A medical practice in the London Borough of Merton

15. Ms R, saw a doctor at the Practice on 18 July with chest pains. Her mother, Mrs R, complains that the doctor did not recognise the seriousness of her condition.

16. She complains the doctor did not call an ambulance. Instead, Ms R had to wait for a taxi to take her to the local hospital’s ED.

17. Mrs R says the Practice’s actions meant there was a delay in Ms R receiving lifesaving treatment for a heart attack, and she died as a result.

18. This was devastating for Mrs R, Ms R’s family and her friends. Mrs R says Ms R’s two young children, her grandchildren, have ‘severely insecure emotional and financial futures.’

19. Mrs R would like financial remedy of £10,000 or more to resolve the complaint.

20. Ms R attended the Practice on 18 July after 9am. She told the reception staff she had chest pain. The GP saw her three minutes after her arrival.

21. The GP decided her chest pain could have multiple non cardiac causes and she needed to see a specialist for assessment.

22. The GP said she should go to a hospital ED and gave her a referral letter. The GP says Ms R asked to attend her preferred hospital, which had the local cardiac thoracic unit for the area. According to the Practice, Ms R left the appointment before 9.30am and left the Practice five minutes later.

23. Ms R arrived at the hospital car park and went into cardiac arrest. Clinicians from the ED arrived to help her at 10.10am. A bystander had been giving her CPR for 5-10 minutes.

24. The records show Trust staff initially treated Ms R in the ED resuscitation department. At 10:50am, Ms R had a coronary thrombectomy (a procedure to break up a clot in the coronary artery) and a coronary angioplasty (a procedure to widen a blocked or narrowed artery). Following the procedure, staff transferred Ms R to the Cardiothoracic Intensive Care Unit.

25. Ms R sadly died four days later. Ms R’s death certificate says the cause of her death was a heart attack (myocardial infarction) which led to her going into cardiac arrest, resulting in multi-organ failure.

59. Mrs R says the GP did not recognise the seriousness of Ms R’s condition and should have called an emergency ambulance for her.

60. Our GP adviser says Ms R had two cardiac risk factors because she had hypertension and she was obese. The hospital records show her BMI was 43.5(morbidly obese) on 19 July. Ms R told the GP she was taking two different medications from her doctor overseas to control her blood pressure.

61. The NHS website says ideal blood pressure is between 90/60mmHg and 120/80mmHg and high blood pressure is 140/90mmHg or higher.

62. Our GP adviser says the GP recorded Ms R had been experiencing central chest pain radiating to both shoulders since the previous day and it was severe enough to prevent sleep.

63. According to the NICE guideline, the GP should have considered a cardiac reason for Ms R’s chest pain because she was describing typical features of cardiac chest pain in her central chest tightness radiating to both shoulders, as well as having two cardiac risk factors (obesity and hypertension).

64. The GP should have suspected acute coronary syndrome because Ms R’s chest pain had been present for over 15 minutes.

65. In line with the guidance for recent onset of chest pain, the GP should have conducted, or asked another clinician to conduct, an ECG.

66. The guidance says if clinicians suspect the patient has acute coronary syndrome and the patient is still in pain, the clinician should refer to hospital as an emergency.

67. Similarly the guidance says clinicians suspect acuate coronary syndrome and a resting ECG is not available then the clinician should refer the patient to hospital as an emergency.

68. The GP should have sent Ms R to hospital as an emergency because she still had chest pain which had been present for over 15 minutes and they had decided not to carry out an ECG.

69. We have found failings in:

· The GP’s decision to not send Ms R to the ED via emergency ambulance

· their view that her symptoms were likely to be non-cardiac in nature

· their decision to not arrange an ECG for Ms R.

Impact

70. Mrs R says the Practice’s actions meant there was a delay in Ms R receiving lifesaving treatment for a heart attack, and she died as a result. Mrs R says Ms R’s death has left the family and her children devastated.

71. To help us determine if the failings we found led to the claimed injustice, we obtained evidence from an independent consultant cardiologist adviser. We accessed information from London Ambulance Service (LAS) that is publicly available on its website. We also made enquiries with Mrs R about Ms R’s treatment overseas.

Time it took to arrive at the hospital

72. Firstly, we considered if Ms R would have arrived at the hospital any sooner if the GP had called an emergency ambulance.

73. Our cardiologist adviser tells us when an ambulance attends to a patient with a suspected heart attack, it has at least one paramedic (trained to an elevated level in resuscitation) with access to a defibrillator and an ECG machine.

74. Ambulance services class calls for an immediate response to a life-threatening condition, such as a current cardiac or respiratory arrest as category one.

75. Ambulance services categorise calls for potentially serious condition such as stroke or chest pain, which may require rapid assessment, urgent on scene intervention and/or urgent transport as category two.

76. Our cardiology adviser says if the GP had called an emergency ambulance it is likely LAS would have categorised Ms R’s symptoms as a category two call. This is because Ms R’s symptoms and history suggested a cardiac cause for her chest pain. LAS would not categorise the call as category one because Ms R had not gone into a cardiac arrest.

