Trust failed to assess patient's risk of early heart attack and death

What happened

Mr A went to a GP with chest pains. The GP called an ambulance, which took him to the Trust's hospital. Doctors in A&E examined Mr A and carried out blood tests and an ECG (a test that records the rhythm and electrical activity of the heart). Mr A was admitted and given initial treatment for his condition. The next day a member of the on-call medical team saw Mr A. The doctor's plan was to discharge him and arrange an exercise tolerance test as an outpatient, but in the event the exercise tolerance test was performed before Mr A was discharged. An exercise tolerance test is an endurance test in which the patient walks or runs on a treadmill. It can help to diagnose ischaemic heart disease, which is the common cause of angina (narrowing of an artery supplying blood to the heart muscle) and other heart problems.

About a week after being discharged from the hospital, Mr A went abroad. While abroad he became ill and was admitted to a local hospital. Tests showed that he needed a triple heart bypass. However, while waiting for surgery, Mr A suffered a heart attack and a stroke. A heart bypass operation was performed, but Mr A died.

What we found

Doctors adequately assessed and treated Mr A's symptoms when he was admitted to the hospital. However, they subsequently got Mr A's diagnosis wrong. Mr A had unstable angina, but doctors decided that he had 'non-specific' chest pain. Doctors did not assess Mr A's risk of suffering an early heart attack and early death, as they should have done.

The Trust's own guidelines would have placed Mr A in the category of a medium or high- risk patient, but doctors decided that he was low-risk and arranged an exercise tolerance test, which was an inappropriate test. Doctors should have referred Mr A to a cardiologist, but this did not happen. Instead, they discharged him without reviewing his medication and without any follow up, other than a request to his GP to repeat the exercise tolerance test once Mr A had stopped taking one of his regular medications. Last, in line with guidance issued by the National Institute for Health and Care Excellence (NICE), Mr A should have been given information about his symptoms, the investigations and treatment doctors proposed, and about any lifestyle changes (including advice about foreign travel). But again this did not happen.

Our investigation concluded that Mr A had been denied any opportunity to make his own choices and to receive treatment that might have saved his life. We could not say on the balance of probabilities that Mr A would not have died but for the failings we had identified. But we recognised that the distress Mrs B suffered, and continues to suffer, will be compounded by the uncertainty of never knowing whether Mr A might have survived if doctors had identified the unstable nature of his condition, arranged the investigations and treatment he needed, and given him the information and advice he needed to know about his illness.

Putting it right

Following our report, the Trust agreed to acknowledge and apologise for its failings and put together an action plan that showed learning from its mistakes so that they would not happen again. It also agreed to pay Mrs B £2,000 by way of a tangible acknowledgement of the additional distress she and her family had suffered.