Expert Medical Lawyers Investigate Whether More Could Have Been Done To Prevent Sudden Death

An NHS Trust has confirmed that it has revised its ‘Unwell Adult Protocol’ for patients with chest pains to prevent further deaths, after a father-of-three died of a heart attack the day after being discharged from hospital.

Terry Best was pronounced dead shortly after being found unresponsive in his car on 28 November 2013. The previous day, the 46-year-old had seen an Emergency Nurse at Whitworth Community Hospital in Derbyshire after experiencing intermittent regular chest pains for a number of days. 

During an inquest into Terry’s death at Milton Keynes Coroner’s Court in May, where his wife Kerry was represented by medical law experts at Irwin Mitchell, the Coroner concluded that there had been a failure by the Emergency Nurse at Whitworth Hospital to refer Terry for emergency care at an acute medical unit which resulted in a lost opportunity for him to receive necessary treatment.

Shortly after Terry’s death, the Trust commenced a ‘Serious Incident Investigation’ to ensure that any lessons which needed to be addressed were learned. That investigation highlighted that the Trust required more explicit protocols in place to ensure that adults with chest pains were treated appropriately. 

This was then echoed by HM Senior Coroner Mr Osborne, who encouraged that Derbyshire Community Health Services NHS Trust implement a revised ‘Unwell Adult Protocol’ for patients with chest pain to ensure that such patients received emergency care. Terry’s wife Kerry, backed by medical law experts at Irwin Mitchell representing her, have now welcomed confirmation from the Trust that the new protocol is now in place.

However, Irwin Mitchell believes that lessons must be learnt throughout the NHS with the protocol implemented in all community hospitals nationwide, to ensure all patients with chest pains have access to the appropriate treatment as quickly as possible.

Adam Wright, a medical law expert at Irwin Mitchell’s Birmingham office representing Terry’s family, said: “This is a tragic case that has left Kerry struggling to come to terms with the loss of her husband and three children without their dad.

“We are pleased that the Trust has now implemented a revised protocol for adults presenting with chest pains, albeit too late for Terry. We will now continue to investigate on Kerry’s behalf, whether Terry would not have died if he had received emergency treatment. We are also looking to secure the family financial security for the future; given Terry was the main breadwinner.

“The NHS must continually strive to learn lessons from any shortcomings and make improvements to its services as a whole to provide the best possible care. We believe that the revised ‘Unwell Adult Protocol’ should be implemented nationwide, in all Community Hospitals, so that every adult patient with chest pains who might present at such a centre is safeguarded and referred for specialist treatment that could save their life.”

Kerry has told lawyers that Terry, a manager for a large garden centre company, had suffered with high blood pressure and high cholesterol for some time and in November 2013 he began to experience intermittent chest pains, dizziness and pins and needles in his left arm. The chest pains would occur approximately every 30 minutes. 

Terry stopped off at the minor injuries unit at Whitworth Community Hospital on 27 November as he had been experiencing chest pains whilst driving to work at one of the garden centres nearby. 

Despite showing elevated blood pressure, the Emergency Nurse did not have the experience to interpret an ECG heart scan and discharged him 25 minutes later and advising him to attend his GP for a blood pressure check.

Terry was able to make an appointment with his GP for late evening the following day, but a police officer visited Kerry’s home in Mosley, Birmingham, that afternoon to inform her that her husband of 11 years had died shortly after being found slumped in his car outside the garden centre where he was working in Milton Keynes. 

Kerry, 40, mum to two of Terry’s children aged 18 and 11, said: “I knew Terry must be feeling very unwell for him to take himself to hospital as he was never one to make a fuss. I was relieved when he phoned to say he had been seen as I thought at least now he was in safe hands.

“To hear at the inquest that more could have been done to help him was very difficult to comprehend and I’m still struggling to come to terms with it now.

“It gives me some peace of mind to know that the Trust has revised and implemented its protocol, as encouraged by the Coroner, but it won’t bring Terry back. I can’t understand why the Emergency Nurse allowed Terry to go home, it seems like common sense to me, that someone with central chest pains requires urgent treatment. I believe that the Nurse was too reliant on a poorly drafted protocol.

“Terry was so full of life and a devoted husband and father. We are determined to see justice for what has happened and hope that the Trust will now work with our legal team to conclude our case so the children have financial security and we can begin the very long process of rebuilding our lives.”

Read more about Irwin Mitchell's expertise relating to fatal claims and inquests