Norwich hospital puts measures in place after ‘avoidable death’ of patient

A Norwich hospital has brought in extra cardiac monitoring equipment and training after an 'avoidable death' of a patient in its accident and emergency department.

The Norfolk and Norwich University Hospital said today it was sorry it could not save the patient involved, but refused to elaborate further on how or why the patient died.

N&N medical director professor Krishna Sethia said: 'We are very sorry that we were not able to save this patient. This case has been investigated thoroughly and it was found to be due to misinterpretation of an ECG (electrocardiogram).

'We have taken immediate action and training to ensure that the error is not repeated.'

The details of the unexpected death were revealed in the hospital's clinical quality and safety report in September, which also revealed that a patient complained about the management and treatment of their miscarriage, while another patient was given an x-ray while they were pregnant.

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The report says that a root cause analysis of the unexpected death, which was reported in June, determined that it was avoidable, and goes on to say that as a result the hospital has bought additional stand-alone cardiac monitoring/defibrillators for use in the A&E trolley bay cubicles which do not have central cardiac telemetry.

Other actions agreed include additional training for an A&E consultant in ECG interpretation and a review of its 'chest pain' patient pathway for direct admissions to cardiology.

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The death was reported as a serious incident in June, but the hospital has not said when the patient concerned died.

It also refused to say what cause of death was, citing patient confidentiality.

When asked why extra equipment had been purchased if the error was down to misinterpretation of an ECG, Prof Sethia said: 'Many patients presenting with chest pain do not have cardiac problems and after triage low risk patients are often placed in bays without electronic cardiac monitoring.

'As a result of the investigation it was concluded that as an additional precaution, patients presenting with chest pain should be monitored electronically.'

With regard to the patient who had a miscarriage, Prof Sethia said: 'We have started an improvement programme to ensure patients who have miscarried are dealt with as quickly as possible. We have provided dedicated theatre slots to minimise any delay and also to ensure any procedures carried out are minimally invasive.'

Commenting on the patient who complained that they were given a dental x-ray while pregnant, he said: 'We regret the error that occurred when an x-ray was carried out on a patient who was pregnant. It is our policy to routinely ask female patients if they could be pregnant on arrival to the radiology department.

'We are also making changes to our computer system to prompt clinicians to explain why an x-ray is necessary before it is carried out. We have reinforced this issue with staff and our clinical guidelines have been re-circulated to all junior doctors.'

Exposing an unborn baby to a certain level of radiation has been shown to increase the risk of learning disabilities and eye problems. Most x-rays are much weaker than this, but pregnant women are advised to avoid having x-rays.

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