PUBLIC SERVICES OMBUDSMAN FOR WALES
INVESTIGATION INTO A COMPLAINT
CWM TAF NHS TRUST
3. The complaint 1
4. My investigation 2
5. Events leading to the complaint 2
6. What Mr M had to say 8
7. What the Trust had to say 11
8. What my Professional Adviser had to say 18
9. Conclusions 18
10. Recommendations 22
Appendix A 24
This report is issued under [s 16] of the Public Services Ombudsman (Wales) Act
2005 (“the Act”). In accordance with the requirements of the Act details which
might identify individuals have been omitted so far as that can be done without
impairing the effectiveness of the report. The report accordingly refers to the
complainant as Mr M.
The report is preceded by a summary.
Mr M complained about cardiac treatment he received at Prince Charles Hospital
Mr M made a number of criticisms of the Former North Glamorgan NHS Trust
that was responsible for the hospital at that time. His complaint was handled by
the successor Trust – Cwm Taf NHS Trust. The Cwm Taf NHS Trust came into
existence in April 2008. Mr M said that the Former Trust mishandled his care
after he had been admitted to hospital after a suspected heart attack. He
accused the Former Trust of:
unjustifiably delaying a follow up appointment to see a cardiac specialist
failing to refer him for an angiogram which was clearly and vitally
indicated by test results
cancelling an appointment with a specialist that had been arranged to
review his case
employing a Locum Consultant for many years without him gaining the
relevant qualifications to be a permanent consultant.
Mr M said that these failures meant that he had to wait many months longer for
cardiac surgery than should have been the case. He said that this left him in
danger of a heart attack and caused him great stress whilst he was awaiting an
appropriate medical response. As a result of the poor standard of care that he
received, Mr M claimed that it has left him with a fear of NHS treatment.
The investigation involved viewing medical records and complaint documents,
interviewing Mr M and the relevant Consultant, speaking to a key Trust Director
and seeking the advice of one of the Ombudsman’s professional advisers.
The Ombudsman strongly upheld Mr M’s complaint in all its aspects. Most vitally,
he found that it was a serious clinical error by the Trust not to refer Mr M for an
angiogram when it had the opportunity in early 2007. Instead, it referred him for
a test that was not appropriate for someone with his condition. This mistake
occurred within and was partly prompted by, a lack of capacity for angiography in
the area of the Former Trust at that time.
The Ombudsman made a number of recommendations. These included redress
to Mr M, revisiting a review of patients who were referred for the same test as Mr
M and carrying out a review of its cardiology arrangements. The Ombudsman
was pleased that the Trust agreed to implement the recommendations.
Report under Section 16 of the Public Services Ombudsman (Wales) Act
2005, of an Investigation into a complaint
made against Cwm Taf NHS Trust
1. Mr M complained about treatment he received from Prince Charles Hospital
(“PCH”) in 2006/2007. At the time of the treatment in question, PCH was under
the management of the former North Glamorgan NHS Trust (“the former Trust”),
which became part of the Cwm Taf NHS Trust from April 2008. Mr M said that
after PCH discharged him following a suspected heart attack, he was not seen
promptly for specialist review. He said that when he did see a cardiac specialist,
the Locum Consultant Cardiologist in charge of his case (“the Consultant”) did not
refer him for an angiogram. The need for this referral was indicated by an
abnormal Electrocardiograph (“ECG”) result after he undertook an exercise test.
Instead, Mr M said that the Consultant apparently placed him on a waiting list for
an unsuitable test after Mr M had made representations. He added that the
Former Trust then cancelled an appointment, which it had planned to follow the
test, without consideration of his clinical needs. Mr M cast doubt on the
appropriateness of the Trust’s employment of the Consultant as a cardiology
specialist, given that he has fulfilled that role for a number of years whilst
remaining a Locum.
2. Mr M stated the Former Trust’s mishandling of his case meant that he had to
wait much longer for a serious heart operation than should have been necessary.
The operation was eventually arranged and performed by other Trusts. He said
that the delays had put in him danger. Mr M said that the issues involved in his
complaint caused him serious concern and anxiety. He added that the matter
has left him with fear and mistrust of using the NHS in future. Mr M noted that
this has already proved a problem on two occasions when he jeopardised his
health rather than readily agree to be admitted to hospital.
3. Letters setting out the matters to be investigated were issued on 9th October
2008. In reaching my conclusions I have considered the information provided by
Mr M and the Trust including evidence gathered at interviews. Both parties have
had the opportunity to comment on a draft of this report. I have based my
findings on advice I have received from my professional Adviser, a Consultant
Cardiologist (“the Adviser”). His report is attached as appendix A. Mr M and the
Trust have had the opportunity to comment on a draft of this report. I have not
referred to every item that is in the investigation files. However, I am confident
that nothing of significance has been omitted.
4. Schedule 2 of the Act excludes the Ombudsman from becoming involved in
most matters of a personnel nature. This includes disciplinary action with regard
to employees of the bodies that he can investigate.
EVENTS LEADING TO THE COMPLAINT
Brief clinical chronology
5. On 10th November 2006 Mr M was admitted to PCH with a suspected heart
attack. PCH discharged him later that day. However, clinicians referred him for
an exercise test and ECG. An ECG measures the electrical currents that pass
through the heart. It can demonstrate the extent of coronary artery blockages,
which can lead to heart attacks.
6. On 28th November Mr M attended PCH and had an exercise test and an
ECG. A physiologist reported on the test results. That clinician noted “frequent
atrial and ventricular ectopics…during exercise…” (This is a worrying feature of
7. On 14th December the Consultant wrote to Mr M’s GP. He said that the
results from the tests had been received. The outcome of Mr M’s exercise test
was “near maximum…with positive results”. It said that Mr M was to be
“reviewed in clinic”.
8. On 8th March 2007 Mr M attended an outpatient’s appointment for review of
his test results. This was about two months after an earlier appointment date,
which Mr M had to cancel due to a pre-arranged trip. A registrar working under
the Consultant saw him. A follow up appointment was made for Mr M to see the
Consultant in November. On the same day the Registrar wrote to Mr M’s GP.
The letter said that it was for “completeness” that he would suggest a myocardial
perfusion scan (“MPS”) for Mr M. MPS is a diagnostic procedure for use in
cardiology. (See Appendix A for more information about MPS.)
