Terence Henry Stilges · Prevention of Future Deaths report

On 09/03/2016 I commenced an investigation into the death of Terence Henry Stilges. The investigation concluded at the end of the inquest 28th June 2016. The conclusion of the inquest was that the deceased died from a myocardial infarction which was not diagnosed before he was discharged home from hospital on 09/12/15. A troponin blood test and referral to a cardiologist should have been completed which would have resulted in him staying in hospital for further treatment.

The deceased was admitted to Birmingham Heartlands Hospital on 06/12/15 having collapsed. He suffered from severe COPD. The cause of his collapse was investigated with a provisional diagnosis of pulmonary embolism. Tests were undertaken including a troponin test (a blood test which is a marker of myocardial infarction and acute pulmonary embolism). He was reviewed on the ward round on 08/12/15 when the troponin result was 520. A further troponin was taken at 10.00 on 08/12/15. This sample was not tested as it was incorrectly labelled so another sample was taken at 16.00. He was reviewed on the morning ward round on 09/12/15 when he said he wanted to go home to attend his sister's funeral. The troponin had again been incorrectly labelled so the result was unavailable. The medical records clearly documented that the plan was for the deceased to go home. The nursing notes recorded his discharge at 11.05.

At 17.21 on 10/12/15 the deceased was readmitted to Birmingham Heartlands Hospital with severe shortness of breath and intermittent chest pain. He was diagnosed as suffering from an acute myocardial infarction. He did not satisfy the criteria for urgent intervention. He was treated in hospital until he died following a cardiac arrest on 12/12/15.

(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding. I am concerned this could result in other patients being discharged before their tests are complete.