Barry Gordon Pike · Prevention of Future Deaths report

On 29 July 2014 I commenced an investigation into the death of Barry Gordon Pike. The investigation is due to conclude with an Inquest that has been listed to be heard on 12 October 2015. The medical cause of death from the Post Mortem Report is:
1 (a) Hypoxic Encephalopathy;
1 (b) Acute Cardiac Failure;
1 (c) Coronary Artery Atheroma

Mr Pike was 57 years of age. He was seen in the Emergency Department of Derriford Hospital on 2 July 2014 complaining of chest pains. He was triaged and then reviewed by a Junior ████████ who felt that Mr Pike was suffering from reflux. It is not clear from the evidence whether Mr Pike was the subject of a Senior review, but in any event, he was discharged from Hospital later that afternoon.
It appears as though the results of blood sent for testing at the time of Mr Pike’s initial triage had not been reviewed. This revealed a raised Troponin level.
Mr Pike died suddenly 10 days later.
Mr Pike’s death has been reviewed in a Root Cause Analysis Investigation Report. That reveals a number of care and service delivery problems. Included in the Root Cause Analysis is that the Emergency Department Acute Coronary Syndrome Algorithm recommended patients with intermediate risk of major acute coronary event to be discharged for GP follow up. Subsequent to this incident that algorithm has been reviewed.

As part of the Inquest process, the revised algorithm has been considered by an independent expert, ████████ A copy of his Report is enclosed. Of concern is that he believes the revised algorithm is not an improvement on the original document and still requires further clarity and detail to avoid confusion and mismanagement of acute coronary syndrome patients admitted to Derriford A & E Department

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) These are set out within the enclosed Report of Dr Stephen Hoole..
(2)
(3)