9. On 5th April the Chief Executive of the Former Trust responded to a
member of the National Assembly whom Mr M had contacted for help with related
matters. The letter stated that the Consultant had been asked for comments. It
said that the fact that Mr M had seen the Registrar in March rather than the
Consultant was due to the volume of patients in the clinic on that day and Mr M’s
treatment had “not been compromised in any way”. The letter added that tests
conducted in November 2006 had “proved negative for a heart attack”. The letter
confirmed that Mr M would receive an MPS in June to rule out coronary heart
disease. On the same day, the Consultant referred Mr M for an MPS.
10. On 30th July PCH wrote to Mr M. The letter cancelled his appointment with
the Consultant in November. The letter said that the reason for this was a
change of administrative practice prompted by the Welsh Assembly Government.
Appointments in future would only be made for six weeks or less in advance.
However, the letter said that PCH aimed to ensure that the new appointment with
the Consultant would be booked for a time near to the original date.
11. On 26th November Mr M saw a cardiac consultant at the Caerphilly District
Miners Hospital (“CDMH”) after a referral from his GP. CDMH is under the
management of Gwent Healthcare NHS Trust. That clinician referred Mr M for an
angiogram. An angiogram is a diagnostic tool whereby the blood vessels of the
heart are X rayed.
12. On 6th February 2008 Mr M had an angiogram at the Royal Gwent Hospital
(“RGH”). RGH is a Gwent Healthcare NHS Trust hospital. As a result of the
angiogram, the Cardiac Consultant at CDMH referred Mr M to the University
Hospital of Wales (“UHW”) for a triple bypass operation on his heart. UHW is
under the control of Cardiff and Vale NHS Trust.
13. On 14th April Mr M received notification of an appointment to see the
Consultant on 29th May.
14. On 13th May Mr M had a triple bypass operation at UHW.
Mr M’s representations
15. Mr M did not initially want to lodge his complaints formally with the Former
Trust. However, he submitted representations directly and via elected
representatives. He also obtained publicity in the media. The bulk of Mr M’s
work in this area took place in the first half of 2008.
16. On 1st April 2008 a senior manager at PCH issued a draft confidential
report into a “clinical incident” which had arisen through a media story. There
was an email, which accompanied the reports that were distributed to various
Trust staff. It stated that the issue:
“…flowed from an initial clinical error, which the patient is not currently
aware of, and all of the further problems stemmed from this. As you know
it is sensitive because of the public profile, the Assembly involvement and
The report made the following points of note:
Mr M was “understandably” concerned about his care, especially in the
“light of family history”.
The error in this case was a misinterpretation of test results and led to a
“delay in treatment”.
Mr M would have probably had his surgery already if that error had not
Mr M’s ECG of 28th November 2006 was “reported” by a physiologist who
“drew attention to a number of irregularities”.
Test results have been checked due to this case and nine patients
awaiting MPS have been reviewed. These had “highly positive results”. It
said that this “suggests” that the interpretation of the exercise and ECG
tests were poor or MPS was not the appropriate choice. Five of these
patients “received other treatment following a change in their clinical
condition”. Four require “urgent outpatient follow up” and may need
“invasive investigation or treatment”.
Further MPS referrals will be suspended.
Use of MPS was introduced as a pilot due to capacity and “funding” issues.
MPS is for “low risk patients”.
A “backlog” meant that Mr M could not be reviewed in November 2007 as
originally planned. This was “a clinical risk in itself”.
17. On 16th April the senior manager’s draft report was finalised. The final
report was very similar to the draft. However, it gave more detail of the four
patients who had urgent outpatient follow up appointments. Three had
experienced no recent chest pain and one had received a satisfactory angiogram.
18. On 5th June the new Trust’s Divisional Director for acute medicine (“the
Director”) wrote to Mr M in response to his representations. The letter said that a
review of the case by a senior consultant cardiologist had found that there was a
clinical error in not giving sufficient weight to the results of the ECG test.
Moreover, opportunities were missed to correct that mistake. He apologised on
behalf of the Trust. The letter outlined the Trust’s response to the case. The
changes in practice were listed as:
features of an exercise test which give cause for concern have been
all positive exercise tests must be reviewed by consultants
exercise tests must be reviewed in clinic by an experienced doctor in the
context of a patient’s clinical history
referrals for MPS have been suspended
The letter added that a review of all the patients remaining on the MPS waiting
list had been carried out by a locum cardiac cardiologist in late March 2008. It
explained the findings. There were 144 patients on the list. 102 had completed
their assessments by the various medical teams. They were either stable or had
already had angiograms. The review found these patients did not require an
MPS. 26 patients were left on the list, as their exercise test results were not
“significantly abnormal”. 16 patients were identified as having “significant
exercise test abnormalities”. The letter said that the clinician performing the
review saw those patients personally and speedily. It said that the writer had “not
been made aware of any other clinical incidents in respect of these patients”.
The letter said that the Consultant is “extremely unhappy” about the “failings” and
passed on his personal apology. It said that he “will be moving from his position
as Locum Cardiology Consultant”. An appointment panel was due to meet in the
near future regarding a new full time cardiac consultant’s position.
19. The various correspondence and contacts culminated in a meeting between
Mr M and the Director on 27th June 2008. The meeting re-iterated and expanded
on some of the responses that the Trust had thus far provided. The notes from
the meeting indicated that Mr M had an opportunity to explain his dissatisfaction
with the Former Trust. The Director stated that he had investigated the matter.
The notes show that he made the following points:
Mr M’s ECG results of November 2006 were “abnormal” and “warranted
consideration of direct referral for angiography”
that although the outpatients appointment that followed the ECG was made
“in a timely manner”, it was “felt that [the Consultant] had not attached a
high enough level of concern or clinical priority to the result”
it was inappropriate to refer Mr M for an MPS, this was “a clinical error”
the error in referring Mr M for an MPS was “due at least in part to problems
accessing an angiography service”
the Director explained that the Consultant was still employed as a Locum
Consultant Physician in the Cardiology Department but was “not accredited
he would personally review the Consultant’s file
it was unknown whether the Registrar who saw Mr M in March 2006
discussed his case with the Consultant, although this had been intended.
