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	England and Wales High Court (Queen's Bench Division) Decisions
You are here: BAILII >> Databases >> England and Wales High Court (Queen's Bench Division) Decisions >> Taaffe v East of England Ambulance Service NHS Trust [2012] EWHC 1335 (QB) (18 May 2012) URL: http://www.bailii.org/ew/cases/EWHC/QB/2012/1335.html Cite as: [2012] EWHC 1335 (QB)

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IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION

		Royal Courts of Justice Strand, London, WC2A 2LL
		18 May 2012

SIR ROBERT NELSON :

1. On 25 February 2007 Mrs Eleanor Taaffe experienced chest pains severe enough for her son, Nicolas, to call an ambulance. She had a history of hypertension, a family history of cardiac decease and no pre-existing history of significant indigestion, which was the nature of the pain she described. Her son called an ambulance at 11.46am and this arrived promptly, within 7 minutes of the call. The paramedics found that the indigestion type pain had subsided by the time of their arrival, that Mrs Taaffe appeared very stressed, was a good colour and cold to touch but not sweaty. They carried out two 12 lead ECGs which appeared to them to be normal, though the computer generated report on the face of the printed record of one of the ECGs stated "Abnormal….T-wave abnormality, consider inferior ischaemia".
2. The paramedics did not consider that they needed to advise Mrs Taaffe to attend hospital that day and did not so advise her. They considered it sufficient that she attend an already pre-planned visit to her GP the next day. No diagnosis of Mrs Taaffe's condition was recorded by the paramedics, nor was their reason for not advising her to attend hospital, but they completed the Patient Non Conveyance Form and sent that, together with a copy of one of the ECG printouts, to the GP.
3. The following day, 26 February 2007, Mrs Taaffe attended her GP who examined her and found no cardiac murmur, noted an unspecified anxiety state, prescribed pills for depression and indigestion and considered further review of the cardiac risk.
4. On 2 March 2007, some five days later, Mrs Taaffe, who was fifty years of age, suffered an acute myocardial infarction from which she died that day. The Claimant alleges that the paramedics were negligent in failing to advise Mrs Taaffe that she should have attended hospital on 25 February 2007 to have her condition properly investigated. It is not disputed by the Defendant that if Mrs Taaffe had been admitted to hospital on that day, her condition would have been diagnosed, and she would have avoided the fatal cardiac arrest on 5 March 2007.
5. The central issue on liability is therefore whether the failure to advise Mrs Taaffe to attend hospital was negligent. The Defendant contends that it was not, and asserts that the paramedics acted properly in light of the fact that the digestion type pain had subsided by their arrival, that the Claimant appeared essentially healthy, and that the ECG results reasonably appeared to them to be normal. The circumstances that they faced, the defence contend, were such that whilst some competent and reasonable paramedics in the same situation might have taken the Claimant to hospital, other similarly competent and reasonable paramedics would not have done so.

The Facts

6. Eleanor Taaffe's medical history

Mrs Taaffe had a history of hypertension and high blood pressure. There are readings in the GP's notes between 1999 and her death ranging from 148/88 (27.11.06) to 185/118 (07.09.05). She took home readings of her blood pressure that are set out in the GP's notes, with the average readings being stated as 140/89 on 26 February 2007. On that day, the day after the ambulance had been called to her home because of her chest pains, the GP measured her blood pressure as 177/112. The figures indicate high blood pressure over a number of years. For this condition Mrs Taaffe had been prescribed a drug for its control, Ramipril. None of these readings were as high as those taken by the paramedics on 25 February 2007; the first reading was 200/118 and the second, after Mrs Taaffe had become somewhat less anxious, was 186/121. These, particularly the first, are very markedly elevated.

7. Mrs Taaffe had a family history of ischaemic heart disease. Her father had died of a heart attack when he was in his late thirties, and her mother suffered from ischaemic heart decease. The family history is relevant as to whether Mrs Taffee had inherited a tendency to a cardiac condition.
8. Mrs Taaffe was overweight; her weight was recorded in the GP's notes for 26 February 2007 as 84 kg as against an ideal weight of 57.4 kg. Mr Taffe said in evidence that his wife had put on weight and that she did not like herself for it.
9. The GP's notes reveal a long history of depression and panic attacks, with intermittent anti-depressant medications being prescribed together with referrals for counselling. In October 2006 consideration was given to her going to The Priory for her problems with depression and anxiety, though she did not go.
10. There appear to have been several causes of her stress and anxiety over the years, one or more of which may have been operating at any one time. In outline they were her conscientious and hardworking commitment to her demanding and responsible job, her son's difficult behaviour, her mother's health, her relationship with her husband in general, and his affair with his PA in the 1990s resulting in the birth of a daughter in 1997. Mr Taaffe married the mother of his daughter in November 2007 some eight months after Eleanor Taaffe's death. It emerged in evidence that Leslie, his present wife and former PA, had been made a Director of Mr Taaffe's company in 1995 and was a 50% owner of the company, the Claimant owning the other half.
11. When she saw her GP on 26 February 2007 Mrs Eleanor Taaffe said that her husband had been "awful-stress+++ at home – Nicolas okay – work stress – long commute…." Mr Taaffe said in evidence that his wife had been drinking, a fact borne out by the medical records, and that this had created problems. One did not know where depression came from when someone is drinking, he said, but that there was no issue as far as Leslie was concerned, as that affair had been over since 2000. He said he did not have any other issues with his wife apart from those with his son Nicolas. He said that he was not perhaps as kind in some of the things that he said as he should have been, and was not as understanding as he should have been because of his frustrated concern for his wife. The fact that Mrs Taaffe was stressed and appeared to be having a panic attack on 25 February 2007 is relevant to the issue of liability.
12. The 999 call

There is a transcription of the ambulance call made on 25 February 2007 by Nicolas Taaffe, Eleanor Taaffe's son. The tape was also played in court. Nicolas Taaffe told the ambulance control that his mother was getting pains in the chest, that this was the second or third time that this had happened but that it was a lot worse this time. He had put her so that she was at an angle and had got her knees up. He said that she had got a history of high blood pressure, was not breathing normally but quite heavily, deep heavy breathing "like panic breathing". When asked whether she was changing colour he said that she was slightly whiter than she was, but still had some colour in her cheeks. She was slightly cold and sweaty, not what he would have called cold cold, but sweaty, and her skin was getting whiter. She had not been sick nor was she feeling nauseous. When asked whether she had a history of heart problems he asked his mother that question and she said that she had got a family history and she had a history of high blood pressure. When asked whether she had taken any drugs or medication in the last 12 hours he asked his mother who replied "Ramipril".

