Scottish Sheriff Court Decisions

2010 FAI 21

 

Determination of Sheriff D. J. Leslie in

Fatal Accident Inquiry into the death of Gordon Greig

(date of birth: 28^th March 1956)

 

 

Dumbarton 30 April 2010

 

 

The Sheriff, having resumed consideration of the cause determines in terms of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 Section 6(1):

 

(a)  that Gordon Greig, born 28^th March 1956, of the West Byre, 2 Colgrain Steading, Cardross Road, Dunbartonshire, G82 5JL, died at the Vale of Leven Hospital, Alexandria on 2^nd March 2007 at 20:45 hours;

(b)  that the cause of death is haemopericardium due to acute myocardial infarction due to coronary artery thrombosis;

(c)  that there were no reasonable precautions whereby his death may have been avoided;

(d) there were no defects in the system of working which contributed to his death and

(e)  there are no other facts pertinent to the circumstances of his death which are relevant in the wider public interest.

 

The Procurator Fiscal was represented by Miss Gillian Climie; the Greater Glasgow Health Board was represented by Mr Heany, Advocate; Mr Watson represented Dr Gary Mason; and Mr Jesiman represented Dr Deepa Somkumar.  Mr James Green by leave of the court represented his sister, Dr Anne Greig, the wife of the deaceased.

 

I heard evidence from Dr Anne Greig, Dr Deepa Somkumar, Dr Gary Mason, Dr Alistair Corfield Consultant Accident and Emergency Department Royal Alexandra Hospital; Dr Brian Cowan Medical Director Acute Services Division GHS Greater Glasgow, Dr John Clark, Pathologist, care of Department of Forensic Medicine and Science University of Glasgow; Dr Michael Johnston Consultant in Emergency Medicine from Ninewells Hospital, Dundee and Dr Adrian Brady Consultant Cardiologist Glasgow Royal Infirmary.

 

Findings in Fact

 

1.        Mr Gordon Greig was born on 28^th March 1956.  He had been married for 27 years to Dr Anne Greig.  There are no children of the marriage.  At the time of his death Mr and Dr Greig were being considered as prospective adoptive parents.  Mr Greig worked as an engineer at the time of his death and was engaged in a project in Dumfries which involved him staying on site from Monday to Friday.

2.        Mr Greig had no significant medical history.  On or around June 2006 he was found to have borderline high blood pressure and an irregular heartbeat.  He was not in receipt of any medication.  He was a light smoker (5 cigarettes a day) and was an infrequent drinker of alcohol.

3.         Mr Greig's family had a history of  coronary heart disease.  His father had died at the age of 62 of a heart attack; his mother died of an aeurtic aneurism in her 70s; his brother had a stroke in his 50s. 

4.         On Friday 23^rd February 2007 Mr Greig returned home from his work in Dumfries.  On the previous evening he had complained of abdominal upset which had resulted in vomiting and diarrhoea and which he attributed to a reaction to food he had consumed.  On his return home he was in good spirits and not obviously suffering from his earlier disorder. 

5.        On the evening of Saturday 24^th February Mr Greig, accompanied by his wife Dr Anne Greig, went to the cinema in Linwood.  At approximately 9:30pm he became unwell.  He left the cinema complaining of an attack of heart burn and being hot.  Approximately 6 weeks previously he had been noted as suffering from hot flushes.  He thought he had become unwell again due to a hot dog he had consumed within the cinema complex.  This complex is located in some proximity to the Royal Alexandra Hospital in Paisley. 

6.        Dr Greig suggested to her husband that he should attend the Accident and Emergency Department of the Royal Alexandra Hospital that evening.  He declined to go and returned home.  He did not go to bed that night.  He was anxious about his condition and what his wife had said about going to hospital.  He was complaining of chest pain. 

7.        On the morning of 25^th February at a time prior to 11am Mr Greig left home accompanied by his wife to attend the Accident and Emergency Department of the Royal Alexandra Hospital.  He continued to complain of a burning sensation  in his chest and feeling unwell.  On route to the hospital he passed his general practitioner's surgery and identified a notice drawing his attention to the NHS 24 telephone service.  He considered it more appropriate to contact NHS 24 and made contact with that service at 10:52am.  He described a burning sensation in his chest and that he was feeling hot.  He advised the recipient of his call that he had consumed a hot dog the previous evening.  He was advised that attendance upon the Accident and Emergency Department at the Royal Alexandra Hospital could give rise to a wait of approximately six hours and that he should self medicate by taking an over the counter antacid remedy. 

8.         Mr Greig attended a chemist in the Braehead shopping complex and purchased Gaviscon which he took as prescribed.  It had no effect.

