Trevor Bailey

Regulation 28:  Prevention of Future Deaths report 

Trevor Coy BAILEY (died 09.05.23) 

THIS REPORT IS BEING SENT TO: 

1.

Medical Director
Northwick Park Hospital
Watford Road
Harrow HA1 3UJ

1  CORONER 

I am:   Coroner ME Hassell 
 Senior Coroner  
 Inner North London 
 St Pancras Coroner’s Court 
 Camley Street 
 London  N1C 4PP 

2  CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009, 
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On  18  May  2023,  one  of  my  assistant  coroners,  Edwin  Buckett, 
commenced  an  investigation  into  the  death  of  Trevor  Bailey  aged  63 
years.  The  investigation  concluded  at  the  end  of  the  inquest  on  18 
October. I made a determination at inquest of death by natural causes.   

Mr Bailey’s medical cause of death was: 

1a) extensive acute myocardial infarction of the left ventricular wall 
1b) severe coronary artery stenosis (stented) 
1c) atherosclerosis 

4  CIRCUMSTANCES OF THE DEATH 

1 

 Mr Bailey attended Northwick Park Hospital emergency department on 
19  April  20223  with  chest  pain,  two  and  a  half  weeks  before  his  fatal 
myocardial  infarction  on  7  May  2023.    He  was  investigated  and 
discharged without referral to the rapid access chest pain clinic because 
his test results proved negative and he seemed stable. 

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving 
rise to concern. In my opinion, there is a risk that future deaths will occur 
unless  action  is  taken.  In  the  circumstances,  it  is  my  statutory  duty  to 
report to you. 

The MATTERS OF CONCERN are as follows.  

I  heard  evidence  at  inquest  that  Mr  Bailey  was  a  (very  recently  ex) 
smoker with a family history of ischaemic heart disease – his brother had 
had two cardiac stents placed in 2006 and two in 2012.   

However, it does not appear that these two pieces of information were 
elicited  by  those  assessing  Mr Bailey  in  the  emergency  department  of 
Northwick  Park  Hospital.    I  heard  evidence  that,  if  they  had  been,  he 
should have been referred to the rapid access chest pain clinic. 

Given  the  sequence  of  events,  it  seems  unlikely  that  such  a  referral 
would  have  resulted  in  definitive  treatment  before  Mr  Bailey’s  fatal 
myocardial  infarction,  but  it  could  be  a  life  saving  referral  for  another 
patient in Mr Bailey’s position. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that you have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 18 December 2023.  I, the coroner, may extend 
the period. 

Your  response  must  contain  details  of  action  taken  or proposed  to  be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

8 

COPIES and PUBLICATION 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I have sent a copy of my report to the following. 

, wife of Trevor Bailey 

• 
•  Care Quality Commission for England  
•  Professor Chris Whitty, Chief Medical Officer for England 
• 
• 
•  HHJ Thomas Teague QC, the Chief Coroner of England & Wales 

 consultant cardiologist, Royal Free Hospital 

, GP, Church Lane Surgery 

I  am  also  under  a  duty  to  send  a  copy  of  your  response  to  the  Chief 
Coroner and all interested persons who in my opinion should receive it.  
I  may  also  send  a  copy  of  your  response  to  any  other  person  who  I 
believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may  find  it  useful  or  of  interest.  You  may  make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response. 

9 

DATE                                                  SIGNED BY SENIOR CORONER 

20.10.23                                              ME Hassell 

3

Coroner ME Hassell 

Senior Coroner 

Inner North London 

St Pancras Coroner’s Court 

Camley Street 

London N1C 4PP 

Dear Coroner ME Hassell, 

Thank you for your feedback and the report regarding the inquest into the death of the late 
Mr.Bailey, held at the St. Pancras Coroner's Court on October 18, 2023. 

Matters of Concern as per your report are 

 1.   Mr.Baileys‘s Family History of IHD – His brother had had two cardiac stents placed in 2006 
and two in 2012. This information was not on Mr.Bailey’s medical record. It was not elicited at his 
2012 or 2018 health checks or when he consulted his General Practitioner, 

 on 19 or 27 April 2023.  

