Recurring concern

Failure to provide clinically indicated ECGs

First to latest report 6 Mar 2014 — 9 May 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
0

What this concern includes

Includes failures in arrangements for recognising the need for, accessing, arranging, performing or making available an ECG when clinically indicated, including inadequate access in community settings and failure to perform an indicated ECG.

What is not included
  • Excludes failures limited to interpreting, monitoring or communicating ECG findings after an ECG has been reliably performed.
  • Excludes generic diagnostic-testing, staffing or equipment deficiencies unless they directly impair provision of a clinically indicated ECG.
  • Excludes failures concerning other cardiac investigations unless the assertion specifically concerns access to or performance of an ECG.
  • Excludes neutral descriptions of ECG use without an identified failure to provide an indicated ECG.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Jake Samuel Lawler · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jake Samuel Lawler collapsed while playing football on 13 October 2024 and died in hospital on 5 November 2024 after a further collapse. He had been diagnosed with exercise-induced asthma, but his exercise-induced syncope and abnormal ECG were not recognised or acted on appropriately; postmortem examination found biventricular arrhythmogenic cardiomyopathy. The report raises concerns about missed ECG warning signs, unclear pathways for children with exercise-induced syncope, limitations in asthma assessment, and access to ECGs for children in community settings.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limited availability of ECGs for children in community settings

    Wider context from the report

    “4. ECGs to rule out a possible cardiac issue cannot easily be given to children in a community setting. ”

    Source location

    Jake Samuel Lawler · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Kalma RAM-HENMAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain a second ECG when clinically indicated

    Wider context from the report

    “(2) An ECG was ordered which showed abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible. A second ECG should have been requested. It was not. She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission. It was the view of the Doctors giving the evidence that she should have received at least four litres to deal with her depleted state. So instructions given within three to four hours of her arrival in A&E (at 12.12pm on 6/6/2018) were not implemented. Why not? ”

    Source location

    Kalma RAM-HENMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    Philip Robinson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to reliably perform ECGs when clinically indicated

    Wider context from the report

    “The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated ”

    Source location

    Philip Robinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    Maureen Annette ELLETT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of ECG machines in the Clinical Decisions Unit

    Wider context from the report

    “(5) There are no ECG machines in the Clinical Decisions Unit; either they should be provided or staff on the Clinical Decisions Unit should not be expected to perform ECG's there. ”

    Source location

    Maureen Annette ELLETT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Shared ECG access between the Clinical Decisions Unit and Short Stay Ward was considered sufficient, so a dedicated female-ward ECG was unnecessary.

    Verbatim wording from the response

    “Unit (CDU) and the neighbouring Short Stay Ward (SSW) - effectively the small adjacent male and female ward areas within the Emergency Department for patients who are asked to stay in the department for a longer period. We believe this provides sufficient access for ECGs to be requested and performed safely in both areas, and that it is not necessary to have a dedicated ECG solely for the 7 female patients in the SSW.”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 31 October 2014

    Open published response

  5. West Sussex

    AI-generated summary

    Natasha Raghoo · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely electrocardiograms

    Wider context from the report

    “3. Whilst under the care of the Dene,and on antipsychotic drugs and with a raised blood pressure an electrocardiogram was not carried out because all routine ECGs are performed by a visiting nurse from a General Practitioners surgery on a set day of the week. An ECG machine is available within the hospital but is not routinely used. ”

    Source location

    Natasha Raghoo · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Routine ECGs were not required under the applicable Maudsley Guidelines for psychiatric patients.

    Verbatim wording from the response

    “As you note, there is an ECG machine available at the site. This is regularly used by the visiting GP and the employed, permanent Advanced Nurse Practitioner.”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 3 · response
    Published 6 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The patient's acute manic state meant a meaningful ECG could not have been obtained.

    Verbatim wording from the response

    “Further, as a result of the patient’s acute manic state, which had led to her admission, it would not have been possible to obtain a meaningful ECG reading.”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 3 · response
    Published 6 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Any enhanced physical observations or ECG testing was expected to be ordered by the visiting GP or responsible Consultant Psychiatrist.

    Verbatim wording from the response

    “However, as you will appreciate, the Dene is a psychiatric unit and PiC complies with The Maudsley Guidelines for such matters as ECG usage. The Maudsley Guidelines in place at the time of the death (the 10th edition) do not recommend that routine ECGs be carried out for every patient. We would expect that if there were any enhanced needs for physical observations or tests of this sort, these would be ordered by either the visiting GP or the Consultant Psychiatrist responsible for the patient's care.”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 3 · response
    Published 6 March 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026