77. In November 2017 LAS set targets for response times. For category two calls, it aims to respond in an average time of 18 minutes with a 90th percentile response target of 40 minutes (this means it must respond to 90% of calls within 40 minutes).

78. NHS England shares data on its website about LAS’s response times in each month of 2018.

79. In July 2018 LAS’s mean (average) response time to category two calls was 20 minutes and 47 seconds and 90% of its responses were within 43 minutes and 19 seconds.

80. The GP says Ms R asked them to refer her to her preferred local hospital, which is the cardiac and thoracic unit for the area and is approximately three miles, by road, away from the Practice. Information from Google maps that shows journeys to the hospital by road from the Practice on weekday mornings, take approximately 22 minutes.

81. We do not know the exact time Ms R arrived on hospital grounds. The hospital does not hold details of the bystander, or the taxi driver Ms R used. The ED notes say clinicians arrived to help Ms R outside of the hospital at approximately 10.10am. The hospital notes say prior to this a bystander had been performing CPR on her for 5 to 10 minutes.

82. The evidence suggests that Ms R arrived on hospital grounds at approximately 10.01am which is around 33 minutes after she left her consultation with the GP, and seven minutes under the 90th centile target response time for an ambulance.

83. We are sorry Mrs R has concerns about the GP’s decision to not call an emergency ambulance for Ms R. We acknowledge her concern that if the GP had called an emergency ambulance, Ms R would have been with paramedics at the time of her cardiac arrest, and she may have gone on to survive.

84. We tried to determine if we can conclusively say how long it would have taken Ms R to arrive at the ED if the GP had called an emergency ambulance. We can see that on average LAS responded to category two calls in 20 minutes and 47 seconds, and 90% of response times were within 43 minutes and 19 seconds. We do not have information to say what factors lead to the variance of the response times in July 2018, or what these figures would have meant to the potential response time if the GP had called for an emergency ambulance for Ms R.

85. There are factors that could have impacted on the arrival time of an ambulance such as traffic levels on the day, the location of the waiting ambulances, roadworks, demand on the service at the time of the call and the number of category one and two calls at the time of the events.

86. We cannot say conclusively that Ms R would have arrived at the ED sooner if the GP had called an emergency ambulance for her at 9.28am, or if the ambulance would have arrived before she went into cardiac arrest.

87. The evidence we have suggests she may have arrived at the hospital later, had she gone by ambulance. We see that if the GP had called an ambulance, it is more likely than not, Mrs R would have been in the presence of a paramedic or the GP when she went into cardiac arrest.

Clinical outcomes of cardiac arrests in the community

88. We asked our consultant cardiologist adviser to explain what potentially could have happened if an ambulance had arrived to see Ms R before her cardiac arrest, or if she had been with a paramedic at the time it happened.

89. Our cardiologist adviser told us that if the GP had called an ambulance and the ambulance had arrived just before the cardiac arrest, the paramedic(s) could have conducted an ECG and would have recognised that Ms R was having or about to have a heart attack. They could have continued ECG monitoring for her, while arranging to transfer her to a heart attack centre at the local hospital.

90. Ventricular fibrillation is a form of heart rhythm disturbance (dysrhythmia) that causes cardiac arrest. Our adviser tells us that clinicians at the hospital detected ventricular fibrillation in Ms R.

91. We considered how likely a person is to survive a cardiac arrest if paramedics are in attendance and start CPR, against the likelihood of survival if a bystander starts CPR and medical professionals or paramedics take over resuscitation (which is what happened in this instance).

92. LAS published a report in December 2019 which looked at outcomes for patients with cardiac arrests when its staff had provided treatment and care between 1 April 2018 and 31 March 2019. NHS England also published patient outcomes for LAS in July 2018.

93. In July 2018 LAS commenced or continued CPR on 297 patients. Of the 297 patients 31 survived to leave hospital. In 41 of the patients, clinicians detected ventricular fibrillation and a bystander was present and commenced CPR which LAS took over. Out of the 41 with this specific presentation, 11 survived to leave hospital.

94. Between 1 April and 31 March 2019 LAS was present when 627 patients went into cardiac arrest. Of the 627 patients, approximately 114 survived to leave hospital.

95. We are sorry to learn Ms R sadly died because of her cardiac arrest. We understand that Mrs R is concerned Ms R could have survived if the GP had called an emergency ambulance and this causes her family significant grief and distress.

96. We made efforts to obtain more information about Ms R’s health and medical history from her doctor overseas, to get a better picture of her physical health leading up to and at the time of her cardiac arrest. We did this to help us determine if we can say with certainty whether Ms R could have survived her cardiac arrest.

97. Unfortunately, our attempt to obtain this information has not been successful and this information is not available to us. The information the Practice holds about Ms R does not help us reach a conclusive view. The information the Practice has is limited because Ms R did not attend the Practice regularly and her other doctor was providing treatment to her.

98. We found Ms R missed the opportunity to have the support of a medical professional at the time of her cardiac arrest who would have training in CPR. She also missed the opportunity to be in a more private and dignified environment when she became acutely unwell.