The Director explained the steps that had been taken in response to Mr M’s
criticisms and the problems that they had highlighted. The notes concluded as
“[the Director] apologised for the poor service [Mr M] had received and
acknowledged the mistakes made. [Mr M] thanked [the Director] for his
openness and time and acknowledged that a great deal had already taken
place. However, he expressed a wish to take the matter further. [The
Director] …reiterated that if [Mr M] on reflection…wished to make a formal
complaint, it would be better to do so by formal letter.”
20. Mr M requested that the Trust make his complaint formal on 18th July.
21. On 8th August the Deputy Chief Executive of the new Trust wrote to Mr M.
The letter said that the meeting of 27th June represented the Trust’s final
response to his complaint and his view was that the matter was “closed”.
22. Mr M submitted his complaint to the Ombudsman on 10th September.
WHAT MR M HAD TO SAY
23. Mr M stated that he was admitted to PCH after a suspected heart attack in
November 2006. However, clinicians told him that it was probably indigestion
and discharged him 12 hours later. He added that it was his understanding that
the ECG test was arranged as a precaution.
24. Mr M said that he knew something was wrong with his ECG results at the
test on 28th November 2006 because he observed the body language and facial
expressions of the supervising nurses. Moreover, he could not complete the test
due to breathlessness. He said that he had told attending staff that he had a
problem with his left knee and had been inactive for some time. Mr M stated that
the nurses would not tell him anything but stated that the Consultant would
explain at a later appointment.
25. Mr M said that he waited until March 2007 for his specialist review. He saw
a Registrar instead of the Consultant. He had declined an earlier appointment
due to a pre-booked holiday. However, he had requested an earlier alternative
than March as he was very worried about his heart. He stated that the Registrar
knew nothing about his case and appeared to be very busy. He had difficulty
understanding the Registrar as his English was poor. Mr M gave him relevant
details including that both his parents had died suddenly of coronary heart
disease. He told him that he had often suffered from chest pain. Mr M said that
the Registrar told him that he had coronary heart disease. He made an
appointment for Mr M to see the Consultant on 1st November 2007. Mr M said
that the Registrar planned to recommend to the Consultant that an MPS was
appropriate to confirm the diagnosis. Mr M stated that the Registrar did not
mention an angiogram.
26. Mr M said that he became increasingly anxious whilst waiting for his MPS,
knowing that it was a long time before his appointment with the Consultant. He
saw his GP in the summer. The GP cast doubt on the appropriateness of the
MPS referral. He referred Mr M to a cardiology consultant at CDMH. As a result
of Mr M’s representations he received a letter from PCH saying that his MPS
would take place in June. Mr M said that he decided to await the MPS and the
follow up appointment with the Consultant as well as the alternative referral to
CDMH. He had decided to take whichever came first.
27. Mr M stated that he never had an MPS. However, he did receive a letter
cancelling his November appointment with the Consultant. Mr M was informed
that this was done in accordance with a Welsh Assembly Government instruction.
The letter said that the Former Trust aimed at providing a new appointment with
the Consultant near to the original date.
28. Mr M said that he saw the cardiac consultant at CDMH in November. An
Angiogram followed in February 2008. The result was a diagnosis of serious
heart disease. This led to a triple bypass operation in May 2008 at UHW.
29. Mr M has a number of outstanding concerns about his treatment by the
Former Trust. He said that delays in his initial dealings with the Former Trust
were not acceptable. He stated that he should not have had to wait four months
to see a specialist after his abnormal test results. Mr M said that he was then
given an appointment for eight months later. This was later cancelled. In the
meantime, he was awaiting an MPS. This did not occur. He noted that
eventually, he was given an appointment to see the Consultant in May 2008.
This date was after his triple bypass operation. Mr M complained that the Former
Trust wasted many months of his time. This was only minimised by his own
efforts in visiting his GP in summer 2007, which led to the angiogram and the
operation, arranged and performed by other Trusts.
30. Mr M maintained that his ECG showed obvious abnormalities, which were
not acted on appropriately. He added that the Director accepted that his ECG
was abnormal and that an MPS referral was a mistake. Mr M said that there was
persuasive and respected research from Holland that led to his view that the
results showed a 99% chance of serious coronary disease that would require a
triple bypass operation. Despite the results, the Consultant appears to have
missed opportunities to realise the significance. Mr M noted that the Consultant
had written to his GP in December 2006 about the results. It was unknown
whether he reviewed them with the Registrar after the consultation in March
2007, but that should have happened. Mr M pointed out that the Former Trust
had sought the Consultant’s comments about his case around that time. The
Trust told Mr M about this in a letter dated 5th April 2007. In addition to the
above, a physiologist had reported that there were concerns with the test results
soon after they were taken. Mr M maintained that the Trust’s actions in his case
was “wholly inadequate”. He asserted that budgetary constraints leading to a
lack of angiogram capacity and the Former Trust’s desire to keep waiting lists
short, were major contributing factors to the clinical errors that he experienced.
Mr M said that he could not accept that the failure to refer him for an angiogram
was purely a clinical error. He said that an angiogram was clearly necessary in
his case but he was added to a waiting list for something he did not need in order
to mask a long waiting list for a test which he did need. Mr M noted that the
Director accepted this, to some extent, at the local resolution meeting of June
2008. Mr M said:
“…potentially life critical decisions were made on the basis of budgets,
political convenience, indeed anything but the need of the patient”.
He added that he feels some patients may have died because of the approach of
the Former Trust.
31. Mr M said that his appointment with the Consultant scheduled for
November 2007 was cancelled in a very casual manner. It was done “without
any concern whatsoever for my clinical condition”. He also suggested that he
may have never been on the waiting list for MPS because he was never called for
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32. Mr M commented that it was not acceptable for the Consultant to have been
employed by the Former and current Trust for many years as a Consultant
Cardiologist, when he was a Locum and not appropriately qualified for the post.
Mr M said he was concerned about the many other patients that the Consultant
has treated over recent years. He suggested that those people may also have
had “sub-standard” treatment. He suggested that the Trust should review them
33. Mr M said that he had to wait about 18 months for his operation after an
ECG indicated that it was likely to be necessary. This was not acceptable. It had
left him in danger for far longer than should have been the case. His experience
had caused him great anxiety. Moreover, it left him with a “serious psychological
mistrust of the NHS and a deep seated fear of ever needing hospitalisation
again.” Mr M said that he has “no faith at all” in the NHS.