The Recording of this information is unlikely to have changed the outcome for Mr.Bailey, 
but it was a vital part of the medical history and it might easily be for another patient.  

 told me in the witness box that she had identified immediately after 

2.   
Mr.Bailey’s death in May 2023 that the duty doctor system at Church Lane Surgery does not allow 
sufficient time to deal with patients appropriately. However, she has not progressed this issue in 5 
months since.  

We have taken these concerns seriously and implemented the following actions to improve future 
patient care: 

 
 
       
      
       
       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Actions taken 

We conducted the Significant Event Analysis and discussed at the Practice meeting on 
23.10.2023 

We reviewed the 2012 entry for the Template. Our Practice nurse had asked the patient about their 
family history of IHD during NHS health check and had recorded as No family history of IHD. The 
template at that time had a provision to record both positive and negative family history. 

During the NHS health check on September 5, 2018, the family history of ischaemic heart disease 
would have been asked routinely as per the NHS health check template.  

On analysis we noticed that the new NHS template did not have a field to record a negative family 
history of IHD.  

We routinely calculate CVD risk percentage which is reliant on the risk factors recorded, including 
family history of ischaemic heart disease. This patient’s record did not have a positive family 
history of IHD at the two NHS health checks conducted in 2012 (a negative history has been 
recorded as the template at that time had a provision)) and 2018 (a negative history could not be 
recorded as the new template had no provision for the same). We have therefore not had a record 
of raised CVD risk score, necessitating initiation of primary prevention. The family history of IHD 
has been disclosed to us only at the coroner’s inquest on 18.10.23. During the inquest 

 was under extreme pressure when questioned why there was no mention of 

family history in the 2018 health check. She was unable to justify the reason, as the fault with the 
template became evident on subsequent detailed investigation of the templates.  

On 19.4.23, during his telephone consultation, Mr.Bailey reported a history of chest pain/tightness 
intermittently for 2 weeks. If a person has a history of chest tightness, it is important to investigate 
the acute and high risk causes of the symptoms, regardless of whether they have any risk factors 
for ischemic heart disease (IHD). This is because there may be a serious underlying cardiac or 
non-cardiac condition that needs urgent attention, such as pulmonary embolism, cardiac ischemia, 
aortic dissection or pericarditis,etc.  Mr.Bailey was hence advised to go to the emergency 
department immediately on April 19, 2023. 

During the triage call On April 27th, 2023, he had already undergone investigations for cardiac 
ischemia in the Accident and Emergency department the previous week for the same symptoms. 
The A&E discharge summary clearly stated that there were no cardiac risk factors, and both serial 
cardiac troponin and ECG were normal and diagnosis of non-cardiac chest pain due to acid reflux 
was made. It was therefore determined that the current dose of treatment for acid reflux was 
ineffective and was advised on the treatment accordingly and safety netted to attend A&E again or 
review at the surgery if symptoms were persistent.  

It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 
and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a 
result, it is now clear that the patient had a family history of cardiovascular disease that was not 
reported in previous encounters. This information was not taken into account, and the patient was 
not prescribed any cardio protective medication due to the low cardiovascular risk score as per 
NICE guidelines. 

We have taken the following steps to update the family history of coronary heart disease 
(IHD). 

We acknowledge that the new NHS health check template given to all practices, had changed from 
the previous one with provision to record positive family history but none to record a negative 
family history, making it impossible to document a negative family history. We did a search on our 

 
 
 
 
 clinical system, for the period 2018 to 2023, and found that family history of ischaemic heart 
disease was being gathered during NHS health checks (positive family history of IHD recorded in 
296 patients). We have updated the template to include the negative findings of ischemic heart 
disease (IHD) related to F/H (family history). Recording a negative family history will only serve to 
provide evidence that this has been sought during the consultation, though it will not change the 
CVD risk score. 

We have addressed the template issue with our PCN, Borough Director and the LMC, as this issue 
has raised concerns if a family history had been sought at all, during the health checks.  We hope 
this will ensure that the information reaches all our area practices that use the same templates, so 
that they can take appropriate action and are not disadvantaged. 