99. If Ms R had been waiting at the Practice for an emergency ambulance, rather than in the taxi, she would have likely been in the company of a trained medical professional (the GP or a paramedic) at the time of her cardiac arrest. Instead, she was on her own outside of the ED which must have been very distressing for her and for her family.

100. We cannot say conclusively that Ms R could have survived if an ambulance had been with her at the time of her cardiac arrest or if she had been at the Practice with a GP.

101. This is because the data provided by LAS does not provide us with an individual clinical picture of each patient who did survive and even if it did, we do not have enough information about Ms R to conclusively say what her individual chances of survival were. The evidence we have seen shows a significant majority of patients die from cardiac arrest even when a paramedic is present to start treatment immediately.

102. We found the failings led to Ms R’s family having unresolved concerns because they cannot know if the outcome could have been different. We understand this is very difficult for the family and we are sorry we have not been able to reach a conclusive view on this for them.

103. We are deeply sorry Ms R did not survive her cardiac arrest. We understand she left behind her children and her mother who are understandably bereft at her death.

Has the Practice done enough in its response?

104. We found failings in the GP’s conclusion about the nature of Ms R’s chest pain, their decision she did not need an ECG, and that they did not call an emergency ambulance for her on 18 July.

105. The Practice did not uphold Mrs R’s complaint that the GP should have called an emergency ambulance for Ms R which could have saved her life. As a response to the complaint overall, the Practice reflected on the events and highlighted the following areas of learning for its clinicians:

· to remember cardiac or heart related pain can present in an atypical (not typical) or uncharacteristic fashion and clinicians must be mindful of this

· atypical cardiac symptoms are more common in women and younger patients

· a duty nurse/ advanced nurse practitioner will now be available to undertake urgent ECG’s when required by clinicians

· clinicians must consider ambulance transfer in patients who are unaccompanied or vulnerable.

106. The Practice says it took the following actions:

· it sent all its clinicians the NICE clinical knowledge summary on chest pain

· it supplied all its clinicians with a general practice-based cardiology refresher teaching session.

107. Our principles for remedy state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.

108. Our principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

109. We considered the Practice’s complaint response in line with our principles for remedy. We do not think the Practice’s actions go far enough in its recognition of what we found went wrong. We are pleased to see the Practice took learning from the complaint, but it did not accept the GP did something wrong.

110. We are concerned the Practice would not do anything differently in the same situation in future. We do not think the response is enough to put right the impact of these failings on Ms R’s family.

1. We investigated Mrs R’s complaint about a medical practice in the London Borough of Merton (the Practice), and we have partly upheld her complaint.

2. We are deeply sorry to hear about the events that led Mrs R to complain to us, and we are sorry to learn her daughter, Ms R, sadly died on 22 July. We understand Ms R’s death was unexpected and caused significant distress to her family and children. We are sorry Ms R’s family has unresolved concerns about her death and question if it was avoidable.

3. We found failings in the GP’s conclusion about the likely cause of Ms R’s chest pain, their decision she did not need an Electrocardiogram (ECG), and their decision to not call an emergency ambulance for her on 18 July.

4. This is because the guidance for recent onset of chest pain of suspected cardiac origin shows that Ms R’s reported symptoms and medical history indicated she had cardiac risk factors. It was therefore likely her symptoms had a cardiac cause.

5. We found the GP should have suspected acute coronary syndrome because Ms R’s chest pain had been present for over 15 minutes.

6. In line with the guidance, we found the GP should have conducted an ECG or asked another clinician to.

7. In line with the guidance, the GP should have sent Ms R to hospital as an emergency because she still had chest pain which had been present for over 15 minutes, and they had decided not to carry out an ECG.

8. We found the failings meant that Ms R missed the opportunity to be with a medical professional, trained in cardiopulmonary resuscitation (CPR), at the time of her cardiac arrest, rather than alone outside of the emergency department (ED).

9. We found Ms R missed the opportunity to be in a more dignified and private environment at the time she became acutely unwell. It is likely this caused her distress, and also caused distress to her family on learning the circumstances of her cardiac arrest.

10. It is likely Ms R’s family will never know if the outcome could have been different if the GP had sent her to the ED via emergency ambulance, and we recognise this causes them a great amount of grief and distress.

11. We cannot link Ms R’s death to the failing we have found. This is because we cannot say conclusively that Ms R would have gone on to survive her cardiac arrest if the GP had sent her to hospital by emergency ambulance.

12. We cannot say for certain that an ambulance would have taken Ms R to the ED sooner than the time it took her to arrive. We cannot say for certain that if the GP had called an ambulance, it would have arrived and been with her at the point she went into cardiac arrest.

13. We cannot say conclusively whether Ms R could have survived her cardiac arrest, even if a paramedic had been with her at the time it happened. This is because we can see London Ambulance Service (LAS) data shows that even when a patient is with a paramedic at the time they have a cardiac arrest, a significant number of patients sadly go on to die.

14. We have made recommendations for service improvements and a financial remedy of £1500 to put right the impact these failings had on Ms R’s family. We have provided more detail about our recommendations at the end of this report.