13. Paramedics are not given the actual text of such a conversation but some or all of the information from it by the ambulance control. In this case they were told that the patient had pain in the chest, that the son was on the scene of entry, and that the patient had high blood pressure. It is agreed by the experts that paramedics must always take a proper history for themselves when seeing the patient.
14. The paramedics arrival

The callout to the paramedics, Janet McCord and Martyn Scoffin, was category A, which meant that the condition was to be considered as life threatening. On their arrival at the house the paramedics noted that Mrs Taaffe was very stressed and upset. Mrs Taaffe told Mrs McCord, who took the history as she was the senior paramedic, that she was having marriage problems which she did not think could easily be resolved. She described having had an indigestion type pain which had now gone. Mrs McCord said that Mrs Taaffe looked well, was cold but a normal colour, and did not "look cardiac". When asked by her, Mrs Taaffe said that she had experienced no nausea or vomiting, that there was no constriction of her chest, and that there was no referred pain.

15. Mrs McCord found that Mrs Taaffe's respiratory rate was high, but reduced when she had calmed her. Her blood pressure at first reading was 200/118 and was later recorded as 186/121, which in her statement Mrs McCord describes as being "still slightly elevated".
16. When she had calmed down, two 3 lead ECGs, together with two 12 lead ECGs were carried out. The two 12 lead ECGs were, as the experts agree, essentially identical, though the computer generated printed report which each of these ECGs bore, differed. The first stated "Normal ECG, Normal Sinus Rhythm" and the second reported as "Abnormal ECG, T-Wave abnormalities, consider inferior ischaemia". The paramedics had been trained to disregard the computer generated printed report on the ECGs as these could be unreliable. They were trained to look at the actual ECG trace and form their own opinion on the basis of such traces, looking in particular for ST wave elevation which if present would indicate a myocardial infarction.
17. There was no ST elevation and the paramedics concluded that the ECGs were normal. In fact neither of the 12 lead ECGs were normal but showed subtle signs suggestive of inferior myocardial ischaemia. Both experts, Dr Fionna Moore, on behalf of the Claimant and Dr Michael Ward, on behalf of the Defendant, agreed that paramedics may not, at that time, have been trained to recognise these subtle abnormalities and cannot therefore be criticised for failing to do so. They should however have appreciated that the absence of ST wave elevation does not rule out a coronary event. This is confirmed in the Ambulance Service Guidelines 2006 and is something that the paramedics should have been aware of. Mrs McCord said in evidence that on walking in Mrs Taaffe appeared to her to be having a panic attack, but that they had to rule out cardiac and that is why they did an ECG.
18. The paramedics found that there was no problem with Mrs Taaffe's airways, her breathing or circulation and that there was no "red flag" apart from her blood pressure. Mrs McCord said that she did not think it was a cardiac case, but a panic attack and her decision was that Mrs Taaffe did not need to go to hospital. As a consequence the paramedics did not advise her that she should go to hospital but asked her whether she wanted to go. Mrs Taaffe preferred not to, but instead to keep the appointment which had already been made with her GP the following day, which the paramedics considered satisfactory. Mr Taaffe said in evidence that had the paramedics advised Mrs Taaffe to attend hospital he would have ensured that she did so and she would have done.
19. Where a decision not to transport to hospital for further assessment was made that decision should be fully justified by the paramedics and the clinical reasoning behind the decision documented in accordance with the Defendant's 2002 Guidelines relating to transportation to hospital. The Guidelines applicable in this case were not mandatory but laid down good practice.
20. The paramedics did not record their diagnosis of Mrs Taaffe's condition, nor set out their clinical reasoning for not advising her to attend hospital. What they did in fact do was to complete the Patient Non Conveyance Form. The observations as to respiratory rate, pulse, blood pressure, Glasgow coma score (normal), ECG and BM level were recorded. Under History/Additional Information the following was set out:-

"PT called out today with indigestion type P. On arrival P had subsided – PT appeared very stressed and stated she is very stressed, PT was a good colour – cold to touch not sweaty. PT does not want to go to hospital but will see GP tomorrow. PT has family at home and is going to get breakfast as B.M low".

21. The form also records the fact that Mrs Taaffe was told by the paramedics that if her symptoms returned she should not hesitate to redial 999. It is also recorded that the paramedics would forward to the GP a copy of the treatment referral form, which they did. One of the ECG reports was sent to the GP, apparently with Mrs Taaffe. It appears that it was the one which recorded normal ECG, normal sinus rhythm rather than the one which recorded abnormality as the experts' opinion is that if the latter had been sent to the GP it would have featured in the GP's notes which it does not.
22. Neither the Patient Non Conveyance Form nor the witness statements from the paramedics indicate that they elicited from Mrs Taaffe that she had experienced earlier chest pain on one or two occasions but that her present pain was worse, that she had been lying on her side with her knees up, that she had been sweating, that she had been pale, that she had taken her drug for hypertension within the last 12 hours, that her family history included her father dying of heart disease in his thirties and her mother having ischaemic heart disease, or that she had no significant history of indigestion.
23. Mrs McCord thought that she asked Mrs Taaffe when the onset of her pain was and how long it lasted but she did not record either of these matters. She was not told about the previous chest pain or how Mrs Taaffe had been lying with her knees up to deal with it even though her son had told the call centre of these matters. She thought she had probably asked whether Mrs Taaffe had been sweating but does not record that in either the form or her witness statement. She did not know whether she had asked if Mrs Taaffe had been pale when experiencing chest pains, as had been reported to the call centre, and she did not ask her if she had taken her medication for her blood pressure. As to the family history she said that she is sure she would have asked but could not recall the answer. She agreed though that the family history was relevant and one of the factors she would take into account. When Mrs Taaffe told her that the pain was indigestion type pain, Mrs McCord said that she thought that Mrs Taaffe was old enough to work out what was indigestion, but did not recall if she had asked her whether she had problems with indigestion before.
24. Both experts agreed that the duty of the paramedic was to consider not just one factor such as the ECG but to look at the whole picture. Mrs McCord was asked in cross-examination whether on the whole of the history, including the previous attacks of pain with this one being a lot worse, the lack of history of indigestion, and the family history, she could exclude a cardiac event. She said she could not but Mrs Taaffe exhibited classic signs of a panic attack and the pain had gone. She therefore thought that Mrs Taaffe was having a panic attack.
25. The visit to the GP the following day

