Prabhabai Cangi

HM Coroner Andrew Walker 
Barnet Coroner's Court 
29 Wood Street 
Barnet 
EN5 4BE 

4 August 2026 

Dear Sir,  

Station/Department/Unit
Headquarters
220 Waterloo Road
London
SE1 8SD

Regulation 28; Prevention of Future Deaths Report (PFD) arising from the inquest into the 
death of Prabhakar CANGI  

Thank you for your Regulation 28 Report dated 5 June 2026, sent to the London Ambulance 
Service NHS Trust (“LAS”), setting out matters of concern arising from the inquest into the 
death of Mrs Cangi. 

We would like to begin by expressing our sincere condolences to Mrs Cangi’s family. 
At the conclusion of the inquest, you identified concerns which may be summarised as 
follows: 

1.  There is no escalation pathway to a specialist doctor when London Ambulance Service 

paramedics need to review ECG traces taken at the scene when they attend.  

2.  A patient with coronary syndrome was not recognised resulting in a late presentation 

myocardial infarction.  

3.  That where the ECG is abnormal, the patient was not advised to show the copy of the 

ECG to their GP (unless the patient is taken to hospital)  

4.  There is no guidance on the photograph of the ECG uploaded to the record of 

attendance being clear and readable.  

We respond to these matters below. 

The Role and Use of ECGs in the Pre-Hospital Setting 

An electrocardiogram (ECG) provides a graphical representation of the electrical activity of the 
heart and may be used to identify a range of cardiac rhythm disturbances and other 
abnormalities. An ECG produces visual wave patterns and these can be interpreted to detect 
abnormal heartbeats (arrhythmias), signs of a heart attack, and coronary heart disease.  

A 12-lead ECG provides an overview of cardiac electrical activity from twelve anatomical 
perspectives. It is an important diagnostic tool which may assist in identifying conditions 
including ST-segment elevation myocardial infarction (STEMI), a form of heart attack. In some 

 
 
 
 
 
 
 
 
 
 
 
 
 
 instances, these findings will prompt direct referral and transfer by LAS clinicians to specialist 
Heart Attack Centres (HACs). 

Training, Guidance, and Clinical Support 

Paramedics are required to complete an approved Bachelor of Science degree prior to 
registration with the Health and Care Professions Council (HCPC). Training in ECG acquisition 
and interpretation is a core component of paramedic education and includes recognition of 
features consistent with myocardial ischaemia and infarction, including STEMI. 

Clinical practice within LAS is supported by national guidance produced by the Joint Royal 
Colleges Ambulance Liaison Committee (JRCALC). This includes guidance on Acute Coronary 
Syndrome (ACS), encompassing conditions such as unstable angina, non-STEMI, and STEMI. 
This guidance highlights that symptoms such as chest pain and breathlessness—including 
when intermittent—may be indicative of ACS. 

LAS provides ongoing training and reinforcement of ECG interpretation through: 

•  The annual Core Skills Refresher (CSR) programme delivered to all frontline clinical 

staff; 

•  A mandatory ECG e-learning package completed by all frontline clinicians; 
•  An ECG interpretation event delivered in April 2025 in conjunction with the Royal 

College of Paramedics; and 

•  Planned inclusion of further ECG-focused training and updated myocardial infarction 

guidance within the 2026–2027 CSR cycle. 

Advanced Paramedic Practitioners (Urgent Care) also undertake Master’s-level education and 
advanced clinical training, further strengthening clinical decision-making capability within the 
service. 

Clinical Decision-Making and Conveyance 

ECG findings form one component of a broader clinical assessment. LAS clinicians are 
required to make holistic decisions based on: 

•  Presenting symptoms (including duration and intermittency); 
•  Clinical observations and examination findings; 
•  Past medical history, including known cardiac conditions; 
•  Available previous clinical records; 
•  The overall clinical condition of the patient; and 
•  The patient’s wishes and consent. 

Under the JRCALC criteria below a patient should be immediately transferred to a specialist 
Heart Attack Centre where the clinical presentation is consistent with ACS: 

•  ST elevation in leads V2–V3 of greater than 1.5mm in women or 2mm in men, or 
•  ST elevation greater than 1mm in two contiguous leads 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 These ECG criteria were not met when Mrs Cangi was attended by the LAS on 7th August 2025 
but were present when she was transferred to hospital on the 12th August 2025.  Where such 
criteria are not met, but clinical features consistent with ACS remain present, patients should 
be conveyed to an Emergency Department for further assessment. 

This guidance is available to all LAS clinicians and is accessible in real time via Trust-issued 
electronic devices. 

In addition, clinicians have access to real-time clinical support. This includes the LAS Clinical 
Hub, which is staffed by experienced Clinical Support Managers, and an on-call clinical advice 
line involving senior paramedics and doctors where escalation is required. In the latter part of 
this year, the LAS is due to commence a trial of ECG transmission to HAC clinicians for 
assistance with interpretation.  This will facilitate early cardiology review and admission to 
specialist units as required. 

During a typical 24-hour period, LAS clinicians record hundreds of ECGs, a significant 
proportion of which demonstrate abnormalities. Many of these reflect known or chronic 
conditions (for example atrial fibrillation), which are often managed in primary care and do not 
in themselves mandate hospital conveyance where consistent with the patient’s established 
diagnosis and absent concerning features.  

Conversely, where ECG abnormalities are new, unexplained, or accompanied by symptoms 
suggestive of acute coronary syndrome, conveyance or onward referral is clearly indicated. 
LAS clinicians are therefore required to apply clinical judgement in interpreting ECG findings 
within the wider clinical context, rather than relying solely on automated ECG interpretation or 
isolated abnormalities. 

