A practice in the North Lincolnshire area

17. Mr X booked an appointment to see his GP with urinary problem. He was given a UTI diagnosis by a local hospital two months earlier and he was having recurring symptoms.

18. A GP registrar saw Mr X at 3.30pm. A GP registrar is a fully qualified doctor completing their specialist training to become a GP in the NHS. Mr X mentioned he had epigastric pain (a discomfort or aching feeling in the upper abdomen, just below the ribs) and the GP registrar prescribed omeprazole (an antacid medication).

19. At 5.15pm the GP registrar was having his debrief with a senior GP at the practice. Following this the GP registrar called Mr X at 5.27pm to tell him that the advice had now changed and he should go to the Accident and Emergency (A&E) department right away.

20. Mr X called an ambulance for himself and Mrs X who was also unwell.

21. An ambulance attended at approximately 7.34pm, at which time Mr X suffered a heart attack. The ambulance took Mr X to the local hospital, rather than the specialist heart centre, because he was not considered stable enough for the longer journey. He arrived at 8.15pm.

22. The hospital medical team treated Mr X before he was then transferred to the specialist heart centre to have a stent inserted. However, he sadly died in the ambulance on arrival shortly before 11pm.

23. Mr X’s cause of death is recorded as 1-cardiac arrest 2-myocardial infarction (MI). MI is a life-threatening medical emergency that occurs when blood flow to a part of the heart muscle is suddenly blocked.

A Practice in the Scunthorpe Area (the Practice)

28. Mrs X complains about the care and treatment the Practice provided to her husband in March 2023. She believes that the Practice should have done more to investigate her husband’s chest pain and support him at that time.

29. The Practice said that following an examination the GP registrar considered Mr X was clinically stable. Mr X had told him he had suffered epigastric heart pain (reflux) the day before between 6.30am and 11am. The Practice said Mr X told the GP registrar he had had no pain on the day of his appointment. We note this differs to Mrs X’s recollections as she mentions in her correspondence that her husband had been experiencing chest pain that morning. The Practice said as Mr X was stable and was experiencing no chest pain the GP registrar prescribed omeprazole.

30. The Practice also said that the GP registrar suggested to Mr X he attend A&E for blood tests and an electrocardiogram (ECG). An ECG is a test that records the electrical activity of your heart, including the rate and rhythm. However, the Practice said that Mr X declined this and said he would attend A&E later with his wife, who was also unwell.

31. The GP records show the Practice completed an online triage for Mr X on the morning of 3 March 2023. This mentioned recurrent urinary symptoms and tiredness, but there was no mention of any chest discomfort or pain. An appointment was given for that afternoon. In the transcript of the call with administrative staff regarding the appointment there is no mention of chest pain. Mrs X says this was because her husband was focusing on his urinary problem and did not mention it. Following this triage Mr X was given an appointment at 3.30pm.

32. We have considered what should have happened at the consultation at 3.30pm. In doing so we have considered the above NICE CKS guidance on chest pain. Our GP adviser said this guidance is a summary of various sources of evidence around the management and diagnosis of Acute Coronary Syndrome (ACS) including from NICE, the Scottish Intercollegiate Guidelines Network (SIGN) and the European Society of Cardiology Guidelines. This guidance is relevant as it covers the management of adults presenting with chest pain to primary care. ACS is a term covering a range of conditions where blood flow to the heart is suddenly reduced or blocked.

33. Our GP adviser said the initial aim of assessment is to identify or exclude a serious cause of chest pain which needs immediate hospital admission, such as ACS. To determine the cause of chest pain the GP should take a detailed medical history, examine the person, and organise appropriate investigations based on the suspected cause, unless immediate hospital admission is necessary.

34. The records show the GP registrar took Mr X’s history, which our GP adviser said had some concerning features of ‘epigastric heart pain (reflux)’ and a description of the pain being a ‘dull ache’. The notes report no further pain since the previous day. A documentation of the absence of pain for the last 12 hours would have been ideal although the notes state ‘no more pain attacks today’. Further details such as no radiation of pain, no difficulty breathing, no cough/fever/headache, no collapse and no lower limb swelling were also recorded appropriately.

35. Our GP adviser said other relevant items missing from this history included

• family history • smoking status • previous episodes of chest pain and any investigations previously organised • discussion regarding the presence/absence of prior exertional chest pain • a further acknowledgment/assessment of risk factors for cardiovascular disease such as age, sex, newly diagnosed hypertension, prior measurement of lipid levels.

36. The NICE CKS guidance indicates a physical examination should be carried out. Our GP adviser said that the GP registrar’s examination was adequate in some parts, but there were some features missing. For example, there was no comment on the pulse rhythm to rule out arrhythmias (abnormal heart rhythms), nor a measurement of respiratory rate and oxygen saturation levels or a comment on the presence or absence of pallor and sweating.