The GP's notes of this visit are as follows:-

"Anxiety state unspecified…had scare yesterday – paramedic called?? anginal attack – been getting cold feeling upper chest – worse bout yesterday – and felt worse – and has FH (family history) father in 50's and mother too – has never smoked herself – seen but ok - ? ? panic – been drinking alcohol to self medicate – husband been awful – stress +++ at home – Nicolas ok – Nicolas ok – work stress – long commute sleep and mood poor – anhedonia omeprazole Capsules (Gastro – Resisted …"

Her weight was recorded as 83 kg, her pulse 100/minute, her pulse rhythm regular, her blood pressure 177/112 and her heart sounds normal.

26. The GP was aware of the family history, previous anxiety, depression and panic attacks. She appears to have considered stress related factors to have been important, prescribed pills for depression, suggested a counsellor, prescribed omeprazole and suggested reconsideration of cardiac risk factors.
27. Mrs Taaffe was not complaining of chest pain when she saw her doctor and the GP's notes revealed the fact that the GP had one of the printed records of the ECGs, probably the one which stated that the ECG was normal and the sinus rhythm normal. The GP did not refer Mrs Taaffe to hospital, or to a rapid access chest clinic.
28. The Expert evidence

Both experts, Dr Moore and Dr Ward, have a high level of expertise in the work of the ambulance service. Dr Moore is the current medical director of the London Ambulance Service NHS Trust, a consultant in Emergency Medicine and a lecturer at Imperial College. Dr Ward is the retired medical director of the Oxfordshire Ambulance NHS Trust and a retired consultant anaesthetist. He also has lectured at Oxford and King's College London. Their conclusions on this case differed significantly though Dr Ward became more diffident in his support of the paramedics' failure to advise Mrs Taaffe to go to hospital because of their apparent failure to elicit and consider the relevant family history relating to her parents.

29. Dr Moore expressed the clear and consistent view that the combination of a history of chest pain in a middle-aged woman with no previous history of indigestion, but with hypertension indicated that ischaemic heart disease could not be ruled out and that Mrs Taaffe should have been strongly advised to go to hospital. It was her view that the hypertension alone would justify referral to a GP and when combined with chest pain justified assessment in hospital. She agreed that the task facing the paramedics was difficult but it was because such decisions can be difficult that there is a low threshold of suspicion requiring admission to hospital. It is only in a hospital that the necessary serial ECGs can be performed. Both experts agreed the fact that no ST wave elevation was present on the ECGs did not and could not rule out a coronary event. A normal ECG did not exclude acute coronary syndrome as research had shown that up to 50% of patients may have a normal ECG after an acute coronary event, and 10% remain normal throughout. Dr Moore said that whilst one should look at the ECG and not at the computer print out of the report, an abnormality recorded on the report was a prompt, a factor which needed to be borne in mind. Dr Ward did not dissent from this view, stating that whilst the algorithms may be mistaken the safe way is to exercise caution.
30. Dr Moore said that a cardiac event cannot be excluded from what the patient looks like; it is necessary to look at the whole picture. Dr Ward agreed that clinical examination is not necessarily very helpful. It was the signs, symptoms and conversation that went into making the diagnosis.
31. Dr Moore expressed doubts about Mrs McCord's knowledge of the signs from an ECG and whether a full history had been taken from the patient. Dr Moore said that she was surprised if the family history was taken, that it did not ring alarm bells, particularly with one parent dying so young.
32. Dr Moore said that the information available to the paramedic did not enable a coronary event to be excluded. The paramedics' failure to advise that Mrs Taaffe should attend hospital was not a reasonable decision; and was not within the reasonable range of responses for paramedics. Whilst this was not a classic infarction the paramedics could not rule out a coronary event.
33. Dr Moore considered that the referral to the GP the following day was inappropriate. The GP was seeing the patient when Mrs Taaffe did not have any chest pain. The GP was looking at the long-term risk and was not faced with the acute circumstances of the callout which the paramedics had had. The GP also had the knowledge that the paramedics had decided not to send Mrs Taaffe to hospital. Dr Moore expressed the view that what the GP did the next day was irrelevant. If there was no significant history of indigestion as appeared to be the case, that would be a concern.
34. Doctor Ward said that in his opinion the paramedics had made a proper assessment of the patient, using their experience and knowledge. The absence of pain by the time of their arrival reduced the chances of it being a cardiac arrest. In his report, Dr Ward stated that the attending paramedic took the history he believed he needed in order to make a diagnosis and that it would not be normal for an ambulance attendant to take a family history. In his evidence, Dr Ward stated that his report should read that it would not be normal for an ambulance attendant to take a full family history and conceded that the paramedics should have asked whether there was any family history of heart disease. Such family history, for example relating to the father, was relevant as to whether Mrs Taaffe had inherited a tendency to a cardiac condition.
35. In re-examination, when asked whether his opinion would alter if no family history was asked about, or volunteered he said that he would find it difficult for the paramedics not to have asked, but if they didn't it might alter his support for them but not to an overwhelming extent. He added that it was only one factor and would not tip the balance as what was far more important was what they found when they got there. Dr Ward clearly found this question in re-examination difficult to answer as he paused before doing so.
36. In his report he also stated that from the information recorded on the Patient Non Conveyance Report it was his view that an adequate history was taken which allowed the paramedics to arrive at a diagnosis. He conceded in cross examination however that the Patient Non Conveyance form contained no clinical reasoning nor any diagnosis, which the Defendant's own guidelines required.
37. Dr Ward said in evidence that the presentation of the patient's own account as to the nature of the pain, the place of the pain, the degree of pain and its duration, were the most important. Here the patient had described going through a stressful experience and had talked in a logical and systematic fashion as to what had happened in her life. That fact, and the absence of pain or sweating on the paramedics' arrival, together with the fact that she could be talked down into a more placid state were all relevant. The paramedics' view that she was suffering a panic attack and did not need to be advised to attend hospital was within the range of reasonable responses for a properly trained paramedic.
38. An indigestion type pain is compatible with cardiac infarction Dr Ward said and the fact that Mrs Taaffe was cold to touch was also consistent. Sweating did not only mean cardiac it could relate to agitation or anxiety. Nevertheless, if an acute ischaemic episode had occurred it had largely gone by the time that the crew arrived. They made a proper assessment to the standard expected of their training. Dr Ward states in his report that the blood pressure was still above normal but the patient was a known hypertensive on treatment. He makes no reference in his report of the significance of the blood pressure readings or hypertension to the risk of a cardiac cause of the chest pain. In his evidence however Dr Ward said that hypertension was a pre-existing problem here, that her blood pressure was significantly raised to 200/118 and that this was a cause for concern. Hypertension had to be treated because it was a cause of cardiovascular, or cerebrovascular or renal disease.
39. Dr Ward confirmed that a normal ECG does not rule out acute coronary disorder and that if the paramedics thought that it did, they were misguided. A significant proportion of myocardial infarctions do not have abnormal ECGs.
40. The computer generated reports on the ECG are often designed to fail safe. Whilst generally they are helpful, they all carry warnings that they are not always 100% accurate and require manual interpretation. The safe way, Dr Ward said in evidence is to exercise caution.
41. Although the ECGs did in fact show a T wave abnormality paramedics are not trained to read abnormal T waves. The paramedics were required to look at the whole picture. They did so, Dr Ward said, and were sufficiently clear in believing that Mrs Taaffe was not cardiac. On what they saw and what they found, Dr Ward said, that was a reasonable conclusion. Dr Ward accepted that the GP was in a different situation as she was carrying out a routine and previously arranged appointment. She also had the view of the paramedics that Mrs Taaffe did not need to go to hospital the previous day and it was reasonable for her to take that into account. Nevertheless the GP did examine Mrs Taaffe and asked her about what had happened the day before. Although it is probable that she did not see the ECG that recorded an abnormality on its face, she did not rule out ischaemic heart disease and considered further investigation over longer periods. The GP did not however feel it appropriate to send her to hospital.
42. Dr Ward expressed the view that if a cardiac condition was only an outside possibility it would cause the patient further stress to inform the patient that this is what they considered. If a cardiac condition was suspected but the paramedics were not sure, it would be a reasonable thing to do to send her to hospital if they were not harming the patient in doing so. There was no point in causing unnecessary stress here where the paramedic reasonably considered that the condition was not cardiac. Mrs Taaffe, or her son on her behalf, called the ambulance because it was thought she may be having a heart attack so she would not have been surprised if she had been advised to go to hospital.
43. Dr Ward accepted in evidence that it could now be supposed, with the benefit of hindsight, that the panic attack diagnosis was wrong. In fact the report from Dr Charles Pumphrey, the consultant cardiologist expressed the view that it was probable that Mrs Taaffe's heart attack began on 25 February given the appearances of fibrosis on the autopsy.

