Coroner warns of nationwide lack of cardiologists following patient’s death
A coroner has written to the government warning of a nationwide lack of cardiologists following an inquest into the death of a 40-year-old woman who died from heart failure after treatment started too late.
Samantha Goward, assistant coroner for Cambridgeshire and Peterborough, wrote a prevention of future deaths (PFD) report in relation to the death of Charlotte Burton in November 2020. The report was sent to the Department of Health and Social Care, NHS England and the Royal College of Physicians.
Burton died after clinicians at a hospital run by North West Anglian NHS Foundation Trust did not escalate her treatment when her condition deteriorated until it was too late, in the absence of a trained cardiologist.
‘The inquest … heard evidence from the treating clinicians that the Trust does not have any Cardiology cover, not even on call, after 5pm weekdays or at the weekend,” Goward wrote in her PFD report. “It was stated that this was not an issue unique to this Trust and that there is a nationwide shortage of trained Cardiologists. The Trust does have the option to call Cardiologists at other hospitals, but there is no provision for on site assessment by a Cardiologist out of hours and transfer is often not possible due to severity of illness or the timescales involved.
‘It was found that had the nature of Charlotte’s condition been recognised, she should have been prioritised for a bed on either the coronary care unit or ICU. Had Charlotte been under the care of ICU or specialist cardiac nurses, they may have recognised the need for cardiology input and discussed this with the on call Physicians to consider seeking advice. It was accepted that that this would not have led to a transfer in Charlotte’s case, but on the balance of probabilities would have led to the Cardiologists or ICU clinicians giving the advice that experts recommended for appropriate treatment.’
Coroners write PFD reports when inquests highlight problems that could lead to future deaths. Goward’s report raised the lack of cardiologists as a ‘matter of concern’.
‘The evidence indicates that there is a nationwide shortage of suitably trained Cardiologists and that, particularly in District General Hospital setting, this means that out of hours there is no provision for patients presenting with suspected cardiac problems to be assessed in person by a Cardiologist,” she wrote. “The system is therefore reliant upon doctors of different specialities or cardiac nurses recognising the condition and the need for contact with specialist at a different Trust. This still does not allow for in person assessment unless there is a transfer which is not always possible due to the severity of the condition or cannot be achieved in a suitable timescale and this represents on ongoing risk of future deaths.’
The recipients of the report are required to respond within 56 days.
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