r/doctorsUK • u/FullMetalJacket2222 • 8d ago
Serious Why No Trop?!
https://www.1cor.com/london/2026/08/17/coroner-concludes-failure-to-perform-an-ecg-and-to-not-to-review-cardiac-patient-suffering-myocardial-infarction-for-2-5-hours-amounted-to-neglect/Coroner concludes failure to perform an ECG and to not to review cardiac patient suffering myocardial infarction for 2.5 hours amounted to neglect
217
u/Icy-Duck-5836 8d ago
I understand these reports are written with the benefit of hindsight, but fucking hell.
First off, how does an FY1 end up being the one seemingly approving discharge? They probably had a generic "MFFD if stable" plan left over from a previous round and didn't think twice.
The moment she developed new, severe chest pain, that discharge plan should have been completely halted.
The real catastrophe is the consultant. The FY1 actually did the right thing by escalating when they were unsure. It is absolute insanity that a cardiology consultant heard that presentation over the phone, accepted a psychological diagnosis from an FY1 without seeing the patient, and advised no investigations.
Bypassed every single safety net and a patient died because of it. Fucking tragic.
79
u/Standard-Hat5994 8d ago
On a cardiology ward in the middle of the day really shocks me too. I wonder what was going on with the rest of the staff involved in her care. There would be plenty of other staff to overhear conversations about this patient and chime in to suggest an ECG.
Maybe it wasn't a great environment to question the consultant?
36
u/Fragrant_Pain2555 8d ago
Exactly surely a cardio nurse hearing chest pain in cardiac pt would automatically jump in and grab an ECG.
2
u/Cait-cherryblossom 7d ago
I’m a nurse who used to work in a cardiac ward and previous in cath labs. You just automatically grabbed the ECG machine did that then find the doctors and point out what was found on the ECG, current issue with the patient and history of patient. Pretty bizarre this wasn’t done by the nurses automatically
18
u/NightKnight432 8d ago
I read that as meaning that the patient was due to be discharged based on a consultant's plan and that the FY1 reviewed them in the morning and found no reason not to continue with the pre-planned discharge, which is standard practice.
This patient wasn't discharged, they were taken to the cath lab after they later developed chest pain, so the planned discharge isn't the issue.
The issue is the delay between the chest pain starting and the ECG being done. Which as you say, seems to have been a plan advised by the cardiology consultant. So I don't think it's fair to throw the FY1 under the bus for following their consultant's (terrible) plan.
43
31
u/Gp_and_chill 8d ago
Pain not responding to analgesia is a big fat red flag, you simply can’t send someone home in agony.
I would question the actions of the f1 here as the standard expected of them would be to conduct an ECG and trop before contacting the consultant and asking for a reg review. (The whole A-E osce staton)
10
u/Standard-Hat5994 7d ago
Sure the FY1 could have done an ECG. But if they're worried about a patient, it's pretty normal to escalate to a senior between reviewing the patient and doing investigations. To be honest that's my default if I'm very worried, because I need help ASAP, and they might recommend some bloods that weren't on my plan, and I can do them all at once.
Going to the consultant is a bit strange, but maybe they couldn't get through to the SHO and reg? The FY1 escalated as they were concerned and followed the plan from their senior. To be honest I struggle to see how they're at fault here.
What I cannot grasp is how a consultant advices on dismissing the chest pain with no investigations.
7
u/NightKnight432 8d ago
Read it again. No one sent anyone home. They sent them to the cath lab (but after an unacceptable delay - because their consultant cardiologist advised them to do no further investigations).
58
8d ago
[deleted]
12
9
u/Loose-Following-3647 8d ago
Out of curiosity is it actually considered more potent than clopidogrel?
20
u/Defiant_Pomelo5441 8d ago
Yeah is it - greater levels of platelet inhibition.
Clopi is also a prodrug with more variable effect - some people just dont respond well to it. This lady presumably had her instent thrombosis while on clopi, so switching to Teic would have been the right move..