The Submissions on Liability

44. I have been greatly assisted by the skeleton openings, the written closing submissions and the oral closing submissions.
45. The Defendant submitted that the paramedics had a difficult task as was conceded by Dr Moore. On the one hand they had a patient with chest pain and some of the other potential symptoms of an acute coronary syndrome whereas on the other hand many of the main potential indicators of ACS were missing. Thus there was no nausea, vomiting, referred pain, constricted chest, arrhythmia, no ST wave elevation, no feeling of impending doom, an absence of pain on their arrival and no pallor or sweating by the time they arrived.
46. Indeed Mrs Taaffe was stressed, said that she was, was a good colour and produced a normal ECG. She did not wish to go to hospital which is itself relevant to the severity and duration of her pain as she surely would have gone if she thought she had been having a heart attack. Instead she was content to remain at home, and wanted to see her GP as already arranged.
47. The court must avoid hindsight Mr Piper on behalf of the Defendant submitted, and when judged objectively as it should be, it simply could not be said that no reasonable paramedic would have acted as these paramedics did. It was therefore a classic Bolam scenario in the sense that there was, on Dr Ward's evidence, a responsible body of paramedics who would have acted as these paramedics did, even if there were also responsible paramedics who would have advised her to go to hospital. Bolam -v- Friern Hospital Management Committee 1957 1WLR 583,587.
48. As the Claimant was well, apart from being stressed and breathing rapidly which was soon resolved when she was calmed by the crew, was asymptomatic on examination and had none of the classic signs of cardiac presentation and simply did not look like a cardiac case, referral to her GP was perfectly proper in the circumstances and would have been advised by some competent paramedics. The court cannot on the evidence conclude, Mr Piper submits, that no reasonable paramedic could have reached the view that these paramedics did in the circumstances. The claim cannot therefore succeed.
49. As to the role of the GP, Mr Piper made it clear in his oral submissions that he was not seeking to suggest that the visit to the GP broke the chain of causation. What he was submitting was that this visit was relevant in two respects. Firstly it showed that a safeguard had been put in place by the paramedics, who had also ensured that the Patient Non Conveyance form and one of the ECG reports was sent to her, and secondly it demonstrated the reasonableness of the paramedics decision, as the GP was presented with the same patient, the same history and decided not to transfer her to hospital.
50. The Claimant submitted that the guidelines show that there should be a high index of suspicion that any chest pain is cardiac in origin because of the potentially fatal consequences of untreated heart decease. Mrs Taaffe had severe indigestion type chest pain, with no history of indigestion, but hypertension and the strong family history of heart disease. She should in these circumstances have been taken to hospital for further assessment.
51. The paramedics, Claire Toogood on behalf of the Claimants submitted, failed to take an adequate history. Their notes on the Patient Non Conveyance form were woefully inadequate, they did not ascertain that Mrs Taaffe had been suffering from chest pain before but this time it was a lot worse. Or that she was lying at an angle with her knees up, or that she had been sweaty and turned pale, or that she had no history of indigestion, or that her father had died of a heart attack at a young age and her mother had also suffered from ischaemic heart disease. Miss Toogood submitted that the paramedics failed to give proper weight to the history that they did in fact obtain and came to the conclusion that Mrs Taaffe was suffering from a panic attack on inadequate evidence. A panic attack was a non-specific diagnosis and consistent with a cardiac problem as the experts agreed.
52. No account was taken of the ECG that recorded abnormality. Mrs McCord did not appear to be aware of the link between indigestion type pain and myocardial infarction, which both the experts said existed, nor did she give the impression initially in her evidence that she knew of the relevance of high blood pressure to cardiac disease. Mrs McCord and Mr Scoffin both stated that Mrs Taaffe had not taken her medication for high blood pressure yet Mrs Taaffe had said a few minutes earlier to call control that she had in fact taken Ramipril in the last 12 hours. Missing one dose would in any event not explain the very high reading. It is probable that Mrs McCord did not ask about the family history of heart disease even though she said she hoped she would have done. It is highly unlikely that Mrs Taaffe would not have told Mrs McCord of her father's death and mother's illness, if asked, when she had said that she had a family history of heart disease to the call centre only a short while earlier.
53. The paramedics failed to take account of the advice in the guidelines that the absence of ST wave elevation on the ECG did not exclude ACS.
54. As to the visit to the GP Miss Toogood submitted that this was of limited assistance on the issue of liability because the circumstances were inevitably different. It was a routine appointment when there was no longer a complaint of chest pain. The GP was aware that the paramedics had diagnosed a panic attack and considered that Mrs Taaffe did not need to go to hospital. The GP probably did not receive the report which showed abnormality and given the history of anxiety and depression the GP would have been more likely to agree with the paramedics' diagnosis of a panic attack. The visit to the GP was neither a safeguard nor a test of the reasonableness of the paramedics own decision and diagnosis in different circumstances.
55. The paramedics should have concluded that Mrs Taaffe's chest pain may have been cardiac in origin and as they could not exclude that, have advised further assessment in hospital. Had they done so, her death at the age of 50 would, on the evidence, have been prevented.
56. Liability

