NHS England
NHS Trust
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Source · Prevention of Future Deaths
Prabhabai Cangi
Ref: 2026-0303
Date: 5 Jun 2026
Coroner: Andrew Walker
Area: North London
Responses identified: 2 / 2
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Response deadline: 31 July 2026 (extracted from report).
Date
5 Jun 2026
56-day deadline
31 Jul 2026
Responses identified
2 of 2
Coroner's concerns
In the circumstances duty to report to you. That there is no clear pathway for interpretation of ECG traces to a specialist doctor, when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital.
View full coroner's concerns
In the circumstances duty to report to you.
That there is no clear pathway for interpretation of ECG traces to a specialist doctor, when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital.
That Intermittent symptoms of:-
– Chest Pain
– Breathlessness
– Abnormal ECG with some ST elevation (using one or more leads) did not result in the patient being taken to the nearest emergency hospital. That where the ECG is abnormal, the patient was not advised should show the copy of the ECG to their GP (unless the patient is taken to hospital). That there is no guidance on photograph of the ECG uploaded to the record of attendance being clear and readable.
That there is no clear pathway for interpretation of ECG traces to a specialist doctor, when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital.
That Intermittent symptoms of:-
– Chest Pain
– Breathlessness
– Abnormal ECG with some ST elevation (using one or more leads) did not result in the patient being taken to the nearest emergency hospital. That where the ECG is abnormal, the patient was not advised should show the copy of the ECG to their GP (unless the patient is taken to hospital). That there is no guidance on photograph of the ECG uploaded to the record of attendance being clear and readable.
Responses
London Ambulance Service
NHS Trust
Received
No AI summary available.
Report sections
Investigation and inquest
On 15th August 2025, I commenced an investigation into the death of Prabhabai Cangi aged 78 years.
The medical cause of death was 1a. Cardiac Arrest 1b. Pericardial tamponade (pericardiocentesis and drain insertion 12/03/2025) 1c. Late presentation myocardial infarction 1d. II. Hypertension, Hypothyroidism
How, when and where Prabhabai Cangi died in Harefield Hospital, Uxbridge on the 12th August 2025. Conclusion Prabhabai Cangi died as a consequence of delayed hospital treatment.
The medical cause of death was 1a. Cardiac Arrest 1b. Pericardial tamponade (pericardiocentesis and drain insertion 12/03/2025) 1c. Late presentation myocardial infarction 1d. II. Hypertension, Hypothyroidism
How, when and where Prabhabai Cangi died in Harefield Hospital, Uxbridge on the 12th August 2025. Conclusion Prabhabai Cangi died as a consequence of delayed hospital treatment.
Circumstances of the death
On the 12th of August 2025 Prabhabai Cangi died in Harefield Hospital having had an ST elevation myocardial infarction at home. An ambulance attended at her home on the 7 August 2025 where she presented with, amongst other symptoms, burning chest pain within the last 3 days associated with breathless on exertion especially on climbing stairs. An ECG taken by the LAS showed an abnormal ECG with some ST elevation.
Mrs Cangi was taken to hospital where despite expert care she died the same day.
Had Mrs Cangi been taken to hospital, rather than being discharged to see her own doctor, it is likely that Mrs Cangi would not have died when she did.
Mrs Cangi was taken to hospital where despite expert care she died the same day.
Had Mrs Cangi been taken to hospital, rather than being discharged to see her own doctor, it is likely that Mrs Cangi would not have died when she did.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
Copies sent to
I can confirm I have sent the report to: 1. NHS England3. London Ambulance
Similar PFD reports
Report details
- Reference
- 2026-0303
- Date of report
- 5 June 2026
- Coroner
- Andrew Walker
- Coroner area
- 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: 31 Jul 2026.
Sent to
- London Ambulance Service
- NHS England