Coroner's Finding: LAWRENCE Rebecca Mary

Contributing factors

• failure to identify diagnostic ECG changes between serial tracings
• incorrect classification of patient as 'very low risk' despite not meeting criteria
• failure to repeat Troponin T testing as per hospital protocols
• failure to adequately interpret ECG traces by experienced clinician
• over-reliance on computerised ECG summaries rather than examination of actual traces
• inadequate supervision of registrar by consultant
• failure to apply established guidelines
• patient falsely reassured by initial negative testing, delaying further medical attention

Coroner's recommendations

1. Reconsider inclusion in guidelines of specific reference to risk factors such as diabetes and the quality and duration of chest pain as important considerations in assessing very low risk
2. Give instructions to all medical staff that the requirements and protocols in the Guidelines should be strictly adhered to, particularly the very low risk criteria
3. Direct medical staff not to discharge patients on the very low risk pathway unless there is an alternative explanation for chest pain with high degree of certainty
4. Provide ongoing training and education to medical staff regarding chest pain management, including ECG interpretation
5. Direct junior medical staff including registrars not to discharge patients with chest pain via the very low risk pathway unless the patient has been examined by a consultant and any ECG examinations have been sighted and evaluated by a consultant
6. Telephone health operators and locum services should advise callers with chest pain to immediately call an ambulance or attend hospital regardless of whether there has been any recent hospital presentation