Rory Badenoch represents family at inquest in which a failure to investigate and promptly treat a cardiac patient’s excruciating pain was found to have been so serious as to amount to neglect.
Facts
Mrs Dawn Shane was admitted to the Royal Cumberland Infirmary on 18/3/2024 with symptoms consistent with unstable angina. Her symptoms included back pain that radiated to her shoulders and chest.
A coronary angiography and angioplasty was performed on 11/4/2024, during which a stent thrombosis was identified and quickly rectified. Instruction was given by the Consultant interventional radiologist to switch Mrs Shane from Clopidogrel to a more potent anticoagulant (Ticagrelor) to reduce the risk of further stent thromboses. Unfortunately the medication change was not written in the notes, the original drug chart or the care plan and was therefore not actioned, a failure which the Coroner considered to be a “serious error”.
On 16/4/24 Mrs Shane was reviewed on the morning ward round by an FY1 doctor and was deemed fit for discharge. She was informed that she would be taken off slow-release morphine on discharge, a decision which she was reportedly “okay with”.
At 12:08 Mrs Shane called her husband reporting significant pain. Medical notes demonstrated that sometime between 12:00 and 13:00 she began “screaming and writhing in pain”, which was described as 8/10 pain between her shoulder blades.
The FY1 doctor reviewed her and, being unsure of the cause of the pain contacted the on-call cardiology consultant. She described the sudden onset of severe pain between the shoulder blades and conjectured that the pain might be “drug seeking behaviour” due to Mrs Shane having recently been informed that she would be taken off slow-release morphine. The consultant, despite considering a cardiac cause, advised that no investigations be undertaken and that the pain team be contacted with a plan to “allow the pain to settle”.
Mrs Shane was given oral morphine at 13:00 and codeine at 13:45 with no effect on her pain. She continued to “scream and writhe” in pain. Despite her excruciating pain (which cardiology witnesses from the Trust accepted was consistent with a myocardial infarction) continuing unabated, she was not reviewed again until 15:30 (2.5 hours later) and after Mr Shane arrived at the hospital and demanded she urgently be reviewed by a doctor.
An ECG was finally arranged at 15:56, more than three hours after the onset of the very severe pain between the shoulder blades. This demonstrated a significant anterolateral ST segment elevation. Mrs Shane was transferred to the Cath lab for PCI, where it was identified that she had acute stent thrombosis of both the LAD and intermediate stents, with no flow down either artery, (suspected to be due to the failure to switch Mrs Shane to a more potent anticoagulant). Reperfusion was achieved at 17:15 (more than 4 hours and 15 minutes after the onset of the myocardial infarction).
This massive heart attack resulted in severe impairment of the left and right ventricles and Mrs Shane’s ejection fraction, which had previously been assessed as normal during her admission (at greater than 55%) dropped to between 25% to 30%.
As a consequence she developed severe decompensated heart failure with resultant multi-organ dysfunction, which was a very poor prognostic sign. Mrs Shane was transferred to Royal Bournemouth Hospital where she suffered further serious medical emergencies including a major haemorrhage from her bowel. Unfortunately due to the severity of her heart failure Mrs Shane’s condition was extremely difficult to manage and after a long and extremely traumatic battle to recover she died on 15/7/2024.
Neglect:
The Coroner, Mr Brendan J Allen, was critical of the care provided. He was clear that the symptom of severe pain between the shoulder blades (which was consistent with an acute coronary event) in a patient with a recent history of stent thrombosis who was on a cardiac ward, should have been immediately investigated.
The investigations that were required (notably an ECG) were basic, readily available on the cardiac ward, and could have been performed within 5-10 minutes. He determined that there was no good reason why ECG did not form part of the plan.
Had the basic investigation been performed it would have revealed an ST elevation MI which would have prompted immediate transfer to the cath lab for PCI, reducing the extent of the myocardial damage to Mrs Shane’s heart. Instead no investigations were performed, no plan was made for a time to review to see if the pain settled with analgesia, and no review was performed for at least a further 2.5 hours.
He concluded:
- There was a failure to undertake any investigation to understand or explain the cause of the sudden onset severe pain.
- The investigation required to identify the source of the pain was not a complex medical procedure and could have been completed within minutes.
- In the context of a medical emergency where time is critical and where each passing hour will result in increased damage to the heart, Mrs Shane was untreated for an extended period between before 1300 and approximately 1530.
- He was satisfied that an ECG at or around 1300 would likely have led to swift treatment and reperfusion resulting in less severe damage to the heart and a greater degree of recovery.
- In the circumstances had Mrs Shane received prompt treatment she most likely would not have died on 15/7/24.
- The failure to perform a prompt ECG and to not review Mrs Shane until 15:30 led to avoidable heart damage and Mrs Shane’s premature death and amounted to neglect.
Rory Badenoch, was instructed by Karen Watts of Lester Aldridge solicitors. The inquest took place between 12 and 16 July at Bournemouth Coroner’s Court before HM Area Coroner Brendan J Allen.