9.         Mr Greig continued to express concern about his condition and felt it appropriate later in the afternoon to attend the Royal Alexandra Hospital.  He arrived there at approximately 16:52pm.  He was accompanied by his wife.  The presenting complaint was registered in the triage record as "burning sensation in chest".

10.      The triage records state "self presentation with epigastric pain/burning sensation to throat, had fast food on Thursday and then had vomiting and diarrhoea.  The new symptoms had settled then today returned with burning sensation.  Tried Zantac and Gaviscon with poor effect".  He was triaged as "4" on a scale of 1 to 5. This implied a minor complaint  He was seen by a nurse who records in the patient's nursing notes "family history of cardio-vascular disease". He was sent for an electrocardiograph.(ECG)

11.      At approximately 17:45 Mr Greig was seen by Dr Deepa Somkumar a junior doctor within the Accident and Emergency Department.  She recorded that he had complained of burning sensations in the throat and chest since the  Thursday before which had settled but the burning sensation in the chest had returned.  She recorded that Mr Greig complained of disturbed sleep and a constant burning sensation in the throat and chest.  There was no positional variation of pain, no abdominal pain, no haemolatosis, no chest pain and no palpitations.  ECG was normal.  Mr Greig's temperature was recorded as 38 degrees. 

12.      On examination Mr Greig was found not to be breathless; there was no swelling in his throat and his tonsils were described as normal. 

13.      A diagnosis was made that Mr Greig was suffering from reflux oesophagitis and a urinary tract infection (UTI).  He was discharged from hospital and prescribed a pain killer namely Co-Codamol, an antacid Zotone, and a general antibiotic Augmentin.  He was instructed to take plenty of fluids and advised that if the symptoms persisted to return to his general practitioner or to Accident and Emergency.  Blood was taken for a blood test.  Mr Greig was discharged from hospital at approximately 18:15.  He did not receive the outcome of the blood tests.

14.      Mr Greig returned to work on Monday 26^th February.  He departed his home at approximately 5am.  He felt "a bit better".  He attended a doctor in Dumfries on 27^th February who de-prescribed all his medication.  Mr Greig complained of tiredness which he associated with a viral condition.

15.      Mr Greig returned home on 2^nd March.  This was a Friday.  He had been unwell all week.  On his arrival home he was distressed and showing a poor palour.  At approximately 19:30 hours Mr Greig collapsed in the living room of his home where he had been watching television.  Paramedics were called and resuscitation techniques were applied.  Mr Greig was relayed to the Vale of Leven Hospital but was pronounced dead at 20:45 hours. 

16.      A post mortem was carried out which revealed Mr Greig had suffered acute myocardial infarction leading to haemopericardium.

17.      Mr Greig's condition when presenting at the Royal Alexandra Hospital on Sunday 25^th February 2007 was misdiagnosed. 

18.      The electrocardiography which was recorded on the medical records as "normal" by Dr Somkumar was a flawed interpretation of the ECG.  The ECG disclosed serious heart irregularity which would have been immediately apparent to a doctor with basic knowledge of ECG interpretation. 

19.      Automatic  interpretation  software programmes for ECG were available within the Royal Alexandra Hospital but were not in general use and were not used on the equipment used on Mr Greig. 

20.      All ECG results in the Royal Alexandra Hospital are now subject to automatic software interpretation analysis. This has been approved on an interim basis. 

  

Note: 

 

The Cause of Death.

 

The post mortem examination of Mr Greig was conclusive that he died as a consequence of a haemopericardium rupture due to acute myocardial infarction due to coronary artery thrombosis. In other words he had suffered a heart attack associated with a blockage of one of the main arteries.  Death had been brought about by a rupture of the infarcted muscle allowing blood to leak out of the heart into the pericardium sack around it.  When the sack fills with blood the heart stops beating.  That event was described by Dr John Clark as causing "a rapid collapse and death".  The heart attack suffered by Mr Greig would not  have been simultaneous with the event which brought about his death.  Dr John Clark determined from the colour of dead portion of the heart muscle, which had become yellow, that the heart attack had been suffered some days prior to Mr Grieg's death.  Dr Clark thought it a possibility that the heart attack had been suffered on 24^th or 25^th February but could have occurred as long back as eight days prior to death.  He thought there was every likelihood that the pain and discomfort experienced on the Saturday, when Mr Greig had attended the cinema, could have arisen as a result of arterial blockage.  The pain experienced by Mr Greig might also have represented a state prior to full blockage if there had been exertion but that pain would have subsided once the exertion terminated.  A heart attack comes about when there is a total occlusion (blockage) of the coronary artery supplying the inferior and posterior areas of the heart.  Such occlusion leads to the interruption of blood flow which results in death to some or all of the muscle tissue.   However in Mr Greig's circumstances this did not bring about his immediate death.  The fatal event occurred when the dead heart muscle ruptured days later causing blood to leak into the pericardium which is the sack around the heart and within which the heart is held by "a scaffold of tissue".  The leaking of blood into the cavity is fatal.  The heart is prevented from beating and death results.  Medical intervention offers no remedy to such an occurrence. 