WHAT THE TRUST HAD TO SAY
34. The Trust supplied Mr M’s relevant medical records and copies of
correspondence. The Trust explained that Mr M only chose to formalise his
complaint after it had responded fully to his concerns. Therefore, it had nothing
to add at that point. The Trust confirmed that its response to Mr M, as outlined in
its letter to him of 5th June 2008 and the meeting of 27th June 2008, represented
35. The Trust added some further information in response to questions that
arose during the investigation. It said that it had introduced the MPS service as a
“pilot scheme for low risk patients”. The Trust confirmed that Mr M’s referral for
MPS was made on 5th April. However, the referral was not marked as urgent.
The Trust stated that no arrangements for the MPS were made. It noted that
apologies had been given to Mr M “with regard to this oversight”. The Trust
stated that the appointment with the Consultant, due to take place in November
2007, was cancelled due to a change in the follow up system. The Former Trust
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had done this to ensure that patients were seen in date order, unless their cases
were urgent. The reason for the alternative appointment not being offered until
March 2008 was due to a “[five] month backlog.” The Trust added that it did take
action to improve angiography capacity by discussing the matter at various
regional meetings. It also made the point that commissioning arrangements are
a matter for Local Health Boards. The Trust also confirmed that “referral
pathways” for angiography were now more appropriate than in the days of the
36. The Trust explained that the Consultant had been a Locum since 2001. He
was still employed as a Locum Consultant Cardiologist. It said that it no longer
employed the Registrar. The Trust stated the following:
“A Locum Consultant can be appointed to cover a vacancy if it is deemed
by the employing Trust that he or she is clinically competent to carry out
the work required…it is not permissible for a Doctor without specialist
accreditation to be appointed to a substantive Consultant position. [The
Consultant] is not on the specialist register either for general medicine or
for cardiology and therefore cannot be appointed a substantive Consultant
Cardiologist. However, he has worked seven years within the Trust during
which time his performance has been satisfactory.”
37. The Trust outlined the action that it had taken in response to the issues that
Mr M’s complaint had highlighted. It had implemented the following:
staff had been reminded of the features of the exercise test and an
ECG which should give cause for concern
raised the matter with the Consultant
all tests that are recorded as positive must be reviewed by a consultant
the tests must be reviewed in clinic by an experienced doctor in the
light of a patient’s clinical history to ensure an accurate interpretation of
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new referrals for MPS had been suspended
a review of the 144 patients that were on the waiting list for MPS was
38. The Trust described the results of the review of patients, which had been
completed by a Consultant in specially arranged “protected time”. 102 patients
were deemed not to require an MPS. The reviewer took the view that those
patients had already been “adequately investigated”. 26 patients were to be
reviewed at their next routine outpatients appointment having had an MPS and
/or other investigations. 16 patients were found to have had “significant [test]
abnormalities”. Those patients had a further clinical review in “additional clinics
set up specifically for the purpose”. The Trust said that no clinical problems were
identified because of the referral for MPS, although some of the patients should
have been referred for other investigations earlier. Furthermore, the referral for
MPS did not in itself pose any danger. The Trust stated that it “had not been able
to ascertain the number of doctors involved in referring these individuals for an
MPS”. Also, it could not produce any evidence about what the reviews found in
terms of further clinical errors, if any, or lessons that were learned and
disseminated. Moreover, it could not explain the overlap, if any, between that
review and the work that lay behind the report dated 16th April 2008 which is
referred to in paragraph 17. It is worth adding that after the Trust read a draft of
this report, it said that more detailed information about the patients reviewed had
been gathered and relevant GPs contacted. The Trust apologised for not
providing that information earlier. However, it did not supply additional written
Interview with the Consultant
39. The Consultant said that he had been a Locum Cardiac Consultant at PCH
for eight years. In that time, his status had not changed.
40. The Consultant commented that he had never met Mr M. However, he had
reported on the exercise and ECG test that Mr M took in November 2006.
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41. The Consultant explained the results of Mr M’s exercise test and ECG. He
said that it showed that Mr M exercised for 8.5 minutes, which is good.
Moreover, he had no chest pain. He noted the physiologist’s report on the tests
but said there was nothing in the results which were alarming. However, there
were positive signs of ischaemia (heart disease). More investigation was
indicated from these results. This would have been addressed at a follow up
appointment. He added that if Mr M had kept the appointment scheduled for
January 2007, he might have seen the Consultant and this may have led to a
different outcome. He accepted that Mr M’s results and circumstances indicated
that a referral for an angiogram would have been his likely recommendation if he
had seen Mr M.
42. The Consultant said that Mr M saw the Registrar in March 2007, two
months later than his original appointment. The Registrar obviously felt
comfortable that there were no alarming symptoms. The Registrar recommended
an MPS. The Consultant thinks that he did not discuss the case with him. The
Registrar’s opinion was a “judgement call”. The Consultant expressed the view
that an MPS would not have added much and he would have chosen an
angiogram as a better option. The Consultant explained that he made the
referral for an MPS for Mr M based on the Registrar’s opinion. His role in doing
so was simply to sign it off. He commented that he did not know why the MPS
had not taken place.
43. The Consultant stated that if Mr M had been concerned about anything
arising from his case he could have telephoned him. He would have arranged to
44. The Consultant said that overall, it was obvious that Mr M should have had
the triple bypass operation much sooner. He was at risk of a heart attack whilst
waiting. He added that many patients did, and still do, have to wait far too long
for cardiac treatment due to long waiting lists. The Consultant said that the
waiting list for angiograms was excessive at the time of Mr M’s consultation with
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the Registrar. This affected a large number of patients. Lack of resources was
the fundamental reason for this. The situation has improved to some extent in
recent months. However, this country was a long way behind nations such as
Holland, where waiting times were minimal. The Consultant said that despite the
Registrar’s judgement, if the waiting list for angiograms had been small, Mr M
would have been referred for one. Clinicians did not make an MPS referral when
an angiogram was clearly indicated. MPS tests were introduced in the Former
Trust to aid diagnosis for some patients and could be a useful tool.
45. The Consultant stated that targets had nothing to do with this case. He said
that if Mr M had been referred for an angiogram, it would have been to a different
Trust. Therefore, Mr M would have been added to a waiting list, outside the
responsibility of his Former Trust.
46. The Consultant maintained that he did not have in depth knowledge of the
Trust’s response to Mr M’s representations. He was not involved in formulating
the Trust’s position. He said that he found that “disappointing”. He added that he
considered that suspending MPS was unwise and he had not concluded that any
serious clinical error had occurred. The Consultant did not know anything about
the review of 144 patients.
