Decision Report 201708580

Summary

Ms C complained to us about the care and treatment that her late partner (Mr A) received at Aberdeen Royal Infirmary when he attended on two separate occasions with severe chest pain. Mr A died during his second attendance at the hospital.

On Mr A's first attendance at the hospital he was seen in the Acute Medical Initial Assessment Unit and the Ambulatory Emergency Care Unit. Ms C complained about the assessment and examination that Mr A received and that he was diagnosed with musculoskeletal chest pain. We took independent advice from consultant in acute medicine. We found that assessments and examinations were reasonable and in accordance with the relevant guidance for chest pain. In particular, Mr A's chest pain was viewed as cardiac until it was positively excluded by the results of a troponin blood test and an electrocardiogram (ECG - a test which measures the electrical activity of the heart to show whether or not it is working normally). We did not uphold this aspect of Ms C's complaint.

Around two months later, Mr A attended the emergency department at the hospital. Ms C complained that Mr A's condition was too serious for him to be asked to sit and wait for an initial assessment. Mr A collapsed in the emergency department waiting area. He then went into cardiac arrest (where the heart suddenly and unexpectedly stops beating) and died. We took advice from a consultant in emergency medicine. We found that it was unreasonable that Mr A was asked to sit and wait for an initial assessment when he presented to the emergency department with chest pain and shortness of breath. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to assess Mr A promptly when he presented to the emergency department with chest pain, clammy skin and shortness of breath. The apology should meet the standard set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

What we said should change to put things right in future:

• Patients in a similar situation and/or with certain conditions and symptoms should be brought to the attention of nursing staff immediately, so that self-presenting patients can be fast-tracked for clinical assessment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.