Dr Adrian Brady, Consultant Cardiologist, theorised on the post mortem findings: he considered that the arterial blockage suffered by Mr Greig was possibly total but was unlikely to have  been less than ninety per cent of the artery; that part of the heart denied blood by the blockage would have died immediately.  Thereafter Dr Brady suggested there was a spectrum of consequence: death could occur immediately or it might occur after a lapse of time; in Mr Greig's case there had been a rupture of the muscle leading to the admission of blood from the dead tissue into the pericardium which is always a catastrophic event.  Dr Brady described this as an unusual occurrence and experienced by only 1% of those who suffer heart attacks; in his experience the consequences are always fatal and he had no record of this ever having been a survivable event.  Where cardiac rupture does not occur then the heart may still function with less energy; scar tissue can form around the damaged or dead part of the muscle and the heart can continue to beat but its capacity is reduced and breathlessness in an individual would be evident.  The risk of subsequent heart attack is increased by five per cent year on year.

Dr Brady considered that a cardiac rupture would have occurred regardless of whether or not Mr Greig had been admitted to hospital.  In the conclusion to his report prepared at the request of Dr Anne Greig (crown production 6) Dr Brady states:

 

  "it is my considered opinion that even if Mr Greig had been offered the very best services available in the West of Scotland at that time, the fact that he presented so late following the onset of symptoms meant that the damage caused by the blockage of his coronary artery had been done.  Intervention with either thrombolytic clot busting drugs or angioplasty would probably not have made any difference and Mr Greig would still have died from cardiac rupture some days later".

 

THE MISDIAGNOSIS

 

Mr Greig was clearly unwell from at least Thursday 22^nd February 2007. He had been in Dumfries and had reported to his wife by telephone symptoms which he self diagnosed as heartburn and abdominal upset.  The accuracy of that intuition cannot be tested.  Dr Greig recalled in her evidence that on Friday 23^rd February she and her husband had enjoyed a lovely evening together.  Fridays were a special night for herself and her husband as he was back home from working away; that Friday had been no exception.  Mr Greig looked to have overcome what he had considered to have been a bad reaction to fast food consumed at some point in the course of his working week.

 

There is no evidence that Mr Greig was unwell on Saturday 24^th February prior to his attendance at the cinema in Linwood.  At approximately 9:30pm there was a clear physiological deterioration experienced by him.  In her evidence Mrs Greig said that she was conscious of the incidence of arterial disease within Mr Greig's own  family and had flagged up with her husband the possibility of an attendance at the Accident and Emergency Department of the Royal Alexandra Hospital which was a short and manageable distance from the Linwood cinema complex.  That suggestion was declined by Mr Greig who was attributing his poor condition again to the consumption of fast food.  On his return home he had remained in the living room where he stayed all night saying in the morning that he had been troubled by the possibility that his chest pain could be potentially attributable to a cardiac condition. 

 

On the morning of Sunday 25^th February 2007, Mr and Dr Greig agreed that he should attend the Accident and Emergency Dept at the Royal Alexandra Hospital in Paisley.  En route to the hospital however he was diverted by a sign for the NHS 24 service on the window of his GP's surgery.  He contacted NHS 24 at 10:57.  That call lasted 3 minutes.  Dr Greig recalled that her husband had referred to a burning sensation in his chest and that he had eaten a hotdog.  Dr Greig wanted him to relate his family's cardiac history but it is unclear whether reference was made to this or not.  Dr Greig understood that the conversation her husband had had with NHS 24 was to the effect that attendance upon Accident and Emergency at the Royal Alexandra Hospital would result in a considerable delay and that the pain her husband was experiencing could be relieved by an appropriate antacid.  Mr and Dr Greig continued to Braehead Shopping Centre where he purchased Gaviscon, a proprietary antacid from a pharmacy. 

The antacid preparation did not relieve Mr Greig's symptoms.  He decided to continue with his initial plan to go to the Accident and Emergency Department at the Royal Alexandra Hospital in Paisley  He arrived there at around 16:57 which is the time recorded as he was triaged.  The presenting complaint on the triage record was recorded as 'a burning sensation in the chest'.  He was triaged at ' 4 ' on a scale of 1 to 5 and was therefore not determined at that point to require treatment for an acute condition. 