47. The Consultant explained that he applied for his current post and was
successful, in 2001. He was trained in cardiology. However, his training pre-
dated the current accreditation system. He said that he has not tried to acquire
the current credentials. The Consultant said that he worked closely with the
Senior Cardiologist in the Department but was not formally supervised.
Interview with the Director
48. The Director said that in the new Trust, he was responsible for surgery,
medicine and anaesthetics in his role as one of the Directors of the Trust’s Acute
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49. The Director said that he was presented with Mr M’s criticisms of the
Former Trust within a week or so of taking up his post in the new Trust. He
understood that the Trust had admitted a delay in diagnosing “significant
coronary heart disease” in Mr M’s case. He had confirmed this to Mr M when he
met him in June 2008. He said that he was pleased to find that Mr M had
eventually received the surgery that he required and was recovering well.
50. The Director said that Mr M’s test results from November 2006 were
“unequivocally abnormal” and suggested coronary heart disease affecting the
important left ventricle (the main pumping chamber of the heart). The results
have been shared with other cardiologists in the Trust and all agreed with the
Director’s view. He added that the Consultant had seen the test in December
2006 and did not seem to have recognised the importance of it. That constituted
a clinical error.
51. The Director commented that in 2006/2007 there was relatively limited
access to coronary angiography. Consequently, there was “a high threshold” for
referral. The Former Trust had no in house capacity for performing angiogram
tests. Patients requiring the test had to be referred to another Trust and many
such referrals were made. However, it was then the case that patients showing
less severe indications of heart disease were not always referred for an
angiogram. A lack of resources available at the time was the major reason for
this, and was the context in which the clinical error involving Mr M was made. If
Mr M presented with the same test findings in 2009, the Director said it was
“virtually certain” that he would have been referred for an angiogram, even
though the Consultant had not recognised the full significance of the test results.
52. The Director, having been asked why the Trust did not take any specific
action to address the problem of angiogram capacity, explained that in late 2006
it was known that re-organisation was imminent and would improve the situation.
He described the Former Trust as “marking time” in that regard.
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53. The Director said that the situation since 2008 is “vastly different” and had
“substantially improved”. The new Trust has capacity to perform its own
angiograms and has additional cardiologists. The threshold for referral has
therefore been appropriately lowered.
54. The Director, when asked a direct question about targets, stated that he did
not believe that the issue of targets was relevant to this case. In 2006/2007 he
was not aware that there were any specific targets relating to angiograms.
55. The Director explained that the Trust had decided to carry out a full review
of all the patients on the waiting list for MPS, as a direct result of Mr M’s
complaint. The Trust had to ask itself the question, “Could Mr M’s experience
have been repeated with other patients?” MPS tests were not being carried out in
a timely manner and some patients were left “in limbo”. This was a potential
clinical governance issue. The Doctor who implemented the review reviewed the
case records of all the patients waiting on the MPS list. He identified 16 patients
whose records gave him cause for concern and personally reviewed all these
patients in additional clinics. The Director understood as a result of this review
that there had been no other problems identified in those patients, however, he
does not know about the individual circumstances of the cases and has not seen
any written report of the review.
56. The Director said that MPS referrals were suspended as a result of Mr M’s
complaint and because they were not occurring at an acceptable rate. However
the Director said he was persuaded by cardiologists that there remains a role for
MPS. He said that in an ideal world it is his understanding that both MPS and
angiograms would be available.
57. The Director said that a backlog was responsible for Mr M’s MPS follow up
appointment with the Consultant, originally planned for November 2007, not
being replaced until May 2008. This backlog has still not been cleared as at
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58. The Director said that he had reviewed the Consultant’s file as he had
indicated to Mr M. He found no upheld complaints or any other worrying
features. However, he would be concerned if the Consultant did not fully accept
that a clinical error had occurred in relation to Mr M.
59. The Director stated that the Consultant was able to remain a Locum for so
many years because the Trust, both former and new, could not fill its vacancies
for cardiac consultants. Thus, there has been a deficiency in substantive cardiac
consultant posts in PCH for many years. In 2008 an advertisement yielded one
new consultant. The Trust would have appointed more if there had been
additional applicants available. Another advertisement is being issued soon.
Once posts are filled the Consultant would be offered transfer to a substantive
post as Cardiology Specialty Doctor – a sub-consultant role. This will happen at
some point in the relatively near future. In the meantime and for eight years, he
has been filling a post and has been deemed competent so to do. He added that
the Trust is “uncomfortable” that he has remained in post as a Locum for so long.
It has “encouraged” the Consultant to gain the necessary accreditation to permit
him to apply for specialist accreditation.
60. The Director concluded by saying that he feels that the Trust has done all it
can for Mr M in response to the issues that he has raised.
WHAT MY PROFESSIONAL ADVISER HAD TO SAY
61. The advice of my Adviser is attached to this report as Appendix A.
62. Mr M made a number of complaints against the Former Trust in relation to
his treatment at PCH. In reaching my conclusions I have considered the analysis
provided by my Adviser, which I regard as informative and plausible. My findings,
concerning the main part of Mr M’s complaint, are that his treatment at PCH was
seriously flawed, leaving him at genuine risk of a heart attack. This was due to a
serious clinical error which occurred within the context of a lack of angiography
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capacity. I also have concerns about other aspects of Mr M’s complaint, to which
the Trust needs to pay due regard. I will explain my conclusions below.
63. Mr M was concerned about the time he waited for specialist consultation
after his exercise and ECG tests took place on 28th November 2006. There is no
doubt that the Consultant should have realised the full significance of the ECG
results that he viewed in December 2006. I will discuss this in more detail below.
This is particularly worrying when it is noted that a physiologist drew attention to
the results. My Adviser indicated the action that he should have taken at that
time. Instead, the Consultant did nothing. In the context of the seriousness of Mr
M’s test results and the appropriate response as outlined by my Adviser, I do not
regard the fact that Mr M cancelled an earlier appointment as relevant to my
findings. Mr M is correct. He had to wait too long to see a specialist after the test
results of 28th November were reported.
64. The most concerning aspect of this case is the previously mentioned clinical
error. It appears that the Registrar was mistaken in not immediately referring Mr
M for an angiogram and taking the steps discussed by my Adviser. It appears,
on the balance of probability, that he did not discuss the case with the
Consultant. However, again I am troubled by the actions of the Consultant.