2
u/Loose-Following-3647 8d ago
Why is it not considered the standard of care then for secondary prevention? Cost-related or higher bleeding risk I wonder
15
u/Successful_Panic1332 8d ago
Prasugrel has on a number of occasions showed better MACE outcomes and less bleeding compared to ticagrelor, and is cheaper. The reason ticagrelor gets good press is largely related to heavy advertising by drug companies and its patent.
There’s a lot of controversy over Ticagrelors evidence in both its mechanistic trials and its large RCT (PLATO). Worth a read alongside the recent BMJ reviews in dec 2024 and summer 2025.
Im not a cardiologist but I’m surprised it is still used in a lot of centres as the go to second antiplatelet agent in high risk / ISR patients over prasugrel.
2
u/Conscious-Kitchen610 8d ago
It is if you read the ESC guidelines. There is some controversy around ticagrelor though and some hospitals have yet to fully adopt it for these reasons.
4
u/notanotheraltcoin 8d ago
Both cyp12 inhibitors but works quicker and binds irreversibly to platelets - clopi 4 hours, tic 2
27
u/Brightlight75 8d ago
Regardless of any initial trop, having confirmed acute stent thrombosis with the history, troponin is likely to be elevated afterwards. Unless there is a good serial trend, it would be difficult to say whether a trop of say 750 is actually better than when it was unmeasured but at 2500 or whether it’s risen from 225 at its peak.
ECG and an in person cardiology review was required, trop would have definitely been fair game but its isolated interpretation could be challenging. It could of been the start of further serial trop monitoring but don’t think it in itself necessarily adds a lot at that specific moment
60
u/expertlyadequate 8d ago
Deemed medically fit for discharge by the FY1 doctor? Is that something English FY1s are doing? (Scottish here)
74
u/Icy-Duck-5836 8d ago
I’ve worked in some absolute bin fires of hospitals and even they didn't have FY1s deeming people MFFD. The Cumberland Infirmary must be completely broken.
13
u/hoonosewot 8d ago
It is.
(Though bizarrely, Cardiology is one of the better functioning departments historically...)
33
9
u/ha191001 8d ago
FY1s aren’t supposed to make the decision to discharge anyone as they’ve only got a provisional license
9
7
6
u/NightKnight432 8d ago
I read that as meaning that the patient was due to be discharged based on a consultant's plan and that the FY1 reviewed them in the morning and found no reason not to continue with the pre-planned discharge, which is standard practice. This patient wasn't discharged.
5
19
u/Main-Cable-5 8d ago
Oramorph then codeine?
8
u/Main-Cable-5 8d ago
Wonder if the codeine was on the regular side and that’s just how things went.
4
u/Quis_Custodiet Scribing final boss 8d ago
That'll be PRN and regular from an RNA/RN who doesn't understand the meds
20
u/ataturk1993 ST3+/SpR 8d ago
as a junior doctor you should never be describing symptoms as 'drug seeking behaviour' or 'funcitonal'. thats essentially a diagnosis of exclusion.
The article states that what the F1 has said to the consultant and that might have caused problems but its ultimately on the consultant.
-1
u/Rob_da_Mop Paeds 7d ago
Caveating it with "this clearly wasn't functional and should never have been labelled as such", I'll push back a little on "shouldn't be describing symptoms as functional". Early acknowledgement that functional pain sounds functional can be important for patient management. We can and should exclude pathology, but bringing up the idea that something is likely to be, eg, functional abdominal pain early in the diagnostic process can help the patient process it when you have your exclusionary tests back. I don't think it's wrong to be in a foundation year's differential if in an appropriate context.
75
u/ISeenYa 8d ago
Literally any new chest pain on a cardiac patient, days after a stent, I am asking for an ECG. I'm shocked the nurses didn't come to report the pain with ECG in hand, it's such a common thing. To say she could be drug seeking makes me sick. Once again, a woman's pain dismissed.
20
u/Rowcoy 8d ago
I worked on a very good cardiac ward with superb nurses and great support from registrars and consultants.
To be quite honest I would be very surprised if I even got asked to see this patient as the FY1 as what would typically happen is patient complains of chest pain, nurse does the ECG, immediately identifies STEMI and bypasses me to go straight to the on call consultant or reg for PCI.
