Report Date

07/03/2023

Case Against

Aneurin Bevan University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202105761

Outcome

Upheld in whole or in part

Mr X complained about the care provided when he attended the ED with chest pain. The investigation considered whether, given Mr X’s presenting symptoms and clinical cardiac history, appropriate examinations and investigations were undertaken on 17 July 2020, whether there was any indication that Mr X’s symptoms were cardiac in nature and that a heart attack was impending, and whether the diagnosis given to Mr X on 17 July2020 was clinically appropriate.

The investigation found that appropriate examinations and investigations were undertaken on 17 July and so this complaint was not upheld.

The investigation found there were clear indications that Mr X’s symptoms were cardiac in nature ,but that these symptoms were not properly considered in conjunction with seemingly reassuring test results. However, since it was not possible to say, with any degree of certainty, either that a heart attack was impending or that it could have been avoided, this complaint was only partially upheld.

The investigation found that the diagnosis given to Mr X on 17 July, that his symptoms were likely the result of musculoskeletal or acid reflux issues, was not appropriate and so this complaint was upheld.

The Health Board agreed to apologise to Mr X for the failings identified and to share the report with clinical staff involved in the care and treatment of patients presenting to ED with chest pain and reiterate the importance of considering patient history alongside test results when reaching a diagnosis.