Currently we assess family history during new patient checks and NHS health checks. We are 
expanding this practice to include updates on family history at additional points of contact, such as 
annual chronic disease checks and structured medication reviews, ECG appointments, and have 
integrated this into our standardised templates. 
We have initiated the process of updating family history for all patients aged 25 and above. We 
have sent the message to all the patients aged >25yrs, to update their family history of IHD. All 
patients will be informed at registration that they will have to update their family history voluntarily if 
there are any changes. We have trained the staff to record it in our system. We are going to audit 
the new entry of family history of IHD every 12 months to assess the progress of our system.  This 
ensures the accuracy of our risk calculations when making medical assessments.  

To enhance our clinical procedures, we have provided comprehensive training to all our staff 
members on how to collect family history information and how to accurately record it in the clinical 
system.  

2.  Actions to re-structure the On-call system for the Duty doctor.  

We have recently made a change to the on-call schedule of Duty Doctors. Three un-booked     
telephone slots and three face-to-face slots have been added at the end of each doctor's shift to 
allow them to attend to patients who require additional consultation. This change has already been 
implemented and is currently in effect. The additional slots will enable the doctors to spend more 
time when detailed consultations are needed, ensuring better care for the patients. 

Kindly contact me if there should be any clarifications required. 

Thanking You, 

Yours Truly, 

Senior Partner 

Date: 15.12.2023.

• A  Putting patients 
~ 
~  T'  ofeverythingwe do 

at the HEA RT 

-

Senior Coroner (ME  Hassell) 
Inner North  London 
St Pancras Coroner's Court 
Carnley Street 
London N1 C 4PP 

15 December 2023 

r.!1:1-1 

London North West 
University Healthcare 
NHS Trust 

Trust Headquarters 
Northwick Park Hospital 
Watford Road 
Harrow 
Middlesex 
HA1  3UJ 

Dear Madam, 

RE: Inquest of TREVOR Coy Bailey 18 October 2023 

We write further to the inquest touching upon the death of Trevor Coy Bailey, which took place 
on  18  October 2023.  At the  conclusion  of this  inquest,  you  issued  a Prevention  of Future 
Deaths  (PFD)  report.  The  PFD noted that following  evidence  heard  at the  inquest, you  had 
concerns which we have addressed below: 

"That  Mr Bailey  was  a  (very  recently  ex)  smoker with  a  family  history  of ischaemic  heart 
disease - his brother had had two cardiac stents placed in 2006 and two in  2012. 

However,  it  does  not  appear that  these  two  pieces  of information  were  elicited by those 
assessing Mr Bailey in the emergency department of Northwick Park Hospital. 

Trevor Bailey  presented to  the emergency department with  a history of chest pain.  He was 
seen  by  the  triage  nurse  and  initial  observations  were  normal  except  for  a  slightly  low 
temperature.  The  initial  ECG  was  normal  and  blood  tests  were  taken.  These  blood  tests 
included  a troponin test (an  enzyme released by the heart at times of ischemia) and he then 
waited to be seen by a doctor in the waiting room. 

He was seen by an emergency medicine registrar and gave a history of discomfort in his chest 
which  he  described  more as burning  than  pain.  He denied  any other associated symptoms. 
He  mentioned  two  bouts  of this  feeling  of  discomfort  in  the  week  earlier  associated  with 
epigastric  burning.  He  denied  any severe  pain  in  his  chest  when  he  was  seen.  He  had  a 
normal clinical examination. 

At the time of being  seen  he did not inform the doctor that he had recently  stopped smoking 
or that he had a brother with a cardiac history. He had a second ECG at this time and this was 
also  normal.  According  to  the  trust  protocol he  needed  a repeat  blood  test to  ensure there 
was  not an interval change in the troponin blood test but the patient declined to wait for this to 
be done.  The patient had capacity to make this decision.  The registrar that saw him checked 

 
 
 this  result with the  intention to call  the  patient if there were any concerns;  this  second result 
was also 7 which is non-dynamic.  That is to say it showed no change,  indicating a low risk. 

