Kasey Beech · Prevention of Future Deaths report

On 19 October 2021 an investigation commenced into the death of Kasey Beech, a 19-year-old woman who died following a cardiac arrest caused in turn by a likely infective exacerbation of her longstanding asthma. Her inquest was concluded on 8 November 2023. The conclusion of the inquest was that she died by natural causes. Following the inquest further submissions and evidence were sought in relation to the risk of future deaths.

On 5 October 2021 Ms Beech self-presented to the urgent treatment centre at Medway Maritime Hospital (MMH), in light of difficulty breathing. She had also been experiencing chest pain. At MMH the traditional Accident & Emergency service has been replaced by an Urgent Treatment Centre (UTC) for walk-in patients. The UTC operates the nationally stipulated STREAMing model (‘Simple Triage Rapid Emergency Assessment Method’), a system whereby patients are assessed on arrival and sent to the appropriate area for further review and care.
Ms Beech was assessed and directed to the Medway on Call Care (MedOCC), where she was informed of a three hour wait. She decided to go to a friend’s home nearby where she could access a nebuliser more promptly. Shortly after arrival there her breathing worsened suddenly, she was unable to inhale deeply from the nebuliser and she arrested. She was subsequently taken by ambulance to MMH, and then transferred to St Thomas' Hospital London. Despite treatment she did not recover and she passed away at St Thomas’ on 13 October 2021.

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:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. 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.

While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.