Rex Brook Hall · Prevention of Future Deaths report

On 10 August 2016 I commenced an investigation into the death of Rex Brook Hall. The investigation concluded at the end of an inquest on 21 November 2016. The conclusion of the inquest was natural causes.

The Deceased passed away at the Solihull Hospital on the 28 July 2016 at 16:10. The Deceased had arrived at Solihull Hospital by ambulance at 14:39 with a reported history of right arm pain and atrial fibrillation, however, at 15:37 an ECG identified that he was experiencing a myocardial infarction and he was admitted to their resuscitation but went into cardiac arrest at approximately 15:50 from which he could not be resuscitated. ECGs taken by paramedics at 13:59 and 14:03 showed ST elevation; this was not recognised by the paramedics nor were the ECGs reviewed on arrival at hospital. If ST elevation had been identified Mr Hall would have been transferred for assessment at the PCI unit at Birmingham Heartlands Hospital but although possible, it is unlikely that he would have survived.

Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:

1(a) ST ELEVATION MYOCARDIAL INFARCTION

That there may be deficiencies in the foundation training of paramedics:
1. one of the paramedics who qualified in 2015 after a 2 year foundation degree gave evidence that he had never had any formal testing on interpretation of 12 lead ECG;
2. the same paramedic gave evidence that he was not aware from his training that arm pain is a recognised, albeit, atypical sign of myocardial infarction; and
3. two paramedics did not identify obvious ST elevation (the other paramedic completed a diploma in paramedic science in August 2012).