37. A BMJ review article (2022) acknowledges the difficulty in diagnosing ACS in primary care. It comments that ‘The suspicion of ACS in the office setting is largely based on clinical judgement and may be assisted by an ECG’. The review article discusses the importance of risk stratification, which our GP adviser said was missing from the original consultation. This is a process of analysing the information about Mr X which may have helped to identify the risk of him suffering an adverse event.

38. With regard to investigations the NICE CKS states ‘if a person with chest pain requires admission or referral to hospital, do not delay management to arrange investigations in primary care’. The guidance goes on to comment regarding ECG readings and explains ‘An ECG does not give a definitive diagnosis of angina but provides information on heart rhythm, conduction abnormalities and identifies signs of myocardial ischaemia, hypertrophy and previous myocardial infarction’.

39. Our GP adviser said if an ECG had been taken on the afternoon of 3 March 2023, this may have helped with risk stratification. It is not clear why an ECG was not taken, but in the NHS England response, the Practice has confirmed that its policy is ‘patients requiring urgent bloods and ECGs for suspected/confirmed chest pain should be advised to attend A&E immediately due to restrictions in primary care’.

40. Our GP adviser said an ECG may have helped to identify or rule out an acute myocardial infarction (heart attack), which may have necessitated an immediate ambulance, but a normal ECG would not have ruled out ACS. For this, further testing would have been needed in hospital (blood tests and serial ECGs). Our GP adviser said the GP registrar’s plan for an ECG at a later stage (booked for 15 March 2023) was not appropriate or in line with the NICE CKS for the assessment of chest pain.

41. Our GP adviser has told us there were some uncertainties regarding the diagnosis at the time of presentation at 3.30pm. These uncertainties mean a decision to rule out ACS was not possible from the information provided. They said there was sufficient evidence to recommend A&E attendance at this point to rule out an ACS with serial ECGs and high sensitivity troponins. Troponin is a protein found in muscles, including the heart. When your heart is injured or damaged, troponin is released into your blood.

42. We note that the Practice said that the GP registrar suggested Mr X attend A&E and that he declined saying he would go later when he took Mrs X to hospital as she was unwell with an unrelated long-term health condition of her own. Mrs [name redacted] says that if her husband had been told to go to A&E he would have gone as she was at home with her daughter. Our GP adviser explained if a patient refuses this advice, again a full discussion regarding risks and an assessment of their capacity should be made. This should be fully documented in the notes. This would be in line with the GMC’s Good Medical Practice. This was not done.

43. There is no indication that the GP registrar made it clear to Mr X the importance of attending A&E at that time. The Practice could also have discussed options if Mr X was worried about managing both his health needs and those of his wife. Our GP adviser said there would have been justification in this situation to call 999 and request an ambulance for suspected ACS if it was not possible to transport Mr X to hospital in another way.

44. We recognise the GP registrar suggested Mr X attend A&E, but we consider more should have been done to fully explain to him the importance of doing so without delay. In the absence of that clear and robust discussion about the risks of not attending A&E promptly, our view is Mr X was not given the information he needed to understand the urgency of the situation and make a fully informed decision about his next steps. We have found this was a failing on the part of the Practice in not emphasising the importance of attending A&E at that time.

45. The indication is that the senior GP was concerned about the GP registrar’s plan, so they asked the GP registrar to call Mr X, which they did at 5.27pm. The GP registrar said the senior GP told them to ‘convince’ Mr X to attend A&E due to his history of chest pain, which indicates the senior GP recognised the urgency involved. Mrs X believes the Practice should have done more for Mr X after GP registrar’s call at 5.27pm.

46. It is not clear what the exact conversation was at the debrief, but it is clear that the senior GP was concerned enough to ask the GP registrar to call Mr X.

47. The GP registrar’s advice during this call to attend A&E was correct at this time. This was to attend A&E immediately. However, the timescale and mode of transport should have been discussed. The GP registrar should also have checked Mr X’s current symptoms. Our GP adviser said a clinician calling 999 at that point would have been best practice as it would have helped with categorisation of the call. However, this in itself is not necessarily a failing, as the ambulance service operates a robust triage of their calls, so it could be argued that to ask the patient to do this is acceptable. Our view is that overall this was not a failing at that time.

48. In summary, we have found the GP registrar should have advised Mr X to attend the A&E department at his 3.30pm appointment for further investigation. We have considered the impact this failing had on Mr X’s outcome with advice from our cardiology adviser.

49. We have considered what would have happened if Mr X had attended A&E after his 3.30pm appointment. Our cardiologist adviser said it is likely that at the time he suffered his heart attack after an ambulance arrived at 7.34pm he may already have been in hospital, blood tests would have been taken and an ECG performed.

