Prabhabai Cangi

Dear Sir,

Regulation 28; Prevention of Future Deaths Report (PFD) arising from the inquest into the death of Prabhakar CANGI

Thank you for your Regulation 28 Report dated 5 June 2026, sent to the London Ambulance Service NHS Trust (“LAS”), setting out matters of concern arising from the inquest into the death of Mrs Cangi.

We would like to begin by expressing our sincere condolences to Mrs Cangi’s family. At the conclusion of the inquest, you identified concerns which may be summarised as follows:

1. There is no escalation pathway to a specialist doctor when London Ambulance Service paramedics need to review ECG traces taken at the scene when they attend.
2. A patient with coronary syndrome was not recognised resulting in a late presentation myocardial infarction.
3. That where the ECG is abnormal, the patient was not advised to show the copy of the ECG to their GP (unless the patient is taken to hospital)
4. There is no guidance on the photograph of the ECG uploaded to the record of attendance being clear and readable.

We respond to these matters below.

The Role and Use of ECGs in the Pre-Hospital Setting

An electrocardiogram (ECG) provides a graphical representation of the electrical activity of the heart and may be used to identify a range of cardiac rhythm disturbances and other abnormalities. An ECG produces visual wave patterns and these can be interpreted to detect abnormal heartbeats (arrhythmias), signs of a heart attack, and coronary heart disease.

A 12-lead ECG provides an overview of cardiac electrical activity from twelve anatomical perspectives. It is an important diagnostic tool which may assist in identifying conditions including ST-segment elevation myocardial infarction (STEMI), a form of heart attack. In some

2 instances, these findings will prompt direct referral and transfer by LAS clinicians to specialist Heart Attack Centres (HACs).

Training, Guidance, and Clinical Support

Paramedics are required to complete an approved Bachelor of Science degree prior to registration with the Health and Care Professions Council (HCPC). Training in ECG acquisition and interpretation is a core component of paramedic education and includes recognition of features consistent with myocardial ischaemia and infarction, including STEMI.

Clinical practice within LAS is supported by national guidance produced by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). This includes guidance on Acute Coronary Syndrome (ACS), encompassing conditions such as unstable angina, non-STEMI, and STEMI. This guidance highlights that symptoms such as chest pain and breathlessness—including when intermittent—may be indicative of ACS.

LAS provides ongoing training and reinforcement of ECG interpretation through:
• The annual Core Skills Refresher (CSR) programme delivered to all frontline clinical staff;
• A mandatory ECG e-learning package completed by all frontline clinicians;
• An ECG interpretation event delivered in April 2025 in conjunction with the Royal College of Paramedics; and
• Planned inclusion of further ECG-focused training and updated myocardial infarction guidance within the 2026–2027 CSR cycle.

Advanced Paramedic Practitioners (Urgent Care) also undertake Master’s-level education and advanced clinical training, further strengthening clinical decision-making capability within the service.

Clinical Decision-Making and Conveyance

ECG findings form one component of a broader clinical assessment. LAS clinicians are required to make holistic decisions based on:
• Presenting symptoms (including duration and intermittency);
• Clinical observations and examination findings;
• Past medical history, including known cardiac conditions;
• Available previous clinical records;
• The overall clinical condition of the patient; and
• The patient’s wishes and consent.

Under the JRCALC criteria below a patient should be immediately transferred to a specialist Heart Attack Centre where the clinical presentation is consistent with ACS:
• ST elevation in leads V2–V3 of greater than 1.5mm in women or 2mm in men, or
• ST elevation greater than 1mm in two contiguous leads

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These ECG criteria were not met when Mrs Cangi was attended by the LAS on 7th August 2025 but were present when she was transferred to hospital on the 12th August 2025. Where such criteria are not met, but clinical features consistent with ACS remain present, patients should be conveyed to an Emergency Department for further assessment.

This guidance is available to all LAS clinicians and is accessible in real time via Trust-issued electronic devices.

In addition, clinicians have access to real-time clinical support. This includes the LAS Clinical Hub, which is staffed by experienced Clinical Support Managers, and an on-call clinical advice line involving senior paramedics and doctors where escalation is required. In the latter part of this year, the LAS is due to commence a trial of ECG transmission to HAC clinicians for assistance with interpretation. This will facilitate early cardiology review and admission to specialist units as required.