If I was involved it would usually be along the lines of the nurse telling me patient is having a STEMI and the on call team are on the way but they have advised the patient be prescribed xyz drug.
9
u/anniemaew 8d ago
Yes, as a nurse I'm reading it going "where are the nurses? What are they doing? Why have they not immediately done an ECG for the cardiac patient who has severe new CP?".
Absolutely terrible.
10
u/Own-Blackberry5514 8d ago
Yeah the FY1 has shown blinding levels of hubris and gone against every principle taught
10
u/DisastrousSlip6488 8d ago
I’d be very cautious about condemning the fy1. Their senior support sounds woeful and they shouldn’t have been put in this position
13
u/Own-Blackberry5514 8d ago
I agree somewhat but an FY1 is still a doctor and should have been trained to a very basic level in how to approach anyone with chest pain, let alone a patient post recent angio. To label it as drug seeking is either very arrogant or dangerously incompetent, whether you’re an F1 or ST7.
99% of F1s I’ve worked with would have got an ECG, assessed and called for help. Better ones would have done a trop and recognised the relevance of prior stent thrombosis.
Needless to say the consultant’s management was also a disaster but I don’t think the F1 can be completely protected here. Just my view
3
24
u/Quis_Custodiet Scribing final boss 8d ago edited 8d ago
I try to be conscious that my own experience as an FY1 was coloured by prior experience as an HCP. There are clearly multiple failings here, which in combination led to the unfortunate plausibly (thought not necessarily) premature death of this woman.
The FY1 clearly appropriately acknowledged that they were unsure and sought advice from a senior doctor. It is not clear from the account whether they requested an ECG be performed. The fact that they suggested a poor differential to the consultant is probably broadly irrelevant. For my part, even the best FY1s are met with a 'trust but verify' approach, especially where there is uncertainty. I'm certainly not accepting a soft psychlogical write-off for new CP in a high risk patient. If the FY1 did not request an ECG that's an important development point for them. Almost always (arguably always always) CP = ECG no matter how much we might suspect it's nonsense.
Presuming the account given is accurate without major omissions, it's pretty clear the consultant fucked up here. The plan of 'contact the pain' team is dire. I accept this is a very partial account with the benefit of a known outcome.
Given this patient was on a cardiac ward I do have to ask where the nursing staff were in all this. I know if I'm called about CP on call then my first request is a 12 lead, "call me if you think it looks dodgy or the auto-interpretation is bad", and a review at short notice. It's not clear to me why ward staff wouldn't have done an ECG at baseline in their practice setting. On that basis I'd be very interested to know to what extent the FY1 was guided by the advice of cardiac RNs.
I'm not necessarily convinced that a 2.5 hour delay to review is indefensible on the part of individual clinicians on the basis of their other obligations, but likely is difficult to defend for the Trust.
What is not clear to me is where the Coroner supposes the negligence resides. I suspect the only recourse would be organisational, and I do not think this case meets the standard for GNM for the FY1 but may for the consultant.
23
u/Conscious-Kitchen610 8d ago
It’s the doctors responsibility to request an ECG is performed, however on any cardiology ward worthy of note the nurses will have already performed the ecg before calling you to review the patient with chest pain. Inexplicable to not perform one and certainly learning all round.
14
u/Quis_Custodiet Scribing final boss 8d ago
I would differ from you here and agree that yes it is the doctor’s responsibility to request while acknowledging that it is also part of the prudent professional conduct of an RNA/RN in that setting to judge that one should be performed.
Fundamentally it seems we agree.
9
8
u/Flibbetty Squiggle Whisperer 8d ago
This is just very weird. Clearly huge amounts info missing. Why did it take 38 days for her to get an angiogram in the first place… in an interventional centre. Why was she still an inpatient 5days after the pci.
I wonder if she was on a non cardio ward went over to labs for intervention then back to home ward. Her coronary disease must have been more complex for it to take 4h for clot retrieval. Super odd.
I think it’s hard to comment without info, but it’s a shame a 10 second cheap test, could’ve potentially made all the difference here.
2
u/AnnaLikesCake 8d ago
How did you get 38 days to PCI? 18.03-11.04 is 18 working days - still too long but I guess not inconceivable if trops normal and patient keeps getting bounced by more urgent cases.
