Overview
Mrs C raised a complaint against Lothian NHS Board (the Board) regarding the care which her son, Mr A, had received when he was admitted by ambulance to the Accident and Emergency Department (the Department) at the Royal Infirmary of Edinburgh (the Hospital) complaining of chest pain. Mr A was discharged with a diagnosis of indigestion. Some weeks later, Mr A collapsed and died. A post mortem examination found that he had been suffering from acute heart disease.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the ECG performed by the ambulance crew was not available to or checked by the Department doctor (upheld); and
- (b) apart from an ECG, no other investigations were undertaken on Mr A when he arrived at the Hospital and local protocols and Scottish Intercollegiate Guidelines Network guidelines for patients presenting with chest pain were not adequately followed (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review their current communication methods between ambulance staff and clinical staff (both verbally and documentary) in respect of patients who are admitted to the Department;
- (ii) remind clinical staff of the importance of ensuring that all ECGs are available for review by clinical staff for patients presenting with chest pain; that their findings are documented in the patient's clinical records; and the Board's audit procedures in relation to ECG sign off are followed;
(iii) remind staff of the importance of seeking details of any family history of heart problems from patients presenting with chest pain and documenting this in the clinical records; and - (iv) apologise to Mrs C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.