When the paramedics observed and examined Mrs Taaffe they knew that she had experienced chest pain sufficiently serious for her son to summon an ambulance. The Guidelines 2006 and their training required them to have a high index of suspicion that any chest pain was cardiac in origin. They must therefore carefully assess the signs and symptoms and the ECG. Some decisions will be easy, where the signs are of a classic infarction, and others will be more difficult where the signs and symptoms are not all present, and are less clear. The fact that the judgement may be difficult in some cases does not mean that whichever the decision the paramedic reaches in such a case is bound to be reasonable. Each case must be judged upon its own individual facts and the expert medical evidence before the court. In considering the facts and such medical evidence however the court must, as Mr Piper rightly submitted, avoid using the benefit of hindsight.

57. Mrs Taaffe did not present as a classic cardiac infarction case; some of the classic signs were absent and some were present. Thus the pain had subsided by the time the paramedics arrived, Mrs Taaffe was a normal colour, had no nausea nor vomiting, no referred pain, no constriction of the chest, no arrhythmia and no sense of impending doom.
58. She had however had recent serious chest pain of an indigestion type, was cold, and had marked raised blood pressure. She was extremely anxious and stressed, and breathing rapidly as if having a panic attack. The paramedics had also been informed that Mrs Taaffe had a history of hypertension.
59. It was Dr Moore's opinion that on the facts known to the paramedics they should have strongly advised Mrs Taaffe to go to hospital for further assessment. The history of chest pain in a middle aged woman with no previous history of significant indigestion, and was hypertensive was sufficient. In her opinion the hypertension alone was sufficient alone to justify referral to a GP, but with chest pain merited assessment in hospital. Although Dr Ward did not express any view in his written report about the significance of the blood pressure and hypertension save to say that the blood pressure was above normal, but the patient was a known hypertensive, he agreed in cross-examination that hypertension was a pre-existing problem here and the fact that the blood pressure was significantly raised at 200/118 was a cause for concern. He accepted that hypertension was treated because, amongst other conditions, it was a cause of cardio vascular disease. He nevertheless maintained his view that the paramedics' decision not to advise Mrs Taaffe to go to hospital was within the range of reasonable responses.
60. It is not however necessary, nor appropriate for the court to decide upon the issue of liability based solely upon that which was known to paramedics. One of their duties was to ascertain a proper history from the patient so that they could make an assessment based upon the whole picture. This I am clear they did not do. The history taken was inadequate. It did not reveal the fact that the Claimant had had chest pains on one or two occasions before but that this was the worst. The level of pain was such that her son had put her in a position so that she was at an angle with her knees up, giving the impression of being doubled up with pain. As this information had been given to the call centre only minutes earlier the overwhelming probability is that it would have been given to the paramedics had they asked about it as they should have done. As Dr Ward said in re-examination the most important part of the presentation is the patient's own account as to the nature, place, degree and duration of the pain.

Had the paramedics asked the appropriate questions they would have also ascertained that shortly before their arrival Mrs Taaffe had been paler than she had been, with her skin getting whiter. The paramedics found on examination that she was cold but did not ascertain from her or her son that she had also been sweaty as he had described to the call centre. The Guidelines of 2006 made it clear that one of the signs which is "strongly indicative of cardiac origin" in association with chest pain, is sweating. Furthermore a typical presentation of myocardial infarction can be a patient who is pale with cold sweaty extremities. (Non-Traumatic Chest Pain/discomfort - Associated signs and symptoms… Guidelines October 2006).