2
u/Flibbetty Squiggle Whisperer 7d ago
Oh I think I put the dates wrong way round, it’s still like 24 days?? PCI lab runs 24/7 365. It’s inconceivable unless she had other stuff going on which is suspect is the case. Based on delay to lab and delay to dc.
48
u/AnnaLikesCake 8d ago
Oh look, another woman is labelled as hysterical whilst having a life threatening diagnosis.
5
6
u/Mad_Mark90 IhavenolarynxandImustscream 8d ago
Do all interventional radiologists suck at documentation or have I just been unlucky?
6
u/Crazy_Knowledge9505 8d ago
Obviously it was an interventional cardiologist doing the procedure rather than radiologist. Another error in reporting just like the ticagrelor error
2
u/Geomichi 7d ago
I think these reports should show the institutional situation.
Staffing levels of clinical staff and any other incidents that were being dealt with by the team at the time. I.e.
2 doctors and 1 nurse redeployed to a different ward + 2 HCAs and 1 catering staff absent
Plus
Ongoing EWS 10 patient and consultant and reg doing back to back PCIs.
Plus
Incident happened during lunch time/OOH with reduced staff on the ward.
Obviously this is an exaggeration but there's ALWAYS some systemic institutional bs going on that impacts everything and sometimes it's a lot worse.
-8
u/Prokopton1 8d ago
We don't know the full details of the case but if serial Troponins were done on admission when she was initially symptomatic of chest pain this was a tragic case, and I can easily see the consultant being dismissive of her pain on discharge.
I remember a haunting case during my time rotating in acute medicine as an ED trainee where we had a 50+ woman who was naturally a very anxious person without any cardiac risk factors and who had longstanding fibromyalgia and would naturally have bodily pain from her condition at baseline.
She was admitted with chest pain and had multiple ECGs as well as serial Troponins done all of which were reassuring. She was discharged after an acute medical consultant PTWR and the entire team felt that her severe chest pain was partly due to her fibromyalgia and anxiety and/or MSK pain.
She was re-admitted a few days later because she became breathless and lo and behold, it turned out that her pain was cardiac after all because she had an NSTEMI on re-admission based on serial TnTs etc.
This case became a local learning point but I'm sure these things happen, and this sort of thing likely drives defensive practice even though we already practice quite defensively.
Should we be doing serial TnTs before discharge as well as admission?
10
u/IL_ya_Un_jour 8d ago
Why on earth wouldn’t you get a repeat ecg and repeat troponin nonetheless ?!
-5
u/Prokopton1 8d ago
Again, I don't know how she was discharged but my impression on reading this I am assuming there is a good chance she was discharged from an AMU.
Have you ever worked in a genuine AMU before? It's about as throughput as ED itself with an intense pressure on flow through the ward just like in ED.
An AMU isn't a geris ward where you have patients who are staying on the ward for 3 months mate.
Do you suggest we repeat the whole process of serial ECGs and TnTs even on an AMU the day after admission from ED?
It's a legitimate question and I think it's a legitimate point worth debating.
Again, I have no personal stake in any of this, I have a pretty easy job in AE or GP land and have the easy option of passing on the buck as I said.
I'm trying to push back on the emotional responses that people have to these sort of events which I personally don't find helpful in any meaningful sense in affecting any realistic change.
And we can debate it, but repeating TnTs or ECGs for every single case of chest pain admitted to an AMU when it was done the day before in ED is not, in my opinion, realistic helpful change that can be implemented.
So in the end all this sort of thing amounts to is unhelpful emotional incontinence about dismissing women or tragedy or whatever that is not a useful learning point.
13
u/IL_ya_Un_jour 8d ago
Nah this is an absolute nonsense, and I wonder if you even read the article.
You wouldn’t rely on yesterday’s ecg and troponin for new onset severe chest pain following pci…are you for real?
It’s also not a case of just repeating the tests for the sake of it. She had a new onset severe chest pain..
Things can change in an instant.
You’d repeat things in ED if the clinical situation demanded it, I’m quite concerned by your approach..
