex) smoker with a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012.

However, it does not appear that these two pieces of information were elicited by those assessing Mr Bailey in the emergency department of Northwick Park Hospital. I heard evidence that, if they had been, he should have been referred to the rapid access chest pain clinic.

Given the sequence of events, it seems unlikely that such a referral would have resulted in definitive treatment before Mr Bailey’s fatal myocardial infarction, but it could be a life saving referral for another patient in Mr Bailey’s position.

Responses

2 respondents

Chuch Lane Surgery

23 Oct 2023 PDF

Action Taken

Church Lane Surgery updated their patient history templates, provided training to staff on collecting and recording family history of IHD, and restructured the on-call system for the Duty doctor by adding un-booked telephone and face-to-face slots. (AI summary)

View full response

Dear Coroner ME Hassell,

Thank you for your feedback and the report regarding the inquest into the death of the late Mr.Bailey, held at the St. Pancras Coroner's Court on October 18, 2023.

Matters of Concern as per your report are
1. Mr.Baileys‘s Family History of IHD – His brother had had two cardiac stents placed in 2006 and two in 2012. This information was not on Mr.Bailey’s medical record. It was not elicited at his 2012 or 2018 health checks or when he consulted his General Practitioner,

on 19 or 27 April 2023.

The Recording of this information is unlikely to have changed the outcome for Mr.Bailey, but it was a vital part of the medical history and it might easily be for another patient.

2. told me in the witness box that she had identified immediately after Mr.Bailey’s death in May 2023 that the duty doctor system at Church Lane Surgery does not allow sufficient time to deal with patients appropriately. However, she has not progressed this issue in 5 months since. We have taken these concerns seriously and implemented the following actions to improve future patient care:

Actions taken We conducted the Significant Event Analysis and discussed at the Practice meeting on
23.10.2023 We reviewed the 2012 entry for the Template. Our Practice nurse had asked the patient about their family history of IHD during NHS health check and had recorded as No family history of IHD. The template at that time had a provision to record both positive and negative family history. During the NHS health check on September 5, 2018, the family history of ischaemic heart disease would have been asked routinely as per the NHS health check template. On analysis we noticed that the new NHS template did not have a field to record a negative family history of IHD. We routinely calculate CVD risk percentage which is reliant on the risk factors recorded, including family history of ischaemic heart disease. This patient’s record did not have a positive family history of IHD at the two NHS health checks conducted in 2012 (a negative history has been recorded as the template at that time had a provision)) and 2018 (a negative history could not be recorded as the new template had no provision for the same). We have therefore not had a record of raised CVD risk score, necessitating initiation of primary prevention. The family history of IHD has been disclosed to us only at the coroner’s inquest on 18.10.23. During the inquest was under extreme pressure when questioned why there was no mention of family history in the 2018 health check. She was unable to justify the reason, as the fault with the template became evident on subsequent detailed investigation of the templates. On 19.4.23, during his telephone consultation, Mr.Bailey reported a history of chest pain/tightness intermittently for 2 weeks. If a person has a history of chest tightness, it is important to investigate the acute and high risk causes of the symptoms, regardless of whether they have any risk factors for ischemic heart disease (IHD). This is because there may be a serious underlying cardiac or non-cardiac condition that needs urgent attention, such as pulmonary embolism, cardiac ischemia, aortic dissection or pericarditis,etc. Mr.Bailey was hence advised to go to the emergency department immediately on April 19, 2023. During the triage call On April 27th, 2023, he had already undergone investigations for cardiac ischemia in the Accident and Emergency department the previous week for the same symptoms. The A&E discharge summary clearly stated that there were no cardiac risk factors, and both serial cardiac troponin and ECG were normal and diagnosis of non-cardiac chest pain due to acid reflux was made. It was therefore determined that the current dose of treatment for acid reflux was ineffective and was advised on the treatment accordingly and safety netted to attend A&E again or review at the surgery if symptoms were persistent.

