Recurring concern

Failure to provide clinically indicated ECGs

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First reported 6 Mar 2014•Latest report 9 May 2025

Definition

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.

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: 5
Individual concerns: 5
Date range: 2014–2025
Stated actions: 0

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

University Hospitals Sussex NHS Foundation Trust2

Department of Health and Social Care1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Partnerships in Care Limited1

Royal Sussex County Hospital1

South London and Maudsley NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

9 May2025
Manchester South
Concerns raised1
1. Limited availability of ECGs for children in community settings
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
23 Oct2018
Brighton and Hove
Concerns raised1
1. Failure to obtain a second ECG when clinically indicated
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
13 Mar2015
Nottinghamshire
Concerns raised1
1. Failure to reliably perform ECGs when clinically indicated
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
31 Oct2014
Brighton and Hove
Concerns raised1
1. Unavailability of ECG machines in the Clinical Decisions Unit
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Shared ECG access between the Clinical Decisions Unit and Short Stay Ward was considered sufficient, so a dedicated female-ward ECG was unnecessary.
  Stated by University Hospitals Sussex NHS Foundation TrustExisting arrangements considered sufficient
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
6 Mar2014
West Sussex
Concerns raised1
1. Failure to provide timely electrocardiograms
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  Routine ECGs were not required under the applicable Maudsley Guidelines for psychiatric patients.
  Stated by Partnerships in Care Group LimitedExisting arrangements considered sufficient
1. Position
  The patient's acute manic state meant a meaningful ECG could not have been obtained.
  Stated by Partnerships in Care Group LimitedUnable to act
2. Position
  Any enhanced physical observations or ECG testing was expected to be ordered by the visiting GP or responsible Consultant Psychiatrist.
  Stated by Partnerships in Care Group LimitedRedirects responsibility
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Limited availability of ECGs for children in community settings

Concerns raised1

Failure to obtain a second ECG when clinically indicated

Concerns raised1

Failure to reliably perform ECGs when clinically indicated

Concerns raised1

Unavailability of ECG machines in the Clinical Decisions Unit

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide timely electrocardiograms

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Respondent positions 1

Respondent positions 3