Lauren Smith

1. 1. incorrect ecg interpretation leading to missed acute myocardial infarction

   “An ecg reading was taken at 08:56 am when both the paramedic and technician were in attendance on Miss [name redacted]. That ecg was abnormal. The ecg identified pathological Q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. Although the rhythm was sinus rhythm, 3 abnormal indicators were clearly present on the ecg. In addition, the auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct which was available for attending paramedics.”

2. 2. failure to act on abnormal ecg results

   “I am concerned that neither the paramedic nor the technician was able to interpret the ecg correctly and that neither paramedic appears to have noted or acted upon the auto diagnostic monitor report.”

3. 3. miscommunication of ecg results influencing patient decision

   “[the deceased] was informed that her observations and ecg were normal. This information was not correct, and it is likely that [the deceased] based her decision not to attend hospital on this incorrect information.”

4. 4. absence of organisational learning from incident

   “I am concerned that there has been no collective learning by West Midlands Ambulance Service following the death of [REDACTED]. There has been no action to address the learning gaps identified by WMAS own internal investigation report in respect of both the paramedic and technician.”

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