Lukasz Pastuszak, 28, was taken to Blackpool Victoria Hospital on October 3, 2021 after starting to have chest pain at around 4.30pm that day.
He was placed in a waiting room at A&E and told to alert a staff member if his condition worsened. However, there was no nurse or doctor in the room.
Instead, he informed a passing paramedic, Leanne Cartwright, around 6:10 p.m. that his chest pain was getting worse. She said: “I went to see (the charge nurse)…he checked his name on the computer and said ‘he hasn’t been sorted yet and he will have to wait’.”
Minutes later, another paramedic who was also approached by Lukasz tried to alert the same charge nurse, but said he was “very dismissive”.
About 30 minutes later, Lukasz collapsed in the waiting room and could not be revived. An autopsy revealed the cause of death was hemopericardium – blood in the pericardial sac of the heart – caused by an aneurysm in the aorta, the main artery that pumps blood away from the heart.
Speaking to Lukasz at Blackpool Town Hall today, his partner Patryk Mosiewicz said: “If everything had been done correctly then I truly believe Lukasz would still be alive. Nobody took him seriously. Because he was not listened to, I lost my partner. It’s something I can’t take or accept.
The court heard that on the evening of October 3, paramedic Roberto Zambon was called by Mr Mosiewicz to the couple’s Beach Avenue home. He examined Lukasz and found that his respiratory rate, temperature and blood pressure were all within normal range. An ECG test, which records the heart’s electrical signal to check for different heart conditions, was also normal.
Lukasz was taken to Blackpool Victoria Hospital, where he was placed on the rapid transfer lane which allows paramedics to transfer patients to A&E without personally handing over paperwork or speaking to a triage nurse.
The court heard that patients with chest pain were generally not allowed to be placed in the path, but Mr Zambon said: ‘Because (Lukasz) said the pain was going down, I decided that he met the criteria for a quick transfer. He said it had eased considerably and he didn’t seem to be in pain, so to me he wasn’t someone with intense, crushing chest pain.
At 6.10pm, Lukasz texted Patryk – who hadn’t been allowed to attend A&E with him due to Covid-19 safety measures – that he was still experiencing chest pains and had started disgusting.
He wrote: “I think I’ll die here before I get help.”
He collapsed shortly after.
Dr Jonathan Argall, an emergency medicine consultant who was on call at Blackpool A&E that night, said: Lukasz collapsed on the floor outside the toilets in the waiting room. It was clear he was breathing, he had a pulse but it had turned blue.
“The ECG was extremely abnormal which led me to believe it was a heart attack which surprised me as it is very unusual for a young person to have heart disease and therefore this led me to suspect an aortic dissection (a tear in the main artery) Unfortunately, Lukasz suffered cardiac arrest before we had a chance to investigate further.
He said that once identified, surgery could be undertaken to repair the artery, but “the prognosis is very poor”.
He said he did not believe an earlier ECG test, taken when Lukasz first sought help from paramedics in the waiting room, would have changed the result, as it would have taken around 90 minutes to take Lukasz to intensive care, and he collapsed just 30 minutes later.
He said: “I think it’s unrealistic to expect us to be out of the department in those 30 minutes. He would still have been in that waiting room when he collapsed.”
He added: “This is a very rare event, especially in a young patient. We can find reports of only 27 cases in 15 years, which shows how rare it is.
A review by the hospital after Lukasz’s death found he should not have been placed on the fast track and there was a delay in care following his collapse in A&E.
Matron Tara Hassett said: “We have identified that there was a backlog in triage and initial assessment due to overcapacity in the department. There was a delay in taking an ECG due to this overcapacity. Following Lukasz’s collapse, there was a delay in providing proper care as he was in the waiting room.
“Following the incident, we placed a nurse in the waiting room 24/7 and this is something we have continued on a daily basis.
“If a patient tells him they have chest pain, they will assign a nurse to perform an ECG as soon as possible, otherwise do it themselves.
“All staff have been made aware of Lukasz’s presence in the hospital. From a lessons learned perspective, we have trained our teams.”
Speaking of the charge nurse who dismissed Lukasz’s complaints, she added: “He says he was overwhelmed. He was dealing with an extreme number of patients in a small space and he was trying to do the best he could.
Coroner Victoria Davies said: ‘I understand there are significant pressures on the NHS and there is a need for flexibility. However, my concern is that Lukasz had a quick transfer on the basis that he could raise concerns, and the evidence is that he raised concerns but there was no review or consideration as to whether it was appropriate for him to wait any longer.
However, she said earlier intervention was unlikely to have saved the 28-year-old’s life.
Returning a finding of death by natural causes, she said: ‘I am pleased the Trust has taken action to prevent something like this from happening again.