Kasey Beech
29 Aug 2024 · Coroner Xavier Mooyaart · London Inner (South)
The coroner's concerns
1. patients sent to MedOCC without adequate assessment of non-cardiac causes of chest pain
“The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC. However: pain can fluctuate over time and may not always be concurrent with the initial assess”
2. delayed or missed diagnosis of non-cardiac life-threatening conditions
“pain can fluctuate over time and may not always be concurrent with the initial assessment;pain may be masked by analgesia taken prior to assessment; and the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain”
3. inadequate attention to immediately life-threatening differentials such as asthma exacerbation
“The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence”
Responses
2024-0473-Response-from-NHS-England.pdf ↗· NHS England
2024-0473-Response-from-NICE.pdf ↗· National Institute for Health and Care Excellence
2024-0473-Response-from-RCEM.pdf ↗· National Institute for Health and Care Excellence
Stated action
“We note the initial assessment took place in an Urgent Treatment Centre (UTC) rather than Emergency Department (ED); from the described circumstances of Ms [name redacted] death, it is not clear whether the UTC was effectively 'gatekeeping' access to an emergency department or not.”