The clinical records noted Mr Greig's history of abdominal and heartburn problems from the previous week.  He inferred, by reference to his earlier experience on the Thursday night, that he was currently experiencing a related problem. Dr Greig thought that she rather than her husband had made reference to his family history of cardiac disease.  That is not recorded in the triage notes but is reflected in the nursing notes which were taken after Mr Greig had been triaged.  It is not clear from the evidence whether a decision to prepare Mr Greig for epicardiography was as a result of reference to his family's history or to the symptoms of his complaint.  In any event an epicardiography was carried out prior to a formal consultation with a doctor who would then have the results of that test.

 

Mr Greig was seen by Dr Deepa Somkumar in the Accident and Emergency Dept within an hour of his presentation at the RAH.  She took a history from Mr Greig that he continued to experience a "burning sensation" in the throat and chest.  She noted, however that there was "no chest pain" which she characterised as a crushing type pain. Clinical examination disclosed a high temperature of 38 degrees, feelings of hot and cold, no abdominal pain, no haemolatosis, no palpitations, no bowel symptoms, no swelling in the throat, no breathlessness, and normal appearance of tonsils.  A blood sample was taken and sent for analysis.  Dr Somkumar recorded alongside her clinical observations that the ECG was 'normal'.  The ECG equipment did not incorporate any Automatic Interpretation software.

 

Dr Somkumar gave evidence that while she had no memory of seeing or examining Mr Greig it was her standard practise to refer her diagnoses to a senior doctor in attendance within Accident and Emergency.  As a matter of routine she would seek confirmation from a senior doctor of any diagnosis she had made and have approved the care management plan she had considered appropriate.  On this occasion she  had spoken to the senior doctor in the ward, Dr Mason. who had endorsed her diagnosis that Mr Greig was suffering from reflux oesophagitis, that he had a urinary tract infection in addition, and that Mr Greig be prescribed accordingly and discharged from hospital. That was recorded in the clinical notes.  She indicated she would not have made any of those decisions without consultation.  Dr Somkumar had been a junior doctor within Accident and Emergency in the Royal Alexandra Hospital since 6^th February 2007 i.e. for a period of approximately 3 weeks prior to Mr Greig's presentation.  Previously she had been in a number of posts in India and England.  She had been a Senior House Officer in the Royal Alexandra Hospital in obstetrics and gynaecology for 6 months prior to her moving to Accident and Emergency.  She had trained and qualified in India.  She accepted that she had little exposure to ECG interpretation.  Heart disease in India was not prevalent and the focus of her training there was in infectious diseases.  She recalled that she had around three hours of formal teaching on ECG interpretation and was aware of her limitations and that therefore her practise was to seek guidance when an ECG had been undertaken.  As she had neither memory of Mr Greig's attendance at hospital nor of her clinical examination she could only conclude that if it was recorded that the ECG was "normal" then that could only be attributed to an interpretation made by a middle ranking or senior doctor to whom she had referred her preliminary diagnosis.  She had no reservation about her inability to interpret an ECG accurately nor had she any reservation about seeking advice from a senior colleague either at middle grade or as consultant.  Her management plan could only be formulated with the approval of a consultant or senior doctor as was recorded in her clinical notes. 

 

The doctor to whom she referred was Dr Mason a staff grade doctor within the Accident and Emergency Department.  He similarly gave evidence that he had no memory of Mr Greig nor of any consultative involvement with Dr Somkumar.  He did recall Dr Somkumar in the Accident and Emergency department.  He had had no knowledge of Mr Greig's death until so advised in the spring of 2009.  As he had no specific recollection of any consultation with Dr Somkumar he could only rely on what would have been his normal practise when reviewing an ECG.  Dr Mason did not demur from the proposition that he had had a case management conversation with Dr Somkumar.  He did not think that he had seen the clinical notes that would have prompted any proposed care plan.  He considered that in all probability he had been provided with an oral account of Dr Somkumar's clinical findings which would have been entirely consistent with her diagnosis. Although he had no memory that he seen the ECG, had he done so he would have signed it as having been noted by him as  was his normal practice.  He had not considered that he would have deviate from that practice.  The conclusion to be reached by him, therefore, was that he had not seen the ECG.  He accepted that on reflection there would have been no difficulty in him looking at the ECG and that in retrospect he probably ought to have looked at it personally.  However at the time of Mr Greig's presentation he had no reason to challenge Dr Somkumar on any of her clinical findings and had proceeded on a working assumption that she was ECG literate.  When the ECG was brought to his attention in the course of the subsequent investigation by the Royal Alexandra Hospital into Mr Greig's death in 2009 he had expressed shock as to the diagnosis which had been made by Dr Somkumar.  He agreed that the ECG disclosed an extremely obvious cardiac abnormality which conflicted dramatically with Dr Somkumar's diagnosis. The secondary diagnosis of a urinary tract infection was a diagnosis with which he could no longer concur as there was a paucity of symptoms to support that finding;  if the ECG was omitted from the clinical findings there were sufficient symptoms might still have supported a diagnosis of reflux oesophagitis.  However Dr Mason accepted that once the ECG was introduced into the diagnostic matrix that diagnosis could not stand and that there had been a clear and evident misdiagnosis of Mr Greig's condition.  The ECG and recorded symptoms,when taken with the clinical history, were entirely consistent with each other.

 

There is no doubt that the ECG disclosed a serious cardiac condition which would have prompted immediate hospitalisation and pro-active treatment of the patient.  I can make no finding as regards the truthfulness or otherwise of either Dr Somkumar or Dr Mason.  Both doctors did not impress me as being deceitful.  Neither had a specific or general memory of the event and were relying on their normal practise procedure at that time.  There was no evidence that the Accident and Emergency Department was particularly busy or that either doctor was under any extraordinary  pressure which might have compromised their approach to the patient.  The target time for consultation for a patient triaged at '4' was two hours however Mr Greig was seen within one hour which would suggest a ward not working at its full capacity. Dr Brady interpreted the ECG as being so clearly evident of cardiac malfunction that it could not have been a marginal decision as to whether or not it disclosed normal heart activity. The interpretation of the ECG was critical for diagnosis of the heart attack and for the immediate and future management of Mr Greig's condition which might have required an acute angioplasm or thrombolysis. In the absence of the ECG the consensus from all the Doctors lead in evidence was that a diagnosis of reflux oesophagitis might stand.  Quite often the symptoms of that condition can mask cardiac disease. However context is of significance equally: when dealing with a middle aged man from the west of Scotland with a family history of heart disease the epidemiology would favour scrutiny of whether the symptoms experienced by the patient were more clearly aligned with cardiac disease than with an epigastric complaint. 

 

I leave aside Dr Somkumar's diagnosis of a urinary tract failure as this has no immediate bearing on the inquiry.  That was accepted by all doctors to the Inquiry  that the diagnosis was unsupportable. That misdiagnosis however played no part in Mr Greig's subsequent death.

 

ACCIDENT AND EMERGENCY DEPARTMENT MANAGEMENT

 

The inquiry heard evidence from Dr Alistair Corfield, Consultant in Accident and Emergency Medicine at the Royal Alexandra Hospital and from Dr Michael Johnston, Consultant in Emergency Medicine at Ninewells Hospital in Dundee.

 

Dr Corfield confirmed that the ECG taken on the 24^th February 2007 was indicative of acute myocardial infarction and that Mr Greig should have been admitted to the Coronary Care Unit at Paisley and not discharged.  He had been Dr Somkumar's educational superior and mentor.  Dr Somkumar was an SHO1 grade in her first year of post registration training.  By definition she would have completed her pre-registration year when she would have trained under supervision and would have encountered electrocardiography.  Dr Corfield had no concerns with Dr Somkumar's training and considered that she ought to have been able to provide basic interpretation of an ECG.  He advised there was a strong mentoring ethos within the hospital and that consultation with a senior doctor either at middle grade or above was actively encouraged.  Consultants were available in the hospital from 8am to 5pm on a Sunday.  Thereafter two consultants from a pool of eight are on call for any emergency.  Dr Corfield advised that Triage operates so as to prioritise treatment for attending patients. Detailed history taking is not a primary function of Triage.  As Mr Greig was triaged at 4 he was targeted to be seen within 2 hours of attendance at the hospital.  In fact he was seen within one hour.

 

Dr Corfield explained that in February 2007 not all ECG equipment incorporated "automatic interpretation software".  That is computer software designed to identify irregular rhythms or pulses from the cardiograph.  That software was available within the Royal Alexandra Hospital but was not routinely deployed.  There were two machines in circulation, one with the software installed and the other not.  Whether the software was used or not depended randomly upon which ECG equipment was available.  The use of that software is not without controversy.  The software has been designed to minimise risk and therefore gives rise to a high number of "false positive" readings.  Visual interpretation of the graph by an expert in cardiology may often not coincide with the computer interpretation that has given rise to a distrust of the software by cardiologists.  Dr Corfield explained that ECG analysis and interpretation is a core skill of a doctor in surgical or acute medicine and is an extremely common method of investigation and for obvious reasons is an important diagnostic tool.

 

Following upon the circumstances of Mr Greig's death coming to light, (a matter pursued vigourously by Dr Greig on her husband's behalf) a review of ECG use within the hospital had concluded that all ECG machines circulated within the Royal Alexandra Hospital should have automatic interpretation software installed and should there be any abnormal pattern identified by the software then this must be discussed with a senior doctor of at least middle grade or a consultant.  Dr Michael Johnston gave evidence regarding the increasing use of ASI in Ninewells Hospital, Dundee:  two ECG machines were used in that hospital one with and one without the software.  However the practise in Ninewells was to have every ECG referred to a senior doctor, a practise which could be achieved in Ninewells because of its resources.  However Dr Johnston was insistent that the emphasis in training was to instil in junior doctors the skills of interpretation of an ECG but that the instruction to refer the ECG to a senior doctor remained in place to assist in ECG interpretation   where there was any doubt.  Such a system required adequate supervision of junior medical staff which Ninewells was fortunate enough to provide.

On his review of Mr Greig's medical records from the Royal Alexandra Hospital, Dr Johnston believed that there were lessons to be learned particularly in relation to the assessment, assimilation and acknowledgement of information.  Particular reference was made to Dr Mason and his involvement with Dr Somkumar. Ideally that consultative process should have been properly documented and recorded by the advising doctor.  In this case that would be key to understanding the process of the diagnosis of Mr Greig's condition.

 

IMPLICATIONS OF MISDIAGNOSIS

 

Without reference to the ECG it was evident that Dr Somkumar's diagnosis was consistent with one set of limited circumstances:  Dr Johnston accepted that gastric and cardiac symptoms often mask each other and that distinguishing one diagnosis from another is an age old problem experienced up and down the country. In Dr Johnson's review of Mr Greig's clinical notes, taking into account the reference to a "normal" ECG, he stated:

      "as it reads it is entirely reasonable to have reflux oesophagitis as the number one diagnosis".

 Dr Corfield affirmed that there was an identity of symptoms between the two conditions:

 "the end results can be miles apart but the symptoms can be similar".

 

Sadly, it is doubtful whether Mr Greig would have survived for any appreciable length of time following an acute myocardial infarction in conjunction with the interval elapsed between the infarction occurring and his attendance at hospital .  The rupture to the heart and the ingression of blood into the pericardium is always a fatal event regardless of whether it should occur at home or in hospital.  The time of admission to hospital is a critical factor in survival.  Dr Adrian Brady advised that admission after twelve hours of the event significantly reduces the chance of restoring the dead muscle tissue.  If admission is twenty four hours after the event the chance of restoration of the dead muscle tissue is lost entirely.  If admission is eighteen hours after the event then in Dr Brady's view there was little or no chance of reviving the muscle.  Dr Brady gave evidence that if presenting within twelve hours then most patients would get angioplasty.  The later the presentation the less likely angioplasty would benefit the patient who would be treated with thrombolysis or block busting drugs which might in the passage of time have more clinical relevance.  He explained that at around twenty four hours after the event the risk of angioplasty outweighs its benefits as there would be no benefit in restoring blood to the muscle which is by that time dead.  Had Mr Greig been referred to the coronary care unit on his admission to hospital he would have been prescribed blood thinning drugs followed by investigation to see if there was any purpose in restoring the blood supply to the tissue.  Whether late angioplasty was done would be determined by the quality of the patient's blood vessels and the overall arterial condition of his heart.  It might also be determined by his general health and age   Had Mr Greig been properly diagnosed i.e. the ECG interpreted correctly, then Dr Brady was of the view that the cardiac rupture would have still occurred:

 "Subsequent treatments would not have made any difference beyond the damage which was done within 12 hours .........  He was unfortunate that sufficient damage had been done at that time"

Dr Brady thought that whether or not Mr Greig had been referred to a specialised hospital such as The Golden Jubilee hospital in Clydebank or referred home his chances of survival had already been significantly reduced by the delay in seeking medical assistance. The opportunity for survival was critically diminished by the passage of time.

Dr Corfield did accept that had Mr Greig been admitted to a coronary care unit immediately the heart attack had occurred then there may have been a chance of survival; however, he did not think that Mr Greig's recovery was likely given the lapse of time between suffering a heart attack and attending hospital: this was beyond that critical period of 12 hours.  In Dr Johnston's view Mr Greig's opportunity for survival was lost:

 "it is more likely the horse had bolted with regard to specific treatment.  The best opportunity [of survival] was within the hours of the onset. [Death] would have happened whether he came to hospital or not."

 

REMEDIAL ACTION

 

I heard evidence from Dr Cowan and Dr Dixon who were appointed by the Greater Glasgow Health Board to review the circumstances surrounding Mr Greig's death.  Dr Dixon looked at the case notes to investigate Mr Greig's death with a view to establishing what processes had been followed and what had been missed.  His remit was to determine whether there had been a system failure.  He was satisfied that there was an established procedure already in place which allowed junior doctors to consult with their seniors.   He accepted that there was a likelihood the junior doctor, Dr Somkumar, had been influenced by the history provided by Mr Greig and that her subsequent presentation of those symptoms to Dr Mason would have greatly influenced his certification of her diagnosis.

In September 2007 automatic interpretation software for ECGs was deployed on a compulsory basis as an interim measure. The reaction to its mandatory use had been mixed in that it is disliked by cardiologists because of the frequency of "false positives" but to less experienced doctors it is an acceptable diagnostic tool. The review concluded that had there been automatic interpretation software in place at the time of Mr Greig's presentation then there would have been a benefit to the diagnosis of Mr Greig's condition. As a direct consequence of Mr Greig's death the use of automatic interpretation software is used throughout the Greater Glasgow Health Board. This has been applied on an interim basis but there appears little resistance from the medical profession and no adverse report has been received that the use of the automatic interpretation software gives rise to difficulties. 

Mandatory use of automatic interpretation software has now been combined with tutorial based teaching of ECG interpretation to junior doctors.  That broadly brings the Greater Glasgow Health Board into line with the practice in Ninewells Hospital  which has adopted a position whereby no assumption is made as to skill levels amongst junior doctors  prior to their employment  in  the hospital.  All training there is developed from the lowest common denominator of knowledge. 

 

Dr Dixon had reported to Dr Cowan the Medical Director of GGHB.  Dr Greig's death only came to the Board's attention as a result of an investigation by the COPF's office in Dumbarton prompted by Dr Greig's insistence that there should be an Inquiry into her late husband's death. Otherwise the GGHB would have been unaware of the circumstances of Mr Greig's presentation at the RAH.  That is a regrettable situation but is outwith the scope of this inquiry.  Mr Greig had been taken to the Vale of Leven Hospital by paramedic staff and his death is recorded at that hospital. There is no mechanism whereby his admission to the Vale of Leven hospital could be linked to his presentation at the RAH six days previously.  Mr Greig's death was not, therefore, a matter of immediate internal inquiry and vital evidence was in consequence lost.

 

CONCLUSION

The purpose of the inquiry is not to establish fault on the part of any party.  It is an exercise in finding the facts which contributed to or caused the death of Mr Greig.  It is not, though some might think it should be, a general inquiry into procedures, irregularities, acts, or omissions of an organisation.

 

I am grateful to all parties for their submissions and in particular to the submissions of Mr Green, Dr Greig's representative, for a very detailed and thought provoking document which raises issues which many of which unfortunately fall outwith the scope of this inquiry. 

 

In all probability Gordon Greig suffered a heart attack on Saturday 23^rd February 2007 whilst attending the cinema.  The incipient process may have taken place on Thursday 21^st February when he first became unwell.  Although he was in some proximity to a hospital on Saturday night he deferred attending hospital until Sunday afternoon.  That interim period may have been critical to any chance of survival he had and was critical to the success of any treatment he might have received in a coronary care unit.  Dr Brady gave clear evidence that unless attendance at the hospital is made within a 12 hour period, and ideally much sooner than that, the success of medical intervention declined significantly .   Even a late presentation by a patient may give rise to acute angioplasty if other factors such as youth, fitness and condition of the muscle permitted. However that intervention would be weighed against the potential for damaging the tissue or scaffold which supports the heart within the pericardium.

 

It is extremely difficult to gauge what might have happened had Mr Greig attended hospital at the onset of acute myocardial infarction; what is more predictable is the outcome had he been referred to a coronary care unit once he presented himself to the Accident and Emergency Department of the Royal Alexandra Hospital on the evening of Sunday 25^th February.  Clearly his best chance of survival was immediate attendance at hospital.  That chance declined significantly according to Dr Brady as each hour passed. Rupture of the heart is an unforeseeable event and regrettably it may have happened regardless of any medical intervention.  Such a rupture is uncommon.  On the evidence I heard as regards Mr Greig's pathology I do not consider it appropriate that I should make a finding under Sections 6(1)(c), (d), or (e) of the Act.  On the evidence it is clear that no reasonable precaution could have been taken by the Royal Alexandra Hospital whereby Mr Greig's death might have been avoided.  I cannot concur with the view of the Crown or of Mr Watson that I should make such a finding.  Dr Brady was quite clear in his terms that the benefit of Mr Greig's admission to hospital would have accrued to his family who would have been better placed and counselled to deal with his condition.  That is outwith the remit of the Inquiry. The evidence does not support a recommendation that all ECG equipment should have automatic software interpretation installed.  Such a recommendation would, in my view, demand an unequivocal endorsement of that software by the medical profession .  The use of the software is undoubtedly controversial and is not universally supported.  I heard no evidence from any party to the Inquiry which would allow me to take such a view. However the fact that there has been no adverse report as to the performance of automatic interpretation software in ECG equipment, in any prejudicial sense to a patient, strongly supports the continuance of the interim measure currently in place within GGHB.

 

I have no recommendation to make arising from the circumstances of Mr Greig's death which are in the wider public interest.

 

There are, however, a number of issues arising from the evidence which do merit comment.  Firstly, I find it extraordinary that a middle aged man with a family history of coronary disease who complains of chest discomfort and indigestion was not immediately referred by NHS 24 to a hospital.  Although it was accepted that even by 10:57 on Sunday 24^th February "the horse had already bolted" (Dr Dixon) the advice received by Mr Greig as relayed to Dr Greig was singularly inadequate and incompetent.  I heard no evidence on behalf of NHS 24.  Dr Greig's account of what she was told by her husband was not in dispute.  There was little information before the Inquiry as to what Mr Greig had actually told the NHS 24 advisor, however, one would regard age combined with chest pain or discomfort to immediately prompt a hospital referral.  The advice given was insufficient and any reference made to a potential and protracted wait in an Accident and Emergency Department was wholly inappropriate.  If indeed NHS 24 err on the side of hospital referral as was suggested  that principle is to be applauded.  However, if such advice is conditioned with a caveat as to accident and emergency waiting times then that should be addressed.  No link can be made however between the advice from NHS 24 and Mr Greig's death and any comments made by me are advisory only.

Secondly, As regards the misdiagnosis of Mr Greig's coronary condition by Dr Somkumar it seems to me more likely than not that Dr Somkumar was persuaded by what Mr Greig presented as his immediate medical history.  That presentation may have conditioned the approach taken by the junior doctor in arriving at her diagnosis of reflux oesophagitis.  Whereas it is in the nursing notes that Mr Greig had referred to his family history of coronary disease there is no clear evidence that Dr Somkumar had acknowledged that in the notes.  There remains a possibility that had she done so that may have diverted her thinking from a gastric to a cardiac disorder.  If the notes were read by her then that history appears to have been overlooked in her diagnosis.  That seems all the more surprising when she distinguished between the pain described as a burning sensation from pain which could be noted as a crushing pain. She made a clear distinction in her clinical examination.  An ECG was carried out which clearly identified an obvious abnormality in the rhythms of the heart.  The identification of that pattern ought to have actioned an immediate referral to the coronary care unit.  Regrettably the audit trail is lost. Consideration should be given, in my opinion, to a form of confirmation that the salient clinical/nursing notes have been read and understood by the consulting doctor.  Had Dr Mason signed, as he would normally do, that he had seen the ECG then he would have clear responsibility for its misinterpretation.  Where an ECG has been looked at a record should be maintained as a matter of practise by the individual who carried out the interpretation.  Similarly a review of notes made by junior doctor by a senior doctor should be a matter of uniform practice and an annotation made to that effect. 

 

Thirdly, it is encouraging that GGHB required  no encouragement to apply automatic interpretation software to all ECG equipment; the fact that false positives are thrown up is to my mind preferable to the situation which has given rise to this Inquiry.    In my view it is for the Glasgow Health Board to determine in the light of all clinical evaluation of the software whether the interim measure in place should continue on a permanent basis.  The use of that software had a clear bearing on whether or not Mr Greig would have been admitted immediately to hospital though it may not have served any purpose beyond that.  The use of such software combined with training and supervision should pre-empt a repetition of the misdiagnosis that was made in respect of Mr Greig.  The handbook provided to junior doctors when taking up employment with Greater Glasgow Health Board now provides inter alia:

 

"Medical staff must ensure they clearly complete their ECG interpretation in the patients ED card. 

·              All ECG machines will have interpretation software active.

·             ECG that are interpreted as abnormal by hospital staff or by ECG's diagnostics software must be reviewed by an experienced member of medical staff (middle grade or consultant).

·               The interpretation by an experienced member of medical staff must be documented."

 

That governance complies with any recommendation I have made and satisfies any of the criticisms which have arisen as a result of this inquiry.

 

Mr Greig's death was very unfortunate in the circumstances in which it happened.  There is little to suggest that Mr Greig's life would have been saved had there been the appropriate level of intervention at his attendance at hospital.  However what is clear is that palliative assistance was denied to him and, correspondingly, his wife had to endure the trauma of his sudden death.

 

My sympathies are extended to Dr Grieg without whose patience and dogged determination this Inquiry would not have taken place.                  

 

 Humbly Reported

 

 

Sheriff of North Strathclyde.