61. When Mrs Taaffe described her pain to the paramedics as "indigestion type pain" Mrs McCord said in evidence that she thought that Mrs Taaffe was old enough to work out that that's what it was. She could not take every patient to hospital with indigestion. There are two difficulties in this evidence. Firstly, indigestion type pain may itself be experienced by some patients with myocardial infarction (Guidelines 2006 and Dr Moore's evidence). Such pain cannot therefore in itself rule out a cardiac event. Secondly, Mr Scoffin said in evidence that Mrs Taaffe thought she was having a heart attack although he and Mrs McCord did not think the signs and symptoms were cardiac. Thirdly, the evidence shows that although there was some evidence of previous indigestion, and that the GP prescribed medication for indigestion the following day, there was no evidence of significant indigestion. Nor had Mrs Taaffe eaten anything before the paramedics arrived. These matters suggest that the paramedics' assessment of the pain was not as thoughtful or as careful as it should have been in ascertaining the nature of the pain or its potential significance.
62. Whilst Mrs McCord said that she hoped she would have asked Mrs Taaffe whether there was any family history of heart disease she could not guarantee that she did. I am satisfied that she did not ask. Had she done so it is inevitable that the coherent account which was given my Mrs Taaffe's son Nicolas and her own answers to the call centre would have included what she told them only minutes earlier. When asked whether she had a history of heart problems she specifically replied that she had got family history. This indicated her own consciousness of that history and its potential relevance to her. It was on its face a significant history, with her father dying young and her mother having ischaemic heart disease. A failure to ask about that family history might, Dr Ward said, alter his support for the paramedics though it would not tip the balance as it was only one factor. Dr Moore regarded the family history and hypertension as being a fairly full flush of factors.
63. The experts both agreed that the ECGs were effectively identical even though the machine picked up a difference between the two in that one bore the computer printout that the ECG was normal and the other bore the printout that it was abnormal. The ECGs were more important than the computer printouts and it was the ECGs which had to be looked at not the computer records. Dr Moore however regarded the abnormal record as a prompt, a factor which the paramedics would need to bear in mind and Dr Ward said that whilst such reports could be mistaken the safe way was to exercise caution where a printout stated there was abnormality.
64. Both experts also agreed that a normal ECG did not rule out acute coronary disease and Dr Ward said that if they thought that it did, the paramedics were misguided. Mrs McCord said that she now knew that the absence of ST wave elevation did not rule out infarction but could not remember whether she would have known it then. Mr Scoffin said that he was not aware that the absence of ST wave elevation did not rule out acute coronary syndrome and considered that if there was a normal ECG chest pain was more likely not to be cardiac. They both said that they were effectively trained to ignore the computer printouts.
65. Upon the basis of the evidence of both experts I am satisfied that the printout of "abnormal ECG" should not have been ignored, but, whilst less important than the reading of the ECG itself, should have been a factor to take into account, or a reason for exercising caution when reviewing all of the information available on the patient's presentation and the observations on examination. I am satisfied that the paramedics gave no weight to the computer printout stating abnormal ECG. I am also satisfied that the paramedics treated the absence of ST wave elevation as ruling out cardiac infarction when it did not do so. It is not clear whether this failure was due to inadequate training or a failure properly to follow adequate training.
66. A further feature of Mrs McCord's evidence which gave concern as to her training was her initial statement in evidence that she did not know why she had been told that Mrs Taaffe had high blood pressure as she did not know what that meant or the significance of that information. She did later agree that as high blood pressure was a factor in heart disease and stroke it was relevant for her to have been told.
67. I conclude therefore that the evidence establishes a failure to take a proper history, a failure to make a proper assessment of the symptoms and signs they did find, insufficient training or knowledge of the potential consequences of high blood pressure, insufficient training or knowledge of the fact that the absence of ST wave elevation did not rule out acute cardiac syndrome with consequent over reliance on the ECGs, and insufficient training or knowledge of the need to at least consider as a factor, the existence of an abnormal computer reading on one of the ECGs.
68. On the basis of such findings, can a Bolam argument be sustained? I find that it cannot. The argument that in these circumstances the paramedics in this case did what a reasonable body of competent paramedics would have done in the circumstances is unsustainable. Dr Ward in any event had his doubts about whether he could maintain his support for the paramedics when he discovered that they had or may not have elicited the family history even though in the end he said that that would not tip the balance.
69. The difficulty for Dr Ward's position in maintaining that the paramedics' view was within the range of responsible responses is that it paid insufficient account to his own evidence that it was essential for a paramedic to look at the full picture. Clearly this could not be done if the paramedic takes an inadequate history and does not have the full picture available to him or her when making his or her decision. The suggestion that even if the paramedics had had all the information which was available to them but which they did not obtain, they should not necessarily have advised Mrs Taaffe to go to hospital, as not all reasonable paramedics would have done so in the circumstances, is a very difficult argument to sustain given that Dr Ward conceded in evidence (though not in his report) that the markedly high blood pressure on the day and the history of hypertension for years were risk factors which caused concern where chest pain had occurred. When one adds to that the initial uncertainty of Mrs McCord as to the significance of raised blood pressure and hypertension the proposition is even more difficult to sustain. Furthermore the argument cannot in my judgment stand when there has been a failure to appreciate that the absence of ST wave elevation does not rule out acute coronary syndrome. It is probable that this erroneous belief held by the paramedics permitted them to take too much account of their view that Mrs Taaffe simply did not "look cardiac" when they should have appreciated that such an observation may be misleading. The diagnosis of panic attack was too readily reached without any apparent appreciation of the fact that a state of panic may well be present in ACS.
70. I do not consider that Dr Ward's support, as he put it, for the paramedics was either reasonable in the circumstances nor consistent with the need to look at all relevant information in making the decision, nor logical. Thus, in accordance with the decision in Bolitho and City and Hackney Health Authority 1998 AC 232 I am not satisfied that a defensible expert conclusion has been reached on this matter.
71. In any event I found Dr Moore's evidence consistent and compelling and preferable to that of Dr Ward's evidence. Although the paramedics' task was a difficult one, as no doubt it often is, when all the information which should have been available to them was considered it could not properly be concluded that Mrs Taaffe's chest pain was not cardiac in origin; the information properly available to them did not permit that to be safely or properly excluded. I accept Dr Moore's evidence that the paramedics, on the facts of this case, should have strongly advised Mrs Taaffe to attend hospital for further assessment and I find that had she be given such advice she would have accepted it and attended hospital. Had she done so the evidence demonstrates on the balance of probabilities that her condition would then have been treated and her life saved.
72. I have given careful consideration to the significance of the visit to the GP the following day. Mr Piper did not submit that this broke the chain of causation but submitted that it amounted to a safeguard put in place by the paramedics, and demonstrated, as the GP was presented with the same patient with the same history and did not advise transfer to hospital, that the paramedics' decision was reasonable. I do not accept these submissions. The visit to the GP was unlikely to provide a safeguard to the Claimant and does not assist in determining the reasonableness of the decision made by the paramedics. The GP's examination was in very different circumstances. It was the day following the ambulance callout; Mrs Taaffe had no chest pain or immediately recent chest pain when she saw the GP; nor any other symptoms or immediately recent symptoms of a heart problem such as being cold, being whiter, and being sweaty; nor was she saying to the GP as she was to Mr Scoffin, that she thought she was having a heart attack. Mrs Taaffe was attending her GP on a previously arranged routine appointment not in a crisis as she had been when the ambulance was called. It is probable that the GP did not have the ECG report which showed abnormality. The GP was also aware that the paramedics had diagnosed a panic attack and considered that Mrs Taaffe did not need to go to hospital. It is likely, given the history of anxiety and depression of which the GP was fully aware, that she would be more likely to agree with the paramedics' diagnosis of a panic attack. The GP was already aware of the family history, but having found no signs of abnormality on her examination simply considered further investigation of Mrs Taaffe's cardiac condition.
73. In these circumstances I consider it unsurprising that the GP came to the conclusions that she did on her examination, and that her prospective examination could not have been, nor properly have been seen to be, a true safeguard for someone showing the signs and symptoms which Mrs Taaffe was when examined by the paramedics compared with what was likely to be facing her GP if the crisis had by then apparently safely passed. It was when Mrs Taaffe was in the crisis that led to the calling of the ambulance, and had the signs and symptoms she had when she was examined by the paramedics that the need to send her to hospital for further assessment arose, and should have been taken.
74. I therefore conclude that on this occasion the paramedics' care fell below the standard expected of the reasonably competent paramedic, and was accordingly negligent. It is clear on the evidence, and is not disputed that had Mrs Taaffe been advised to attend hospital as she should have been, she would have been examined, tested, and her true condition established.
75. Quantum

