Trust failed to act on early signs of a heart attack in older woman

What happened

Mrs J, who was in her nineties, arrived by ambulance at the Trust's A&E department in autumn 2012. She was short of breath and had pulmonary oedema (an excess of watery fluid on the lungs). She was triaged in early afternoon but died in the emergency department in the early evening of the same day.

Mr J complained that his wife spent four hours on a trolley in the A&E department without being attended to. After two hours staff started her on a drip to reduce her heartbeat and later gave her an injection into her wrist to help the pain. Minutes later, she died. Mr J said his wife should have been sent to a cardiology ward to receive care.

What we found

We partly upheld this complaint. Mrs J arrived at A&E in early afternoon with heart disease and heart failure, and the doctors were aware that she had suffered a heart attack (when the supply of blood to the heart is suddenly blocked, usually by a blood clot) in the 24 hours before she arrived.

A junior and a senior doctor both saw her, she had an ECG, and appeared to respond reasonably well to an infusion of medication.  She suddenly became agitated in the early evening, most likely because of the heart attack she had before arriving at that Trust. Staff gave her some intravenous morphine but her condition deteriorated to a cardiac arrest (fast heart beat leading to an electrical malfunction of the heart) from which she died. This was almost certainly due to an extension of her earlier heart attack rather than any mismanagement by the Trust. We found nothing of concern in these aspects of Mrs J's care.

Shortly before her death however, a second ECG showed changes in her condition which prompted doctors to call cardiologists at another hospital (as the Trust did not have a cardiology department), but while they were on the phone, Mrs J died.

We found that the ECG tests taken on Mrs J's arrival at the Trust showed that she had a high indicator for a possible future heart attack. It appears that the clinicians did not act on this and could have considered referring her to cardiologists much sooner than they did.

In its response to Mr J's complaint, the Trust said there was nothing more it could have done, but this was not reasonable. The doctor, when he called the cardiologists at another hospital, was actually discussing whether Mrs J was a candidate for heart surgery when she died.

While Mr J was concerned about Mrs J's time on the trolley, we did not reach a view that this was unreasonable but instead we focused on the care she received. Mr J complained that she was left for four hours with no medical intervention, but this was not the case.

Putting it right

The Trust wrote to Mr J to acknowledge and apologise for not referring Mrs J to cardiologists much earlier that it did.

The Trust conducted an investigation to find out why Mrs J's positive indicator for a heart attack was missed and the abnormal ECG results were not reviewed, escalated or acted on. It also produced an action plan to show how it would reduce the likelihood of this happening in the future; to make sure that staff seek earlier cardiology investigation; and to show that it had learnt lessons from the failing we found.