London North West University Healthcare NHS Trust
NHS / Health Body
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.
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.