According to the letter from the Chief Executive of the Former Trust dated 5th
April 2007, the Consultant was asked for comments about Mr M’s case. His input
demonstrated again that he did not grasp the full significance of the test results.
Moreover, it was the Consultant that made Mr M’s MPS referral on 5 th April 2007.
At interview he said that his role in making that referral was to “sign it off”. I
cannot accept that this is a reasonable position. This and his role in contributing
to the letter to a member of the National Assembly, represents another missed
opportunity to review Mr M’s test results in conjunction with other indicators that
Mr M was at risk. In short, the Consultant made serious errors in responding to
Mr M’s clinical presentation. I am further concerned about that because at
interview he did not appear to fully appreciate the magnitude of the error. I am
very surprised and perturbed that his evidence at interview seemed to imply that
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the Trust has done little to alert him to the importance of this matter. I note the
Trust’s assurance that it did raise the matter with him. However, the Consultant
did not appear to recall that happening. There are only two conclusions that I can
draw. Either it was not raised with him or he was not able to bring it to mind
when questioned. Both these options reflect badly on the Trust as the matter
should have been addressed in a robust manner and recorded properly.
65. Mr M has stated that he believes that a lack of resources was to blame for
the failure to refer him for an angiogram. This is strongly disputed by the Trust.
However, the Director during his meeting with Mr M and at interview with my
investigator acknowledged that a paucity of angiogram capacity did affect
decision making for patients who were on the borderline between requiring that
test or not. At interview the Director suggested that he thought the Former Trust
did not do a great deal to increase access to angiography in the knowledge that
the situation would improve later. I regard this as a feeble approach to a lack of a
vital resource. The Consultant and the Director have stated at interview that if
angiography had been readily available in 2007 for PCH patients, Mr M would
have been referred appropriately. That being the case, I conclude that a lack of
resources contributed to the error that that occurred in Mr M’s case in the sense
that it would not have happened if resources were adequate. That is a highly
plausible statement because the Trust has openly stated that MPS was
introduced for low risk patients as an alternative to highly sought after
angiography. Extra resources inevitably lead to clinicians being more willing to
obtain additional test results, as they are less concerned by the need to avoid
potentially wasting a scarce resource. Nevertheless, Mr M was not a borderline
case. In light of Mr M’s symptoms, test results and background, I conclude that it
was a serious clinical error not to refer him for an angiogram regardless of
concerns over resources.
66. The clinical error was further exacerbated by the long waiting list for cardiac
follow up appointments. Mr M’s appointment scheduled for November 2007 was
cancelled in July. Due to the backlog it was not re-made until April 2008. The
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new appointment was scheduled for May. That appointment followed Mr M’s
triple bypass operation which took place at UHW earlier that month. In any case,
the follow up appointment would not have been following up anything as the
erroneous MPS referral did not happen due to another mistake by the Former
Trust. I understand Mr M’s view that the appointment was cancelled without
apparent reference to the seriousness of his condition. He is right. This was an
unfortunate by-product of the greater error. Mr M should not have been waiting
for a follow up appointment after MPS. Even bearing in mind that the Former
Trust did not appreciate his clinical condition in July 2007, it is nevertheless
concerning that it could not successfully organise MPS for Mr M or carry out
follow up appointments in a reasonable time scale.
67. Mr M is deeply troubled by the knowledge that the Consultant has been
employed as a Locum for eight years. I share his concerns. The Consultant as a
Locum does not have the accreditation to perform the role permanently. Despite
this, he has held the position for many years longer than is the case with many
permanent employees. This makes a mockery of the term “Locum”. Moreover,
the Director has made it clear that the situation is regarded by the Trust as
unsatisfactory. The Former and current Trust has apparently tried on numerous
occasions to recruit a replacement for the Consultant, in which case he would be
moved to a less senior position. This is not a ringing endorsement of his
appropriateness for the vital role he occupies. This reflects badly on the Trust
and bearing in mind that Consultants work largely unsupervised, has clinical
governance implications. This matter requires urgent action.
68. I regard the Former and current Trust’s actions once it knew of the errors in
Mr M’s case, as praiseworthy to an extent. It appears to have addressed the
clinical governance issues affecting patients by carrying out a review (or reviews)
of patients referred for MPS and expediting those where earlier test results were
concerning. However, I am disappointed that the Trust has not been able to
produce a report which:
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reported clearly on the clinical findings on the patients involved
outlined any further clinical errors that had occurred
recommended the action to be taken in the light of the review’s findings.
The Trust has failed in this regard to learn vital lessons from a serious error
involving at least one patient – Mr M. There may well have been other serious
errors. As it stands, the relationship between the report of the senior manager,
issued on 16th April 2008 (but without accreditation or date) and the work referred
to by the Director in his letter to Mr M in June 2008, is not known. A major
opportunity to minimise the risk of future mistakes being made was lost. The
Trust’s lax attitude to this matter has been exemplified by the lack of evidence of
the Trust working with the Consultant to ensure he learns lessons from Mr M’s
case. I regard these matters as sufficiently serious for me to raise them directly
with Health Inspectorate Wales on publication of this report.
69. It is clear to me that Mr M had to wait, probably without appropriate
medication, many months longer for his triple bypass operation than should have
been the case. He had enough information available to him to mean that he was
concerned about his health from November 2006. He was right to be concerned.
He was at risk of death or a debilitating heart attack. I understand in that context,
that Mr M has lost faith in the NHS. Therefore, he has suffered a significant
injustice. I uphold his complaint.
70. I recommend that the Chief Executive of the Trust issue a further apology to
Mr M for all the errors and injustices that were apparent in this case.
71. I recommend that the Trust pay Mr M the sum of £2000 to reflect the
injustice that he has suffered.
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72. I recommend that the Trust does all it can to return to the review(s) of the
patients who were awaiting MPS in spring 2008. It should then issue a report
which addresses at the least, the issues that I raised in paragraph 68.
73. I recommend that the Trust carries out an audit of recent and relevant ECG
results that have been reviewed by doctors at PCH and takes appropriate action
as indicated by the findings. The Trust should also include an appropriate
sample of other recent cases handled by the Cardiology Department of PCH to
assure itself that a wider investigation into standards of care is not required.