There is considerable agreement between the parties as to life expectancy, multipliers and individual heads of damage. There are however significant issues relating to the prospects of the marriage failing and the consequences of that upon the claim, and the true financial situation of the Claimant.

76. The Claimant and the deceased married in 1987. It was the second marriage for both of them. They had one son, Nicolas who was born on 15 August 1998 and who no longer sees his father.
77. The deceased worked for Lonza Biologics in Slough. She had been extremely successful in her job having been promoted in 2004 to Head of Quality Control for the whole of the UK. She worked extremely hard, long hours and found the commute to Slough stressful. Her salary at the date of death was £64,000 gross per annum. The Claimant owned and ran a company overhauling and repairing gas turbine engines, called Aviation Turbine Services.
78. The respective working hours of the Claimant and of the deceased were very different. The deceased set off early in the morning and returned in the early evening whereas the Claimant, because of the need to fit in with the working hours of foreign corporations, did not leave for work until about midday and returned late in the evening. In 1992 Leslie Zobiah became the Claimant's PA. In 1995 she became a Director of the Claimant's company and an affair commenced between them some months after that. A daughter was born of this affair in 1997.
79. Mr Taaffe said in evidence that the affair ended in 2000. He told his wife about the affair and about his daughter and said that the affair had ended. Leslie carried on in the company and the Claimant supported his daughter by that union both financially, and through seeing her, on an occasional basis in the school holidays, sometimes rather more often. It was only revealed in evidence that Leslie was the only other co-Director with the Claimant, that she had put her property up as surety for the purchase of industrial premises for the company, and that she continued to work with the Claimant after the affair had been revealed.
80. The Claimant said that he saw his daughter only occasionally at his office but that also his son Nicolas got on very well with Leslie's children whose son was his best friend. The Defendant submitted that it was clear that Mr Taaffe saw his daughter more often than he was prepared to admit. Mr Taaffe and Leslie married in November 2007, some nine months after the death of Eleanor Taaffe.
81. Mr Taaffe said in evidence that his son Nicolas supported the marriage to Leslie but after his mother's death Nicolas's relationship with the Claimant broke down and they were no longer in contact. There had been a very difficult period, Mr Taaffe said, when his son had been encouraged by his late mother's sister to ask for more money from the Claimant, and the fact that he did not provide this caused friction. Eventually the Claimant's house where Nicolas was living was "trashed" by him, Mr Taaffe said.
82. There is no doubt that one of the causes of stress to the deceased was her relationship with the Claimant. Mr Taaffe said that shortly prior to her death this had been due to his frustrated concern about her drinking, together with the issues that had arisen over problems with their son Nicolas for many years. His affair with Leslie and his continuing working relationship with her were, he said, not a cause of a problem. It is correct to say that the GP's notes recall several different causes for the deceased's stress and anxiety. Her job, her commuting, her son's difficult behaviour, her mother's health, as well as her relationship with her husband. There are references in the GP's notes to the relationship with her husband which describe him in 2004 as supportive, but state in October 2006 that the deceased complained of relationship problems which Mr Taaffe agreed in evidence referred to his relationship with her. When Mrs Eleanor Taaffe saw the GP on 26 February 2007 she stated that her husband had been "awful – stress+++". When the paramedics called Mrs Taaffe complained of serious marriage problems, which her son confirmed.
83. Mr Taaffe's evidence was that the affair with Leslie was in the past, that he had decided to stay with the deceased and had no intention of leaving her or divorcing. There was some uncertainty about the date when the affair had ended. The GP's notes of 11 September 2000 record the deceased's account as "other stress – found husband has three year old daughter by secretary (affair long over)". This was not consistent with the affair having ended in 2000 as Mr Taaffe had said in evidence. Further uncertainty was created in the evidence when Mr Taaffe said that they had put the affair behind them in 2005 which he then said was a slip of the tongue for 2000.
84. Mr Taaffe said that times were difficult in the aviation industry but that he hoped to be able to continue working until he was 75 in some five and a half years time when he proposed to sell off the business and recoup the balance of the loans that he had made to his company. The schedule was pleaded upon the basis that Mr Taaffe had earnings of £30,000 from his company but it transpired in evidence that he was being repaid the loans that he had made to it at the rate of £30,000 per annum. He had disclosed his full accounts to his lawyers but initially only the abbreviated accounts were in the bundle. Nothing appears to have turned on the full accounts. He did not disclose his bank statements.
85. He took some income from his company, but mostly loan repayments. The Defendant submitted that without the bank statements it was not possible to ascertain what his true level of income was.
86. The evidence revealed that the holding company of the Claimant's company owned a property worth about £400,000 and that the trading company had stock valued at £548,858 offset by creditors of £567,467. Mr Taaffe said that much of that latter figure was represented by loans that he had made to the company. It was therefore Mr Piper's submission that the Claimant's capital available as an income source to him on his retirement was half the value of the property, the majority of the loans and some of the stock values. It is not clear what the Claimant's income was or his net worth, but it appears that if his company continues to trade, as he hopes, for a further five years he should be able to realise a substantial cash sum of from it on his retirement. The precise figure is simply not ascertainable.
87. The evidence as to the financial arrangements between the Claimant and the deceased was clear. The Claimant paid the mortgage on the matrimonial home, whilst the deceased paid for the household bills and outgoings from her salary. There was no joint bank account and each operated their finances separately. There is no evidence to suggest that the Claimant was dependant upon the deceased to any extent greater than the deceased's payment of the household bills and outgoings. These have been estimated by the Claimant's counsel at £5,000 p.a and by the Defendant's counsel at £6,000 p.a.
88. The Prospects of Divorce