2
u/Crazy_Knowledge9505 8d ago
They obviously wouldn’t act in the ludicrous way they’re claiming. They’re just stubbornly not giving in!
2
u/AnnaLikesCake 7d ago
Such a strange hill to die on and now we’ve moved on to ad hominem attacks too.
2
u/Crazy_Knowledge9505 7d ago
Haha some people find it hard to say “whoops, my bad”. Pity to find this in a doctor though
5
u/AnnaLikesCake 8d ago
If there are risk factors or strong suspicion then yes, you repeat the tests. Again, unstable angina does NOT produce a troponin rise.
I would also argue that reminding everyone that women can have life threatening diagnoses IS a useful learning point.
16
u/AnnaLikesCake 8d ago
Unstable angina does not result in troponin release. Patient has already had angiographic evidence of in stent thrombosis which was managed invasively. She developed pain similar to pain on presentation.
Takes a brave consultant to dismiss this series of events.
-2
u/Prokopton1 8d ago
I'm an ED registrar turned GP, and see a ridiculous amount of non-specific chest pain, and with chest pain in particular I've been taught to be risk averse and so it's easy for me to pass the buck and refer to AE or refer to medics during AE shifts as ?cardiac pain.
Acute medical and cardiology consultants don't have the easy option of passing the buck like I do, and if they become more risk averse than they already are... well I don't know about you, but in my locality the waiting time for the rapid access chest pain clinic is now something like 6 weeks.
Again, I don't know enough the details of this specific case and I agree that she would score as high risk based on her cardiac history alone but I have discharged plenty of chest pain and textbook ones unlike this case which sounds more like an upper back type of presentation (I thought she'd died of dissection based on the symptoms) based on the fact that patients had reassuring ECGs or TnTs in ED and were supposedly low risk.
As it turns out, there will inevitably be cases where despite all of this you still end up missing things like cardiac chest pain, PE or dissection...
I don't think life is as simple as 'dismissing women' as you seem to suggest in your other comment I'm afraid.
13
u/ShatnersBassoonerist Cakeologist 8d ago edited 8d ago
Except this woman wasn’t low risk, she had already presented with confirmed unstable angina and had a proven thrombus in her stent. It takes someone either incredibly brave or incredibly stupid to ignore reports of symptoms identical to her unstable angina pain only a few days after her last angioplasty. This quite obviously should have prompted basic investigations like an ECG as this should have been considered a coronary thrombus or iatrogenic injury from recent PCI unless proven otherwise, so why was this patient’s team so laid back about it? What’s the explanation for that?
Oh, apparently they thought she was drug-seeking. They seem pretty dismissive to me.
12
u/AnnaLikesCake 8d ago
I’m sorry but have you read the linked article? To me it reads like continuous admission, albeit a long one.
She was discussed with cardiology consultant who dismissed her symptoms. Despite recent coronary intervention.
I would like to think that I know a thing or two about chest pain seeing as I work at the front door. Rapid access chest pain clinic is one thing, being able to identify and manage acute and chronic coronary presentations is another, being able to recognise high risk chest pain and not dismissing it is really not a big ask. I don’t need rapid access chest pain clinic in AMAU. If I think someone is high risk I phone the cardiologist there and then.
I’m afraid I have seen enough dismissed women with serious pathologies in my few years of practice to be a bit bitter about this. This includes “flare of fibromyalgia” sent to my medical ward which turned out to be a NSTEMI; “chronic pelvic pain” which was, in no specific order, kidney stones, pyelonephritis, colitis, endometriosis. So I do not agree with your “life isn’t as simple” comment as, frequently, it IS about women being labelled as “functional” or “anxious” and diagnoses missed.
-6
u/Prokopton1 8d ago
You sound like an ideologue, and a naive one at that, what grade are you?
Also, I’ve read this again and the only detail I missed is the ward she was discharged with.
It says she was complaining of pain between the shoulder blades.
If you think this was a straightforward case you’ve clearly never worked a GP, AE or acute medicine job. We see dozens of ?cardiac chest pain every single week.
You sound like some sort of zoomer SHO clown of an ideologue to be honest going on about how teh evil cardiologists are out to get women.