74. I recommend that the Trust reviews its cardiology arrangements to ensure it
has sufficient numbers of appropriately skilled staff to offer a prompt and effective
75. The Trust has agreed to implement the recommendations set out above.
Peter Tyndall 9 July 2009
Report Reference Number: 2045/200801427
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Report by the Professional Adviser to the Public Services
Ombudsman for Wales on the clinical care given to Mr M by the
former North Glamorgan NHS Trust in 2006 and 2007
(Dr John L Caplin MB BS (Lond) BSc (Lond) MD FRCP – Consultant
Background to report
A1. This report was compiled on the instruction of the Public Services Ombudsman for
Wales. All documentation provided by the office of the Ombudsman was considered.
This includes relevant clinical records.
Mr M’s treatment and plans from his brief admission to hospital in November 2006
A2. Mr M developed chest pain at 23:00 on the 09/11/2006. He arrived at Prince
Charles Hospital at 02:10 on 10/11/2006. An ECG obtained at 02:11 shows normal sinus
rhythm with some minor non-specific ST-T wave changes in leads I, II, aVL, and aVF.
This is not diagnostic of ischaemia and may be within normal limits.
A3. Mr M was clerked by the doctor at 03:00. It was noted that he had had chest pain
with a severity of 7 out of 10 (10 being the most severe pain), which had occurred at rest
and had radiated into his left arm and throat. He was also short of breath. He had never
had this type of chest pain previously. He did have heartburn and indigestion, but this
was unlike his admission pain. It was noted that he had a past history of tuberculosis and
high cholesterol. He had smoked until 30 years previously, and there was a family
history of premature coronary heart disease, with his father having had his first heart
attack in his 50s.
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A4. Physical examination showed a mild elevated temperature at 37.7oC. There were
some crackles at the lung bases. The pulse and blood pressure was normal, and the
remaining physical examination was normal.
A5. An initial differential diagnosis was of acute coronary syndrome, or indigestion, or
A6. He had been given pain relief with morphine, and was given Clexane (low
molecular weight heparin), and lansoprazole, a proton-pump inhibitor drug for
indigestion. In addition he was prescribed aspirin and simvastatin, a cholesterol lowering
A7. Subsequent ECGs obtained at 03:11, 03:46 and 09:45 were all normal.
A8. He was reviewed on the post take ward round, where the history was reviewed, and
the ECGs were noted to be normal. The plan was to await the result of his troponin I test.
Troponin is a chemical released by heart muscle cells when damaged. If the troponin
level was normal then Mr M could be discharged on lansoprazole therapy with a plan for
an exercise ECG test to be performed. Follow-up appointment with the Consultant was to
A9. Although the result is not documented in the medical notes, Mr M’s troponin I
level was 0.01 ng/ml (normal range 0.01-0.04), and was thus normal. He was therefore
A10. There is no record in the notes, provided to me, of a discharge summary or details
of his discharge medication, which were probably lansoprazole and simvastatin.
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A11. I consider Mr M’s management and treatment plan following his first episode of
possible ischaemic chest pain to be appropriate. Without the discharge summary it is not
possible to comment on whether this was conveyed to his general practitioner.
The exercise ECG result from November 2006
A12. The exercise ECG performed on 28th November 2006 showed Mr M reached
stage 3 of a Bruce protocol exercising for 8 minutes and 32 seconds. His heart rate rose
from 53 beats per minute at rest to 141 beats per minute at peak exercise, which is 92% of
predicted maximum heart rate for a man of his age. His blood pressure response to
exercise was normal. The resting ECG was within normal limits, but on exercise he
developed moderately frequent atrial and ventricular ectopic beats, including one
ventricular couplet. The peak exercise ECG showed up to 3.5mm of ST segment
depression in leads II, III, aVF, and V4 through V6. Exercise was discontinued because of
shortness of breath without any chest pain. This is an abnormal test suggesting reduced
blood supply to the heart muscle at a reasonable level of exercise.
A13. The result of this test was communicated by the Consultant to Mr M’s GP, in a
letter dated 14 December 2006. The conclusion of the letter was “Near maximum ETT
with positive result. The patient to be reviewed in the clinic”. There is no
recommendation with regard to additional treatment or the urgency of follow up.
A14. This exercise test has some worrying features. It is undoubtedly abnormal, and
the presence of new ventricular ectopics during exercise is especially concerning. The
fact that Mr M has no symptoms of chest pain, despite an abnormal exercise ECG is
particular concerning since it suggests that he has “silent ischaemia”, and would therefore
not limit himself during exercise despite the development of ischaemia. I believe that at
that stage, the Consultant should have made a recommendation with regard to the
prescription of anti-ischaemic medication such as beta-blocker, nicorandil or nitrates, and
should have recommended aspirin therapy as well. I also feel that, in view of Mr M’s
recent admission with chest pain, arrangements should have been made both to review
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him urgently in clinic, and to organise for him to go onto the waiting list for coronary
The timeliness of the referral to outpatient’s for March 2007.
A15. See my comments above. Mr M waited nearly 4 months for his outpatient
appointment where he was seen by the Former Trust’s Registrar in cardiology. At that
appointment the history of his admission and the results of the exercise ECG were noted,
together with a note that it was “obviously abnormal”. It was noted that Mr M had
remained well without further chest pain. In addition it was noted that he “is a cross
trainer in a gym and since that event he does regular treadmill exercise at home for
around 1 hour and ten minutes about 3-4 times a week.”. The Registrar clearly did not
recognise the implication of the ventricular ectopy on exercise and silent ischaemia as
demonstrated on the exercise ECG in November 2006.
A16. The Registrar noted Mr M’s lipid results and also that he was currently only
taking lansoprazole. His simvastatin had been discontinued because of muscle and joint
aches. The Registrar concluded that Mr M’s single episode of chest pain sounded non-
cardiac, and then goes on to document “his significant risk factor in terms of ex-smoker,
dylipidaemia (abnormal blood lipids), and a significant family history of IHD,”. He then
states that “for completeness I feel he may benefit from a myocardial perfusion scan to
rule out any underlying CAD.”.