During a typical 24-hour period, LAS clinicians record hundreds of ECGs, a significant proportion of which demonstrate abnormalities. Many of these reflect known or chronic conditions (for example atrial fibrillation), which are often managed in primary care and do not in themselves mandate hospital conveyance where consistent with the patient’s established diagnosis and absent concerning features.

Conversely, where ECG abnormalities are new, unexplained, or accompanied by symptoms suggestive of acute coronary syndrome, conveyance or onward referral is clearly indicated. LAS clinicians are therefore required to apply clinical judgement in interpreting ECG findings within the wider clinical context, rather than relying solely on automated ECG interpretation or isolated abnormalities.

Notwithstanding this, LAS recognises the Coroner’s concern and will reinforce existing guidance and training, particularly in relation to patients presenting with symptoms suggestive of ACS, including where symptoms are intermittent.

Provision of ECG Copies and Information Sharing

Where a patient is conveyed to hospital a photograph or digital copy of the ECG is uploaded to the electronic Patient Care Record (ePCR); and a paper copy of the ECG is routinely provided to the receiving clinician during handover.

The ePCR is accessible to receiving hospitals across the LAS operational area and is also available via the London Care Record, enabling access by other healthcare professionals involved in the patient’s care.

Where a patient is not conveyed to hospital it is standard practice to provide the patient with a paper copy of the ECG; and the patient is advised to retain the ECG and present it to any healthcare professional with whom they subsequently have contact, such as their General Practitioner. In addition to this, following clinical interaction with patients, completed clinical

4 records (which include a photographed copy of the ECG), are uploaded into the London Care Record, which is visible to healthcare professionals (including other LAS clinicians) involved in the patients care as long as accessed electronically by healthcare professionals. This combined standard approach by all LAS clinicians ensures oversight of ECGs and clinical records. The Learned Coroner may recall that Mrs Cangi’s grandson gave evidence that the paramedic left the family with a copy of the ECG.

The LAS are also part of the NHS England Single Patient Record (SPR) Programme Clinical Reference Group. The SPR programme aims to create one unified, secure view of a patient’s health and care information across NHS services in England. This intends to bring together data currently held in multiple systems (e.g. GP, hospital, ambulance, mental health etc.) into a single, joined-up record, and is a core part of the NHS 10-year plan. The initial roll-out will focus on two identified priority areas (maternity and frailty) before looking to further areas. It is intended that the first priorities will go live around 2028. The LAS remains committed and engaged with key stakeholders in technological advances which will improve oversight of clinical records and pertinent clinical information.

Quality and Clarity of ECG Records

LAS policy requires that all clinical images, including ECG photographs, are relevant, clear, and clinically usable. The Trust recognises the importance of ensuring that ECG images recorded within the ePCR are consistently clear and readable and will reinforce this requirement with staff.

The Trust is also due to commence a procurement process for new ECG monitoring equipment during the 2026–2027 financial year. A key requirement of this procurement is the capability for ECG data to be uploaded directly from monitoring equipment into the ePCR, thereby removing the need for photographic capture and improving accuracy and quality of records.

Conclusion and Ongoing Actions

The LAS has carefully considered the concerns raised in your report and is satisfied that clear national guidance exists regarding the management of suspected acute coronary syndromes, including when ECG findings necessitate conveyance. Robust training and clinical support mechanisms are in place for ECG interpretation and decision-making; and systems are in place to ensure ECG information is recorded, shared, and made available to patients and healthcare professionals.

Notwithstanding this, LAS will reinforce guidance relating to intermittent symptoms and potential ACS presentations; re-emphasise best practice regarding provision of ECG copies and patient advice; and strengthen messaging regarding the clarity and quality of ECG image capture pending implementation of enhanced digital solutions. Furthermore, an interim review of results from ECG transmission to cardiologists is planned once the pilot phase of this programme of work is complete. This will be used to guide and inform future approaches to ECG transmission pan London.

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We hope this response is helpful and provides assurance that LAS remains committed to continuous improvement and the delivery of safe, high-quality patient care.

Thank you for bringing these matters to our attention.