Notwithstanding this, LAS recognises the Coroner’s concern and will reinforce existing 
guidance and training, particularly in relation to patients presenting with symptoms suggestive 
of ACS, including where symptoms are intermittent. 

Provision of ECG Copies and Information Sharing 

Where a patient is conveyed to hospital a photograph or digital copy of the ECG is uploaded to 
the electronic Patient Care Record (ePCR); and a paper copy of the ECG is routinely provided to 
the receiving clinician during handover. 

The ePCR is accessible to receiving hospitals across the LAS operational area and is also 
available via the London Care Record, enabling access by other healthcare professionals 
involved in the patient’s care. 

Where a patient is not conveyed to hospital it is standard practice to provide the patient with a 
paper copy of the ECG; and the patient is advised to retain the ECG and present it to any 
healthcare professional with whom they subsequently have contact, such as their General 
Practitioner. In addition to this, following clinical interaction with patients, completed clinical 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 records (which include a photographed copy of the ECG), are uploaded into the London Care 
Record, which is visible to healthcare professionals (including other LAS clinicians) involved in 
the patients care as long as accessed electronically by healthcare professionals. This 
combined standard approach by all LAS clinicians ensures oversight of ECGs and clinical 
records. The Learned Coroner may recall that Mrs Cangi’s grandson gave evidence that the 
paramedic left the family with a copy of the ECG. 

The LAS are also part of the NHS England Single Patient Record (SPR) Programme Clinical 
Reference Group.  The SPR programme aims to create one unified, secure view of a patient’s 
health and care information across NHS services in England. This intends to bring together 
data currently held in multiple systems (e.g. GP, hospital, ambulance, mental health etc.) into a 
single, joined-up record, and is a core part of the NHS 10-year plan. The initial roll-out will 
focus on two identified priority areas (maternity and frailty) before looking to further areas. It is 
intended that the first priorities will go live around 2028.  The LAS remains committed and 
engaged with key stakeholders in technological advances which will improve oversight of 
clinical records and pertinent clinical information.  

Quality and Clarity of ECG Records 

LAS policy requires that all clinical images, including ECG photographs, are relevant, clear, and 
clinically usable. The Trust recognises the importance of ensuring that ECG images recorded 
within the ePCR are consistently clear and readable and will reinforce this requirement with 
staff. 

The Trust is also due to commence a procurement process for new ECG monitoring equipment 
during the 2026–2027 financial year. A key requirement of this procurement is the capability for 
ECG data to be uploaded directly from monitoring equipment into the ePCR, thereby removing 
the need for photographic capture and improving accuracy and quality of records. 

Conclusion and Ongoing Actions 

The LAS has carefully considered the concerns raised in your report and is satisfied that clear 
national guidance exists regarding the management of suspected acute coronary syndromes, 
including when ECG findings necessitate conveyance.  Robust training and clinical support 
mechanisms are in place for ECG interpretation and decision-making; and systems are in 
place to ensure ECG information is recorded, shared, and made available to patients and 
healthcare professionals.  

Notwithstanding this, LAS will reinforce guidance relating to intermittent symptoms and 
potential ACS presentations; re-emphasise best practice regarding provision of ECG copies 
and patient advice; and strengthen messaging regarding the clarity and quality of ECG image 
capture pending implementation of enhanced digital solutions.  Furthermore, an interim review 
of results from ECG transmission to cardiologists is planned once the pilot phase of this 
programme of work is complete.  This will be used to guide and inform future approaches to 
ECG transmission pan London. 

4 

 
 
 
 
 
 
 
 
 
 
 We hope this response is helpful and provides assurance that LAS remains committed to 
continuous improvement and the delivery of safe, high-quality patient care. 

Thank you for bringing these matters to our attention. 

Yours sincerely, 

Chief Executive 

5

Mr Andrew Walker  
HM Senior Coroner  
North London  
Barnet Coroner’s Court  
29 Wood Street 
Barnet  
EN5 4BE 

Dear Mr Walker, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

17th July 2026  

Re: Regulation 28 Report to Prevent Future Deaths – Prabhabai Cangi who 
died on 12 August 2025 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 June 
2026  concerning  the  death  of  Prabhabai  Cangi  on  12  August  2025.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Mrs  Cangi’s  family  and  loved  ones.  NHS  England  is  keen  to 
assure the family and yourself that the concerns raised about Mrs Cangi’s care have 
been listened to and reflected upon.   

Your Report raised concerns around the following:  

1.  The  lack  of  a  clear  pathway  for  interpretation  of  ECG  traces  to  a  specialist 
doctor, when attending paramedics decide, when an ECG trace taken at the 
scene  show  abnormal  automated  interpretations,  not  to  convey  a  patient  to 
hospital.  

2.  The intermittent symptoms of chest pain, breathlessness, abnormal ECG with 
some ST elevation using one or more leads, did not result in the patient being 
taken to the nearest emergency hospital.  

3.  Where an ECG is abnormal, the patient was not advised to show the copy of 

the ECG to their GP.   

4.  That there is no guidance on photograph of the ECG uploaded to the record of 

attendance being clear and readable.  

Having  reviewed  these  concerns,  and  shared  them  with  the  ambulance  team  for 
comment, we consider that they relate to specific operational matters, which are the 
responsibility of the local ambulance service. We note that your report has also been 
addressed to London Ambulance Service, and so we have agreed that they are best 
placed to respond to your concerns.  

We  would  also  refer  the  Coroner  to  the  Joint  Royal  Colleges  Ambulance  Liaison 
Committee (JRCALC) who develop clinical guidelines for UK NHS ambulance service 
paramedics  on  behalf  of  the  Association  of  Ambulance  Chief  Executives  and  are 
working closely alongside National Ambulance Service Medical Directors.  

                                                                                                                       
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Mrs 
Cangi, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director   
NHS England