It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.

We have taken the following steps to update the family history of coronary heart disease (IHD).

We acknowledge that the new NHS health check template given to all practices, had changed from the previous one with provision to record positive family history but none to record a negative family history, making it impossible to document a negative family history. We did a search on our

clinical system, for the period 2018 to 2023, and found that family history of ischaemic heart disease was being gathered during NHS health checks (positive family history of IHD recorded in 296 patients). We have updated the template to include the negative findings of ischemic heart disease (IHD) related to F/H (family history). Recording a negative family history will only serve to provide evidence that this has been sought during the consultation, though it will not change the CVD risk score.

We have addressed the template issue with our PCN, Borough Director and the LMC, as this issue has raised concerns if a family history had been sought at all, during the health checks. We hope this will ensure that the information reaches all our area practices that use the same templates, so that they can take appropriate action and are not disadvantaged.

Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates. We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system. This ensures the accuracy of our risk calculations when making medical assessments.

To enhance our clinical procedures, we have provided comprehensive training to all our staff members on how to collect family history information and how to accurately record it in the clinical system.

2. Actions to re-structure the On-call system for the Duty doctor.

We have recently made a change to the on-call schedule of Duty Doctors. Three un-booked telephone slots and three face-to-face slots have been added at the end of each doctor's shift to allow them to attend to patients who require additional consultation. This change has already been implemented and is currently in effect. The additional slots will enable the doctors to spend more time when detailed consultations are needed, ensuring better care for the patients. Kindly contact me if there should be any clarifications required. Thanking You, Yours Truly,

Senior Partner Date: 15.12.2023.

London North West University Healthcare NHS Trust NHS Trust

15 Dec 2023 PDF

Noted

London North West University Healthcare NHS Trust argues that the patient's management in the emergency department was appropriate based on national scoring and existing chest pain pathways and describes the introduction of an Emergency Assessment Unit designed to improve waiting times. (AI summary)

View full response

Dear Madam, RE: Inquest of TREVOR Coy Bailey 18 October 2023 We write further to the inquest touching upon the death of Trevor Coy Bailey, which took place on 18 October 2023. At the conclusion of this inquest, you issued a Prevention of Future Deaths (PFD) report. The PFD noted that following evidence heard at the inquest, you had concerns which we have addressed below: "That Mr Bailey was a (very recently ex) smoker with a family history of ischaemic heart disease - his brother had had two cardiac stents placed in 2006 and two in 2012. However, it does not appear that these two pieces of information were elicited by those assessing Mr Bailey in the emergency department ofNorthwick Park Hospital. Trevor Bailey presented to the emergency department with a history of chest pain. He was seen by the triage nurse and initial observations were normal except for a slightly low temperature. The initial ECG was normal and blood tests were taken. These blood tests included a troponin test (an enzyme released by the heart at times of ischemia) and he then waited to be seen by a doctor in the waiting room. He was seen by an emergency medicine registrar and gave a history of discomfort in his chest which he described more as burning than pain. He denied any other associated symptoms. He mentioned two bouts of this feeling of discomfort in the week earlier associated with epigastric burning. He denied any severe pain in his chest when he was seen. He had a normal clinical examination. At the time of being seen he did not inform the doctor that he had recently stopped smoking or that he had a brother with a cardiac history. He had a second ECG at this time and this was also normal. According to the trust protocol he needed a repeat blood test to ensure there was not an interval change in the troponin blood test but the patient declined to wait for this to be done. The patient had capacity to make this decision. The registrar that saw him checked