As a department we  encouraged the patients to make their own decisions and  be involved in 
their  own  care  and  decisions.  Trevor  Bailey  had  the  risks  explained  to  him  about  leaving 
without having a repeat troponin and  he chose to do this. 

I  heard evidence  that,  if they had been,  he  should have  been  referred to  the  rapid access 
chest pain clinic.  Given the  sequence of events,  it seems unlikely that such  a referral would 
have resulted in definitive treatment before Mr Bailey's fatal myocardial infarction,  but it could 
be a life saving referral for another patient in Mr Bailey's position." 

The  point  we  would  like  to  make  is  that  even if he  had  not  self discharged,  based  on  the 
information given to the team  at the time if the patient underwent a HEART score the patient 
would score  1. 

A heart score is an evidence based score we use to risk stratify patients to decide on whether 
they need  urgent treatment or can  be  discharged and if discharged whether they would need 
actively following up in  a rapid access chest  pain clinic. 

A score of 1 would not have triggered a rapid access chest pain referral. 

If the  patient had  volunteered  that  they  had a  positive  family  history  and  had  been  a  recent 
smoker he would have scored  a heart score 2,  still not triggering. 

Of note if he scored one higher for highly suspicious history his maximum score would still be 
3 and would therefore still have be  classed as low risk. 

According to this scoring system , scores 0-3:  0.9-1.7%  risk  of  adverse cardiac  event.  In the 
HEART Score study, these patients were discharged (0.99% in the retrospective study,  1.7% 
in the prospective study) 

This is a well established nationally used protocol. As with any guideline there will be patients 
that sadly come  into  the  low risk  category  with that  under  1.7% chance  of having  a cardiac 
problem.  Unfortunately this is one such sad case. 

As  further evidence  we do routinely  satisfy our selves  that  even  though  this  is  a well  used 
guideline  we  are  still  happy  with  it.  In  December  2022  our  cardiology  team  attended  the 
emergency department clinical governance meeting to present data from  referrals.  The data 
showed that patients with referrals with a low heart score did not go on to have investigations 
in  the rapid  access  chest  pain  clinic  and  based  on  this  data the  cardiology  team  confirmed 
that a low heart score did not require a referral to the rapid access chest pain clinic. 

The  attached  cardiac  pathway  shows  that this gentleman  followed  the  low  risk  side  of the 
pathway and was then correctly discharged for management by the general practitioner. 

As  part  of  our  ongoing  governance  and  improvement  cycles,  in  November  2023  the 
Emergency department introduced  a separate unit called  Emergency Assessment Unit.  The 
unit is designed to see the low and medium risk patients that do not need to be on a monitor. 
Trevor Bailey would  have fit into this category.  The patients in this unlt are  rapidly seen and 
assessed.  The  unit  has  improved the waiting  time  for these  patients  and  has  ensured  that 
ECGs can be done in a timely manner. The outcome of the management of the patient would 
be the same in this unit as the HEART score would be the same. 

 The following documents that are the audit presented by cardiology at the clinical governance, 
details about the trust chest pain pathway, details about the new emergency department EAU 
and the mandatory training details for capacity training. 

In  summary,  Mr  Bailey  self-discharged  prior  to  completing  his  clinical  encounter.  He  had 
capacity to make this decision,  and the  ED  registrar provided safety netting  by checking the 
repeat  troponin  result.  At the time of the encounter, and  even  if the additional  unknown  risk 
factors had been factored in, he would not have met the criteria for referral to the rapid  access 
chest pain clinic as  per national scoring.  The Trust has a robust process for evaluating chest 
pain  patients,  including  a  new  EAU  service,  and  currently  follows  the  agreed  pathway 
developed with our cardiology services to refer appropriate patients to the rapid access chest 
pain clinic. 

We hope that this satisfies your concerns in this matter and if there is anything further that 
the Trust can  aid with,  please do let us know and we will be happy to address any further 
issu es. 

Yours sincerely 

Chief Exec utive Officer