Coroner slams Dagenham GP practice as man dies of heart attack after surgery fails to call him back

A coroner has strongly criticised a GP practice over the death of a patient whose repeated phone calls complaining of chest pain were not returned.

Keith Smith, 75, died of a heart attack last July after trying for three days to get medical help from Church Elm Lane Medical Practice.

On two of those days the practice said it would call him back, but did not do so.

Coroner Graeme Irvine has now strongly criticised the Dagenham practice for its "chaotic" and "unprofessional" handling of Mr Smith’s calls, in a damning report.

The practice says it has recruited "more qualified staff" following his death, but health and social care regulator the Care Quality Commission (CQC) is investigating whether it needs to take regulatory action.

An inquest carried out by Mr Irvine found Mr Smith died as a result of a heart attack, caused by artery disease.

The grandfather-of-two, who lived with his wife in Western Avenue, began experiencing severe chest pain radiating into this neck in July 2023.

His family says he initially presumed the pain was related to his chronic sciatica.

Mr Smith sought medical treatment from his GP, with phone calls to the surgery’s reception on July 3, 4 and 5, said the coroner.

“The response from the surgery was chaotic and at times the behaviour of those taking telephone calls was unprofessional and inappropriate,” said Mr Irvine in a rare ‘prevention of future deaths’ report issued to the practice. “On 4th and 5th July 2023 Mr Smith was informed that he would receive a GP call-back, on both days that did not occur.”

Mr Smith’s daughter, Karen Smith, told the Standard her father would have visited A&E or a walk-in hub had he been advised to, but said he instead awaited a call-back as per instructions from the GP practice.

She said: “I’m disgusted with the way they treated my dad - we all are. The lack of communication...big, big changes should be made.

“It just seems like they don’t care. They didn’t care. They were complacent.”

She added that she feels GP receptionists should be aware of the lesser-known symptoms of heart attacks, and signpost people who need it to emergency care. On the evening of July 5 Mr Smith’s family, frustrated with the lack of contact, called 111 who diverted the call to 999.

An ambulance rushed to Mr Smith’s home, where paramedics found he was suffering a heart attack.

“Moments later”, Mr Smith lapsed into cardiac arrest. Paramedics tried to revive him, but he was pronounced dead shortly after midnight on July 6.

In a statement to Mr Smith's inquest, his family said: "We will miss our Keith, my husband, our dad, our grandad every day.

"Keith was the biggest part of our lives and his pureness, inspiration and motivation spurred us on with his love and great passion for everything.

"Keith's memory will live forever in our heats and souls for the rest of our lives."A ‘prevention of future deaths’ report is made when coroners believe “there is a risk that future deaths could occur unless action is taken”.

Mr Irvine wrote: “The GP surgery cannot offer persuasive evidence that changes in procedures, staffing and training since Mr Smith’s death have resulted in the improvement of, the recording of patient calls, the escalation of patient enquiries to GPs and the monitoring of GP call-backs to patients.”

When approached by the Standard, a Church Elm Lane Medical Practice spokesperson said: “Mr Smith’s death was a tragedy and our sincere condolences go to his family, friends and loved ones.

“The practice takes on board the Coroner’s comments and has reflected on this incident in great detail to ensure the concerns raised are addressed and acted on as a matter of priority.

“Since this tragic incident the practice has recruited more qualified staff and introduced clear guidelines on appropriate care and escalation of calls for all staff to follow.

“In addition, the practice is undertaking an audit of calls to the practice to assess for appropriate handling and escalation to ensure the matters of concern raised by the Coroner have been appropriately addressed.”

Church Elm Lane Medical Practice was rated ‘good’ in all areas, when it was last inspected by the CQC in 2017.

By chance, on the day of Mr Smith’s death, July 6, 2023, the CQC carried out a review into whether another inspection was needed. It said at the time: “We have not found evidence that we need to reassess the rating at this stage.”

Following the coroner’s criticism, a CQC spokesperson said in a statement to the Standard: “We’re aware of the coroner’s report on the sad death of Keith Smith and our condolences go out to his loved ones.

“We’re currently reviewing the report to determine whether there is any regulatory action we may need to take.

“We also encourage anyone with concerns about a health or social care service to raise these with CQC, through our website, email at enquiries@cqc.org.uk, or phone at 03000 616161. This information helps us decide when and where we inspect.”