this result with the intention to call the patient if there were any concerns; this second result was also 7 which is non-dynamic. That is to say it showed no change, indicating a low risk. As a department we encouraged the patients to make their own decisions and be involved in their own care and decisions. Trevor Bailey had the risks explained to him about leaving without having a repeat troponin and he chose to do this. I heard evidence that, if they had been, he should have been referred to the rapid access chest pain clinic. Given the sequence of events, it seems unlikely that such a referral would have resulted in definitive treatment before Mr Bailey's fatal myocardial infarction, but it could be a life saving referral for another patient in Mr Bailey's position." The point we would like to make is that even if he had not self discharged, based on the information given to the team at the time if the patient underwent a HEART score the patient would score 1. A heart score is an evidence based score we use to risk stratify patients to decide on whether they need urgent treatment or can be discharged and if discharged whether they would need actively following up in a rapid access chest pain clinic. A score of 1 would not have triggered a rapid access chest pain referral. If the patient had volunteered that they had a positive family history and had been a recent smoker he would have scored a heart score 2, still not triggering. Of note if he scored one higher for highly suspicious history his maximum score would still be 3 and would therefore still have be classed as low risk. According to this scoring system, scores 0-3: 0.9-1.7% risk of adverse cardiac event. In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study) This is a well established nationally used protocol. As with any guideline there will be patients that sadly come into the low risk category with that under 1.7% chance of having a cardiac problem. Unfortunately this is one such sad case. As further evidence we do routinely satisfy our selves that even though this is a well used guideline we are still happy with it. In December 2022 our cardiology team attended the emergency department clinical governance meeting to present data from referrals. The data showed that patients with referrals with a low heart score did not go on to have investigations in the rapid access chest pain clinic and based on this data the cardiology team confirmed that a low heart score did not require a referral to the rapid access chest pain clinic. The attached cardiac pathway shows that this gentleman followed the low risk side of the pathway and was then correctly discharged for management by the general practitioner. As part of our ongoing governance and improvement cycles, in November 2023 the Emergency department introduced a separate unit called Emergency Assessment Unit. The unit is designed to see the low and medium risk patients that do not need to be on a monitor. Trevor Bailey would have fit into this category. The patients in this unlt are rapidly seen and assessed. The unit has improved the waiting time for these patients and has ensured that ECGs can be done in a timely manner. The outcome of the management of the patient would be the same in this unit as the HEART score would be the same.

The following documents that are the audit presented by cardiology at the clinical governance, details about the trust chest pain pathway, details about the new emergency department EAU and the mandatory training details for capacity training. In summary, Mr Bailey self-discharged prior to completing his clinical encounter. He had capacity to make this decision, and the ED registrar provided safety netting by checking the repeat troponin result. At the time of the encounter, and even if the additional unknown risk factors had been factored in, he would not have met the criteria for referral to the rapid access chest pain clinic as per national scoring. The Trust has a robust process for evaluating chest pain patients, including a new EAU service, and currently follows the agreed pathway developed with our cardiology services to refer appropriate patients to the rapid access chest pain clinic. We hope that this satisfies your concerns in this matter and if there is anything further that the Trust can aid with, please do let us know and we will be happy to address any further issues.

Report sections

Investigation and inquest

On 18 May 2023, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Trevor Bailey aged 63 years. The investigation concluded at the end of the inquest on 18 October. I made a determination at inquest of death by natural causes. Mr Bailey’s medical cause of death was: 1a) extensive acute myocardial infarction of the left ventricular wall 1b) severe coronary artery stenosis (stented) 1c) atherosclerosis

Circumstances of the death

Mr Bailey attended Northwick Park Hospital emergency department on 19 April 20223 with chest pain, two and a half weeks before his fatal myocardial infarction on 7 May 2023. He was investigated and discharged without referral to the rapid access chest pain clinic because his test results proved negative and he seemed stable.

Copies sent to

Care Quality Commission for EnglandProfessor Chris Whitty, Chief Medical Officer for Englandconsultant cardiologist, Royal Free Hospital, GP, Church Lane Surgery

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Shared signals

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Report details

Reference: 2023-0419
Date of report: 20 October 2023
Coroner: Mary Hassell
Coroner area: Inner North London

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Jan 2024 (estimated).

Sent to

Church Lane Surgery

Northwick Park Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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