50. Our cardiology adviser said if these investigations had shown evidence of myocardial ischaemia or infarction, then prompt treatment would have been commenced. In this case, there is a potential likelihood of the treatment reducing the risk of the sudden cardiac arrest. However, our cardiologist adviser said four hours is not very long window, depending on the ambulance response, time to hospital, time to be assessed and to await blood test results (usually one hour).

51. Our cardiologist adviser also explained the potential treatments the medical team may have given Mr X including aspirin. However, a clinical trial of aspirin administered early after diagnosis, showed there was no early mortality difference between placebo (medical treatment with no active ingredient) and aspirin. Another medication, clopidogrel again did not show an early mortality benefit. Other standard blood thinning medications (heparin, enoxaparin or fondaparinux) also have not shown an early mortality benefit. Therefore, even if these treatments were indicated they may not have made any difference to Mr X’s situation.

52. If the ECG had shown ST elevation which indicates a myocardial infarct (a completely occluded artery) then very prompt treatment would have occurred i.e. transfer to the specialist heart centre for immediate angiography (assuming the team were ready to proceed with no other patients undergoing procedures at that time, but our cardiologist said again it is a short time window – and the absence of pain at the time of the ambulance arrival at 7.34pm makes it unlikely there was ST elevation myocardial infarct (a completely occluded artery).

53. However, our cardiologist adviser said there is a small possibility of the ECG showing a marker of severe coronary disease, being transferred to the specialist heart centre and having successful treatment – but it is a low possibility in that timeframe. They said unfortunately, even today patients present with occluded arteries and opening the artery results in cardiac arrest which does not respond to resuscitation.

54. Our cardiologist adviser has told us that it is unlikely the time delay would have changed Mr X’s outcome. They said unfortunately, coronary artery disease remains the leading cause of death in the UK simply because it can be so dangerous.

55. In summary, taking into account the available evidence and the clinical advice we have received, we have found there was a failings on the part of the Practice in not referring Mr X to A&E at 3.30pm for further investigation and not emphasising the urgency of him attending A&E at that time. We note Mrs [name redacted]’s comments above but we cannot say for certain that he would have attended even if the GP registrar had emphasised the importance. Furthermore, we are unable to say if his outcome would have been different if he had attended A&E sooner. However, Mrs X has been left with uncertainty as to whether earlier A&E attendance and treatment may have improved her husband’s chances of a better outcome. This will be a source of significant distress for her and we do not underestimate that. Mrs X has said says the loss of her husband has been devasting and left her feeling alone and isolated.

56. We note that the GP registrar has said they have reflected on this matter as part of their learning. Furthermore, the Practice said in its response that it would be sharing this event with the clinicians to learn from the experience. We consider this is appropriate. However, the Practice has not fully acknowledged the failing in care provided to Mr X or the significant impact this has had on Mrs X.

57. In the circumstances, we partly uphold this complaint. We have therefore made recommendations below to provide a personal remedy to Mrs X.

East Midlands Ambulance Service NHS Trust

58. Mrs X complains that the Trust paramedics took her husband to the local hospital rather than the specialist heart centre. The Trust has said the paramedics made the decision to take Mr X to the local hospital rather than the specialist heart centre because following his heart attack he needed to be stabilised.

59. The national guidelines are the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines. In the guidelines, it states:

• “Transfer the patient directly to the nearest appropriate hospital in accordance with local pathways for primary percutaneous coronary intervention (PPCI) or ECMO (where available).”

60. The EMAS ‘Management of Cardiac Events Procedures’ document, 6.1 states that “Patients who have been in cardiac arrest, now with return of spontaneous circulation (ROSC) meeting the STEMI ECG criteria as above” would be accepted by all the regions’ PPCI centres. The document has a flowchart with a similarly worded bullet point.

61. In following the flowchart’s ‘YES’ arrows, this leads to guidance for the ambulance clinician to call the PPCI centre, give patient details and seek guidance from the cardiac practitioner. However, there is a suggestion that not all calls will lead to direct admission to PPCI.

62. In the circumstances, the paramedics do not appear to have followed Trust policy to call the specialist heart centre to discuss the suitability of direct transfer to that hospital.

63. Our paramedic adviser noted Mr X’s agitation appears to have influenced the ambulance crew in deciding to go to the nearer hospital. Agitation can be a common situation where there is return of spontaneous circulation (ROSC). ROSC is the resumption of a sustained, effective heart rhythm and pulse following cardiac arrest. JRCALC offers advice to consider hypoglycaemia (low blood sugar), hypoxaemia (low oxygen in the blood), need to remove airway device, or pain. The paramedics appear to have considered these.

64. JRCALC also states that “If available, request additional support from enhanced care teams to consider the need for anaesthetic management or sedation, as per local procedures.” This is suggestive of enhanced skilled clinicians that could attend the scene to provide sedation. The ambulance clinicians appear to have sought sedation from staff at the local hospital before transferring to the specialist heart centre. Our paramedic adviser said seeking sedation at the local hospital could be interpreted as aligning to the principle of the JRCALC point.

