Dr Imad Hassan · Prevention of Future Deaths report

On the 20th April 2016 I commenced an investigation into the death of Dr Imad Hassan. The investigation concluded at the end of an inquest on the 16th August 2016. The conclusion of the inquest was that: “On the 17th April 2016 the deceased suffered an out of hospital cardiac arrest following a heart attack. He was resuscitated and diagnosed with having sustained an ST Myocardial Infarction. Remaining clinically unstable he was taken to the nearest hospital, Prince Charles, Merthyr Tydfil. Treatment partially stabilized his condition to the extent that transfer to another hospital for a rescue PCI Intervention procedure was not clinically indicated. Even if a rescue PCI Intervention procedure had been indicated, there was no critical care capacity (at the time) to undertake this, at UHW Hospital, Cardiff or Morriston Hospital, Swansea”.

On the evening of the 17th April 2016 Dr Hassan suffered (an out of hospital) heart attack and went into cardiac arrest. He was resuscitated by the emergency services at the scene and taken to Prince Charles Hospital for urgent medical attention. His condition was partially stabilised and there were discussions between the clinicians at Prince Charles Hospital, University Hospital of Wales in Cardiff and Morriston Hospital in Swansea as to Dr Hassan's suitability for Percutaneous Coronary Intervention (PCI) to be performed as at either Morriston Hospital or UHW in Cardiff. Dr Hassan suffered a further Cardiac Arrest at Prince Charles Hospital and died 04:35hrs on the 18th April 2016.

1) In the event that a patient at Prince Charles Hospital is deemed suitable for PCI there is currently no formal back up plan in place, to enable the PCI to proceed, should UHW in Cardiff or Morriston Hospital in Swansea be unable to accept that patient.
2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI.
3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place.
4) There is currently no agreed pathway for an unconscious STEMI patient requiring PCI in tertiary services as there is currently for conscious patients with STEMI. Although in the case of Dr Hassan transfer to another hospital for a rescue PCI was not clinically indicated, that may not necessarily be the case in the future, particularly in a patient who has had a short period of unconsciousness and a PCI is clinically indicated.
5) In similar circumstances as pertained on the evening prior to / the morning of Dr Hassan's death such a patient (as described in 4)) may be deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea.