Fatal heart attack leads to multiple jeopardy

01 October 2019

Mr M, a 66-year-old man with a complicated medical history of poorly controlled insulin dependent diabetes, angina, hypertension and inflammatory arthritis, was admitted acutely with symptomatic bradycardia and hypotension secondary to complete heart block.

Dr F, a newly appointed consultant cardiologist, decided he required insertion of a temporary pacing wire. The procedure was technically difficult as Mr M found it difficult to lie flat and was intermittently agitated. The radiographer was relatively inexperienced and struggled to obtain clear images.

Two hours post-procedure Mr M suffered a cardiac arrest and, despite prompt resuscitation, he died.

A postmortem identified that the pacing wire had perforated the right ventricle and the tip lay in the pericardial space, which was filled with fresh blood.

Three weeks later, while Dr F was on holiday abroad, she was informed that the case had been passed to the police.

Deeply upset, Dr F contacted the Medical Protection advice line.

How Medical Protection helped

The Medical Protection advisory team liaised with the police officer dealing with the case, obtained a copy of Mr M’s records, instructed a solicitor with extensive experience of dealing with such cases, and arranged to meet with Dr F on her return from leave. After the meeting the solicitor drafted a comprehensive statement on her behalf.

Medical Protection also instructed a cardiology expert who commented that it was a technically challenging case. She explained perforation of the ventricles is a recognised, but infrequent, complication and said that the suboptimal imaging contributed to the complication not being recognised more promptly.

What happened next?

Hospital investigation

Dr F had a meeting with the hospital, who offered her occupational health input and explained they were considering restricting her practice, such that she would not undertake any interventional procedures pending the outcome of the police investigation.

Aware this could take many months, the Medical Protection advisory team – with Dr F’s agreement and with the support of her colleagues – advocated that she would not do on-calls and would have supervision for interventional procedures. This would ensure patient safety and avoid Dr F becoming deskilled. The hospital agreed it was a proportionate way forward.

The hospital conducted a serious incident (SI) investigation, which was critical of some of Dr F’s actions but also accepted the imaging equipment was suboptimal.

Police investigation

A Medical Protection solicitor accompanied Dr F to the police interview, following which the case was put under consideration for prosecution. Ten months later, it was decided that no charges should be brought.


Shortly after the case was closed by the police, the coroner listed the case for an inquest and Dr F was called as a witness to give evidence. The coroner returned a narrative conclusion, which identified where there were failings, and commented positively on Dr F’s open and candid approach when giving evidence.

The family subsequently made a claim in negligence, which was settled by the hospital.

Six months later, Dr F returned to full independent practice.


  • Seeking advice at an early stage is crucial. Medical Protection provides a 24-hour advice line for members to speak to a case adviser or medicolegal consultant. In this case, even though Dr F was abroad, the adviser was able to take immediate steps to assist Dr F.
  • It is essential to have access to the contemporaneous records before providing a statement. By obtaining the records, Dr F was able to refresh her memory of the case and Medical Protection was able to instruct an expert.
  • An early expert opinion can be invaluable in identifying the strengths and vulnerability of a member’s position. In this case it gave Dr F an opportunity to consider the expert’s view; while she did not agree entirely with it, she was accepting of the main criticisms.
  • Attending a police interview is a very daunting experience for most healthcare professionals, and it is vital they have a solicitor who is experienced and familiar with the process to advise and support them. Medical Protection strongly advises members to use a solicitor instructed by us, who knows the professional ramifications and can provide advice on the other aspects of the case.
  • Where concerns arise about a practitioner’s capability, hospitals often consider if the practitioner’s practice should be restricted. In some cases, the practitioner may be excluded from all duties. In this case the incident arose from a discrete aspect of Dr F’s practice. She showed insight into how she should have acted differently and she was willing to accept supervision, so the hospital was reassured she could continue to practise safely.
  • This was a very difficult and distressing time for Dr F, especially so early in her consultant career. The advice and guidance from the adviser and the solicitor helped her to cope with the various investigations.