A17. The role of myocardial perfusion scanning (MPS) in the diagnosis and
management of coronary heart disease is well established. MPS is indicated in the
1) To assess the presence and degree of coronary obstruction in patients with suspected
coronary artery disease
2) To aid the management of patients with known coronary disease
3) To determine the likelihood of future coronary events, for instance after
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myocardial infarction or related to proposed non-cardiac surgery
4) To guide strategies of myocardial revascularisation by determining the
haemodynamic significance of coronary lesions
5) To assess the adequacy of percutaneous and surgical revascularisation
6) To assess myocardial viability and hibernation, particularly with reference to planned
7) To assess the haemodynamic significance of known or suspected anomalous
coronary arteries and muscle bridging
8) To assess the haemodynamic significance of coronary aneurysms in Kawasaki’s
I do not believe that Mr M falls into groups 2-8, and it is arguable that he fulfils the
criteria for group 1, since his exercise ECG was unequivocally abnormal.
The referral for MPS
A18. The MPS was requested on the 5 April 2007. The request contains very limited
details: “Chest pain (2 indecipherable words) ST depression ?IHD”. This limited amount
of clinical detail is unacceptable for a procedure which requires the administration of
ionising radiation to a patient.
The cancellation of the MPS follow-up appointment.
A19. It is unclear from the record why this was cancelled. I believe that it certainly
should have been chased up, and a further clinic appointment made.
How things were left after that cancellation before Mr M approached his GP
A20. Mr M had a clear indication for coronary angiography following his exercise
ECG in November 2006. He subsequently turned out to have extensive three vessel
coronary artery disease and was referred for coronary artery bypass surgery. He was
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clearly at risk from further coronary events, including further admissions with chest pain
or a heart attack, and sudden cardiac death. The reason that coronary angiography is
offered to patients after having an abnormal exercise ECG is that the prognosis of patients
with an abnormal exercise test is worse than those with a normal exercise ECG.
The likely/potential suffering or danger that any inappropriate delays did, or may
A21. Please see above. Patients with coronary heart disease have a risk of heart
attack and death, but this is essentially unpredictable. Approximately one third of
patients have sudden cardiac death as their first presentation of coronary heart disease.
Many patients with have stable anginal symptoms which are well controlled, and are at
low, but not zero risk. Mr M had had chest pain, had multiple risk factors for ischaemic
heart disease, and had an abnormal exercise ECG. I believe that it was inappropriate that
he was not treated with anti-ischaemic medication and secondary prevention therapy, and
was not referred for coronary angiography.
The Trust’s response to the apparent problems that Mr M’s case has uncovered.
A22. The Trust has undertaken an investigation led by a senior doctor into the
appropriateness of referrals for MPS. I believe this is an appropriate response. I also
believe that there are educational issues related to the management of patients with
abnormal exercise ECGs. I do not believe that there is any evidence that Mr M was
referred for a MPS in an attempt to reduce the waiting list for coronary angiography.
Supplementary comments after further information received
A23. In the light of further information provided to me in April 2009 I have updated
this report as follows:
1) The discharge advice letter from the admission of the 10th October 2006 is
available to me. The diagnosis is that of chest pain with a normal troponin level and two
normal ECGs. The plan was for an exercise ECG as an outpatient, and the medication on
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discharge was aspirin, simvastatin and lansoprazole. The management at this stage was
2) The exercise ECG does contain worrying features, including the development of
significant ST segment depression and ventricular ectopic beats during exercise in the
absence of chest pain, suggesting both silent ischaemia (the development of significant
ischaemia in the absence of warning chest pain which would cause him to limit his
activity), and exercise induced rhythm problems. These features were noted by the
Senior Clinical Physiologist.
3) The Consultant communicated this result to the GP, but failed to make any
recommendation with regard to anti-ischaemic medication, nor did he, in a patient with a
recent admission with chest pain and an abnormal exercise test, make any decision with
regard to further investigation. In particular he did not refer Mr M for a coronary
angiogram. When Mr M was reviewed in the clinic by the Registrar, the error was
compounded, when despite observing that Mr M’s exercise ECG was obviously
abnormal, he either failed to consult with the Consultant about the need for coronary
angiography, or if he did consult with him he (the Consultant) failed to recommend a
coronary angiogram. The Consultant refers to this as a “judgement call”, however I
believe it was a significant error. Furthermore he has indicated that he believes that “an
MPS would not have added much and he would have chosen an angiogram as a better
option. He explained that he made the referral for MPS based on the Registrar’s opinion.
His role in doing so was simply to sign it off.” The Ionising radiation (Medical
Exposure) Regulations (IRMER) 2000 states that the role of the practitioner is as follows:
5.10.1. Decisions on who is entitled to act as a practitioner should be taken
at local level by agreement between the employer and the healthcare
professionals involved in medical exposures. Such decisions should be
based on the type of medical exposure and on specific circumstances and
may be restricted e.g. it may be appropriate to agree that certain health
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professionals can act as a practitioner for radiographic procedures for
extremities, but not for complex interventional examinations.
5.10.2. The primary responsibility of the practitioner is to justify medical
exposures. This requires the practitioner to have a full knowledge of the
potential benefit and detriment associated with the procedure under
consideration. Clearly all practitioners need to be adequately trained to
undertake this function (2).”
The Consultant was clearly acting as practitioner in this case, and should have
justified the medical exposure to radiation, not simply sign it off. This should have
involved reviewing the indication for myocardial perfusion scanning before signing
4) It is clearly unfortunate that the Trust has had to employ the Consultant as a locum
consultant cardiologist for eight years, but it has to be acknowledged that in some areas it
is difficult to recruit consultant staff to definitive posts.
5) The Trust has reviewed the patients on the waiting list for myocardial perfusion
scanning, but has as yet failed to give details of the clinical outcomes and the lessons
6) The Director has commented that there was “relatively limited” access to coronary
angiography in 2006/7, and that consequently there was a “high threshold” for referral. I
do not believe that limited access should have had an effect on clinical priorities in this
case. An angiogram was definitely clinically indicated. The Consultant also commented
that “despite the Registrar’s judgement, if the waiting list for angiograms was small, Mr
M would have been referred for one.” This suggests that the Former Trust was using the
waiting list and waiting times for myocardial perfusion scanning as a method to reduce
the waiting list and waiting time for coronary angiography.
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(1) Procedure Guidelines for Radionuclide Myocardial Perfusion Imaging. Adopted
by the British Cardiac Society, the British Nuclear Cardiology Society, and the
British Nuclear Medicine Society
Report prepared by Dr John L Caplin MB BS (Lond) BSc (Lond) MD FRCP
Consultant Cardiologist - 2nd December 2008 & 28th April 2009
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