David Charles Martin · Prevention of Future Deaths report

On 8/10/24, I concluded the inquest into the death of David Charles Martin who died in RCHT on 17/9/22.

I recorded the cause of death as:
1a) Left ventricular cardiac failure (post-stenting)
1b) Coronary artery thrombosis
1c) Coronary artery disease
II) Atrial fibrillation; Chronic kidney disease

I recorded a conclusion of Natural Causes.

Mr Martin was an 83-year-old man with a history of progressive heart failure. He was admitted into Royal Cornwall Hospital on 30/8/22 with deteriorating symptoms. He had a diagnostic angiogram on 5/9/22 before a decision was made at a cardiology MDT on 12/9/22 that he was not for surgical intervention and was offered stenting (PCI) instead. The procedure took place on 16/9/22. It was Trust policy that patients undergoing PCI should have dual anti-platelet therapy (DAPT.). In error, Mr Martin was prescribed Aspirin only and the oversight was only identified post-operatively when Mr Martin was immediately given a loading dose of a second anti-platelet therapy. Mr Martin collapsed later that afternoon. He was resuscitated but then deteriorated and died in the hospital on 17/9/22. It is unlikely the cause of Mr Martin's collapse was a clot in an inserted stent and thus the oversight in the provision of a second anti-platelet therapy was not causative of Mr Martin's demise.

1) The inquest heard evidence that the locum SHO involved in the care of Mr Martin was 9 days into a 3-4 month period of cover. She had not received any cardiology induction and was unaware of the Trust DAPT policy regarding PCI patients. It was accepted that while it was a challenge to ensure locums who covered 1-2 shifts had a thorough induction, where one was being asked to work in the service for an extended period of time, it was necessary that there was a proper induction process. The inquest heard changes have already been made in this regard.
2) There were multiple opportunities where the fact Mr Martin was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues.