Decision to discharge patient may have contributed to his death

What happened

Mr H went to A&E in autumn 2013 with chest pains and shortness of breath. Following assessment, the doctor discharged him with a referral to the Trust's outpatient Rapid Access Chest Pain Clinic. Mr H died at home two days later.

One month later, and again in spring 2014, Mr H's son complained to the Trust. He raised concerns about the decision to discharge his father and asked for details of his assessment, diagnosis and treatment.

In its responses, the Trust gave an account of what had happened in A&E, including the examination and tests that it carried out. This included a troponin test (a test that measures proteins in the blood which are released when the heart muscle has been damaged).

The Trust acknowledged that it would have been more appropriate to admit Mr H to hospital, and refer him to the medical team for further investigation into the cause of his chest pain. The Trust explained the actions it had subsequently taken to address its failing.

Mr H's son was dissatisfied with the Trust's responses and asked us to investigate his complaint.

What we found

The doctor who assessed Mr H in A&E should have sought a senior doctor to sign off his findings, in line with National Institute for Health and Care Excellence guidance. Although Mr H's initial troponin test was normal, the doctor should have repeated this test, in line with European Society of Cardiology (ESC) guidance when he suspected Mr H was suffering from acute coronary syndrome (ACS). This did not happen.

While we cannot know whether Mr H would still have died if he had been admitted to hospital, there was a missed opportunity for him to have a second troponin test. Although we do not know what the outcome of this test would have been, it may have given information about protein levels which, if acted upon, could have increased his chances of survival.

Putting it right

Following our investigation the Trust acknowledged and apologised for its failings with regard to its decision to discharge Mr H. It paid Mr H's son £1,000 for the distress it had caused him by not repeating the troponin test, and for the uncertainty of not knowing whether the outcome could have been different for his father.

The Trust also prepared an action plan to make sure medical staff follow the Trust's policy for managing patients with suspected ACS in line with NHS Emergency Medicine Quality Indicators.