Keith Ronald Martin · Prevention of Future Deaths report

On 18th March 2013 an investigation was commenced into the death of Keith Ronald Martin, 64 years of age. The investigation was concluded at the end of the inquest on 5th February 2014. The medical cause of death given was:

1a. Myocardial infarction
1b.
1c.

2.

My conclusion was: Natural Causes

Mr Martin attended the A&E department of St Peter’s Hospital Chertsey at 2200 hours on March 2013 after complaining of central chest pain and tingling down his left arm from approximately 1600 that day. He was not triaged by an A&E nurse until 2250 hours and did not have an ECG or blood tests until one hour later. His initial ECG showed no significant changes but his troponin level was significantly raised. No treatment was instituted until 0140 hours when he became significantly unwell and further ECG’s showed a significant myocardial infarction requiring emergency transfer to Frimley Park Hospital for angiography and possible recanalization of his coronary blood vessels. This was undertaken but Mr Martin subsequently bled from a cannulation site for attempted introduction of an intra-aortic balloon pump but his myocardial infarction was incompatible with life.

1. The length of time taken to initially assess Mr Martin in A&E, given his presenting symptoms
2. The significance of Mr Martin’s symptoms were not appreciated at triage
3. The length of time taken to undertake an ECG and blood tests after initial triage
4. The length of time taken to receive the results of these tests
5. The significance of the rise in troponin was not appreciated or acted upon promptly
6. The length of time taken for Mr Martin to be reviewed by a senior member of staff
7. The length of time taken to provide standard pharmacological treatment for chest pain or myocardial infarction
8. A lack of clarity as to the protocol for the management of chest pain in A&E
9. An overall lack of effective documentation