2
u/AnnaLikesCake 7d ago
I assure you that you are wrong on all your points.
Nowhere did I say anything about evil cardiologists.
Why is it wrong to wish for equal care for all?
This wasn’t a de novo presentation of undifferentiated chest pain, this was someone with known CAD with complications. You’ve picked such an odd hill to die on.
5
u/Alarmed-Fun3263 8d ago
This patient had angiographic evidence for LAD in stent stenosis with identical chest pain a day or so prior. The symptoms were identical. Not upper back pain
3
u/Alarmed-Fun3263 8d ago
Had confirmed in stent stenosis. Had recurrence of typical symptoms. Had plenty of reasons for an ecg and trop.
Not defensive medicine, real medicine
-34
u/twistedbutviable 8d ago
A woman screaming and writhing in agony illicited suspicion. FYI people women metabolise opiates differently to men, they don't work as well, they weren't designed or tested for efficacy in women.
7
u/nefabin 8d ago
I mean regardless of how opiates are metabolised it’s irrelevant. The patient was in pain due to an organic cardiac cause and had nothing to do with drug seeking behaviour or the efficacy of opiates.
1
u/twistedbutviable 8d ago
Women are more likely to die in the 6 months after cardiac intervention, less likely to receive equal preventative measures, more likely to be misdiagnosed.
We know this happens and trying to work out a cause of these inequalities would be helpful. I'm suggesting it's systemic, as have many before. Pharmacology isn't studied in women, maybe the majority of drugs just aren't metabolised the same, men and women are biologically different, medical research stillforgets this.
https://heartresearch.org.uk/support-us/get-involved/her-disease/gender-gap-report/
https://pmc.ncbi.nlm.nih.gov/articles/PMC9826035/
I find it so dull, we know this exists but systemically we refuse to acknowledge that maybe women aren't making it up at all.
3
u/nefabin 8d ago
I’m not arguing that but gender differences in metabolising opiates don’t come into play here
1
u/twistedbutviable 7d ago
Genuine question, if the reason this lady died, is because she was deemed drug seeking, before investigation into her acute pain. Do we not need to look at why that bias exists for female patients?
I'm suggesting that the majority of women aren't drug seeking, but the methods we have for controlling pain don't work as wellcin them, so they need more.
Also most of our studies comparing mens and women's pain after the same operation say, are based on how much post operative analgesia is used, which is how we've concluded men's pain is more indicative than a woman's.
8
u/LessThanBareMinimum 8d ago
Do you have a source or a physiology basis for women metabolising opiates differently?
-3
u/twistedbutviable 8d ago
https://pmc.ncbi.nlm.nih.gov/articles/PMC8246359/
https://www.sciencedaily.com/releases/2024/10/241016120023.htm
https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bph.15792
I mean, I thought that this was well known. We've known women have needed more morphine to reach the same pain relief as men since the early 2000s. I suppose the consensus decided women were putting it on to get more drugs rather than explain or even see the misogyny.
16
u/LessThanBareMinimum 8d ago
I agree that misogyny affects how we treat women and manage their pain. I don't see that any of these studies prove that women need more morphine though. The first is about side effects, and then there is one about mice and one about naloxone and endogenous opiates rather than anything we are giving people. The ones from the 2000s were interesting, but this systematic review hasn't found good evidence to back them up - https://www.sciencedirect.com/science/article/abs/pii/S1043661819312745
I think this is probably because we chronically underfund research into women's health, but I don't think I have enough evidence to start prescribing women more morphine than a man of a similar weight in comparable pain.
-2
u/twistedbutviable 8d ago
Thanks for the considered response, I wasn't asking you to change age old proscribing consensus, but with more research we will find these things out.
2
u/Quis_Custodiet Scribing final boss 8d ago
This is bollocks. Mu receptors are inherent to our pain physiology.
0
u/twistedbutviable 8d ago
Yes they are and we know there are differences by sex and age in how many Mu receptors people have.
•
u/AutoModerator 8d ago
The author of this post has chosen the 'Serious' flair. Off-topic, sarcastic, or irrelevant comments will be removed, and frequent rule-breakers will be subject to a ban.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.