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Communication criticised after patient death

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A hospital has been criticised for a “communication breakdown” after a man who was told by doctors he had indigestion died two months later suffering from heart disease.

Edinburgh Royal Infirmary has now apologised to the family of the 41 year old.

The Scottish Public Services Ombudsman found there was a “communication breakdown” among hospital staff.

The man, who is not identified in a report by the ombudsman today, was admitted to Edinburgh Royal Infirmary with chest pains on 25 January 2008.

He was discharged with a diagnosis of indigestion but collapsed while cycling two months afterwards and later died in hospital.

A post-mortem examination found that he had acute heart disease, prompting the man’s mother to complain about his treatment at the hospital.

The ombudsman found that an electrocardiogram (ECG) heart test carried out on the man in the ambulance on his first visit to the hospital was not available to, or checked by, the doctor.

“It is clear that there was a breakdown in communication, both verbally and in passing the physical copy of the ambulance ECG to the doctor to be reviewed,” the report found.

The differences between the results of the ambulance test and a separate ECG carried out in the accident and emergency department should have raised the possibility that “there was a possible cardiac cause” of the man’s chest pain, the report found.

The failure to take the ambulance ECG into account meant staff “failed to pick up on the possibility that the chest pain Mr A experienced was cardiac in nature”.

The ombudsman recommended that NHS Lothian review its communication methods between ambulance staff and doctors, remind staff of the importance of ensuring ECGs are available for review and to apologise to the dead man’s family.

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Readers' comments (1)

  • I can recall this information being passed onto my father, when in fact it turned out that he needed a triple heart bypass and was only alive as he has an uncommon fouth artery? What trust do we put in Doctors. My Mum died 30 years ago, she was diagnosed after she had given birth to me with Post Natal Depression and yet she died when I was six months old with heart disease. What I can gather is if the client doesn't tick enough boxes they are not diagnosed correctly, but if they have family that use their innitative and actually question what is happening and why isn't something more being done, then the clients ends in suffering with the undiagnosed illness. We need to speak out more and be heard to ensure a correct diagnosis is found early on and treated accordingly to elimate the unfortunate end of life that could have very well been avoided from a family member speaking out .

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