65. Furthermore, a Trust consultant paramedic has told us anaesthetic or sedation could not be provided on scene. Our paramedic adviser said they can understand the rationale to seek critical care support at the nearby emergency department to stabilise Mr X for the reasons stated by the Trust and JRCALC.

66. The Trust’s consultant paramedic also told us that it is unlikely that the specialist heart centre would accept a ROSC patient. We have thoroughly explored this directly with the specialist heart centre and our paramedic adviser.

67. The trust responsible for the specialist heart centre has told us that it is not unusual for the centre to ask an ambulance crew to take a patient who has suffered an out of hospital cardiac arrest to their nearest ED if the patient is unstable to be stabilised prior to transfer to the centre for intervention. This is also the experience of our paramedic adviser who said that these centres do not normally accept agitated and combative ROSC patients when there is an ED much closer.

68. In summary, this appears to have been a difficult situation for the paramedics. The local pathway indicates the paramedics should have called the specialist heart centre regarding Mr X. We have found this was a failing on the part of the Trust. However, taking into account the comments from our paramedic adviser and the specialist heart centre it is unlikely they would have accepted Mr X at that time. Furthermore, the advice from our cardiology adviser suggests that even if Mr X had been transferred to the specialist heart centre we are unable to say that his outcome would have been different. That said, Mrs X will be left wondering if the call had been made the centre may still have accepted him. This is a source of upset to her which has not been recognised and addressed by the Trust.

69. In the circumstances, we partly uphold this complaint. We have therefore made recommendations below to provide a personal remedy to Mrs X.

1. We have identified failings in the Practice’s management of Mr X’s care relating to his appointment with the Practice at 3.30pm in March 2023.

2. However, we are unable to conclude that but for the above failings Mr X’s sad outcome would have been any different. However, these failings would have caused uncertainty and distress for Mrs X which will be a source of ongoing upset for her.

3. The Practice has not fully recognised the failings in the care provided to Mr X or the impact this has had on Mrs X. Therefore, we partly uphold the complaint.

4. We have made the following recommendations:

• The Practice should acknowledge the failings summarised in paragraph 55 and apologise to Mrs X for the significant distress and upset these have caused her.

• The Practice should pay Mrs X £500 as a personal remedy in recognition of the significant distress and upset she has suffered as a result of the failings we have identified in Mr X’s care and treatment. We cannot underestimate how difficult and distressing this will be for her and we are sorry about this.

East Midlands Ambulance Service NHS Trust (the Trust)

5. We have identified a failing in the Trust’s management of Mr X’s care. This was a failure to contact the specialist heart centre in line with Trust policy.

6. We are unable to conclude that but for the above failing Mr X’s sad outcome would have been any different. However, this failing would have caused uncertainty and distress for Mrs X which will be a source of ongoing upset for her.

7. The Trust has not fully recognised the failing in the care provided to Mr X or the impact this has had on Mrs X. Therefore, we partly uphold the complaint.

8. We have made the following recommendations:

• The Trust should acknowledge the failing summarised in paragraph 68 and apologise to Mrs X for the significant distress and upset this has caused her.

A Practice in the Scunthorpe Area (the Practice)

9. Mrs X complains about the care and treatment the Practice provided to her husband, Mr X, in March 2023. She believes that the Practice should have done more to investigate her husband’s chest pain and support him at that time.

10. Mrs X believes that with better care and treatment her husband may have had a better outcome.

11. Mrs X says the death of her husband has caused her devastation. It has left her feeling lonely and isolated.

12. Mrs X is seeking an apology, service improvements and a financial remedy.

East Midlands Ambulance Service NHS Trust (the Trust)

13. Mrs X complains about the Trust and the decision to take her husband, Mr X, to the local hospital rather than the specialist heart centre.

14. Mrs X believes that this decision led to a delay in her husband receiving the treatment he needed and affected his chances of a better outcome.

15. Mrs X says the death of her husband has caused her devastation. It has left her feeling lonely and isolated.

16. Mrs X is seeking an apology, service improvements and a financial remedy.

70. In considering our recommendations, we have referred to our ‘Principles for Remedy.’ These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

A Practice in the Scunthorpe Area

71. Within one month of the date of this report the Practice should acknowledge the failing summarised in paragraph 55 and apologise for impact this has had on Mrs X. A copy of the letter should be sent to us.

72. The Practice should also pay Mrs X £500 in recognition of the impact on her.

East Midlands Ambulance Service NHS Trust

73. Within one month of the date of this report the Trust should acknowledge the failings summarised in paragraph 68 and apologise to Mrs X for the impact on her. A copy of the letter should be sent to us.