Miss Toogood submitted to me that this was a marriage which had lasted twenty years, the affair was in the past and there was no reason not to accept Mr Taaffe's evidence that whatever the difficulties both parties intended to remain married. There was no evidence that she intended to leave him and it is likely that once her depression had improved, as it had done following previous episodes, the marriage would have come through its bad patch. Miss Toogood submitted that the marriage to Leslie was no evidence that his marriage to Eleanor would not have continued had she lived.

89. Mr Piper submitted that the deceased and the Claimant had very severe relationship problems. The ambulance crew were informed of these when they saw Mrs Taaffe and the GP's records of 26 February 2007 confirmed it. Mr Piper said in his written closing submissions that "whatever the Claimant may have asserted in his evidence, it must have been difficult for the deceased to see her husband going off to work everyday with a woman with whom he had admitted to having a long affair, who remained single and without another partner of her own, who was the mother of a girl born to the Claimant, and who was also the co-Director and co-owner of his business."
90. I have come to the clear conclusion based upon the evidence and the documentation that there was a substantial risk that the marriage would not have lasted for any significant number of years after February 2007. Of course there can be no certainty in these matters but the evidence satisfies me that the relationship between them was so poor, and the underlying continuing problems between them so grave, that there was a very high risk that their relationship and marriage would have ceased. It is accepted that the court should take these risks into account in determining the value of the claim, and in particular the appropriate multiplier. Owen v Martin 1992 PIQR Q151 and D and DV Donald 2001 PIQR Q5.
91. I consider that a discount of 40% should be made for the risk that there would have been a divorce, or an ending of the relationship so as to terminate any dependency.
92. The Dependency

There is no evidence to suggest the dependency other than the extent of the deceased's payment for household bills and outgoings. This is not an appropriate case for taking a conventional one third, two thirds split. There is no evidence to justify that. Nor has the Claimant produced any evidence as to what the level of expenditure was that the deceased made in respect of household expenses and other outgoings. In the circumstances I have considered the assessment which each party has made of these expenses and taken the higher figure of £6,000 submitted by the Defendant. There is no evidential basis to justify any higher figure than this.

93. After retirement the probability is that the Claimant would have had access to capital from the sale of his business premises, stock and final repayment of loans, which he himself was confident would be paid back. Even when the deceased's generous pension is considered there is no evidential basis for assessing a dependency at any higher figure than that which existed before her retirement. The figure therefore remains at £6,000 per annum post the deceased's retirement.
94. I now turn to the individual heads of damage:-

1. General Damages

The Claimant submits that the appropriate figure is £2,500 and the Defendant submits that it is £1,000. Miss Toogood relies upon the case of Singh Gahir (Lawtel 2000) where a settlement of £1,569 (now worth £2,246) was approved by Mr Justice Buckley. I assess damages under this head at £2,000 and interest thereon at £65.56.

2. Bereavement

The figure of £10,000 is agreed as is interest in the sum of £1,329.

3. Funeral Expenses

These are agreed in the sum of £5,049.65 with agreed interest of £671.10.

4. Spouse's love and affection

I do not consider it appropriate to make any award under this head of damage. The evidence suggests that the marriage was exceptionally strained at this time and I have already found there was a high risk of the marriage failing. In the circumstances an award under this head would be highly artificial and it is inappropriate to make a nominal award.

5. Past dependency

I have as indicated above taken £6,000 as the multiplicand, which for five years is £30,000. From this must be deducted 40% to represent the risk of the marriage failing which produces an award under this head of £18,000 (£30,000 x 60%). Interest is £1,197.

6. Past loss of services

This is now agreed in the sum of £13,229.32. Sixty percent of this figure (to allow for the deduction of 40%) is £7,937.59. Interest thereon is £527.85.

7. Miscellaneous losses

These represent the cost to the Claimant of having surgery upon his knee which it is said the deceased's insurance would have paid for. The amount for both past surgery and future prospective surgery is £22,632.24. The Defendant submits that there is no documentary proof of the policy and in all the circumstances nothing should be awarded this head of damage.

The task of obtaining a copy of a specimen policy in force at the time and providing the same cover as the deceased should not have proved a difficult task. The circumstances in which family members would be entitled to such cover are simply not before the court and in these circumstances it is not appropriate to award any sum under this head of claim.

8. Future loss of dependency and pension

The multiplier for the total period is 13.88 which x £6000 is £83,280. 60 % of this (allowing for the deduction of 40%) is £49,968.

9. Future loss of Services

The multiplicand is agreed at £2,678 per annum. When multiplied by the full period multiplier of 13.88 a total of £37,170.64 is reached. Sixty percent of this (allowing for the deduction of 40%) is £22,302.38.

95. Summary of Quantum

General Damages	£2,000.00
Interest thereon	£65.56
Bereavement	£10,000.00
Interest thereof	£1,329.00
Funeral expenses	£5,049.65
Interest thereon	£671.10
Spouse's love and affection	Nil
Past dependency	£18,000.00
Interest thereon	£1,197.00
Past loss of services	£7,937.59
Interest thereon	£527.85
Miscellaneous losses	Nil
Future loss of dependency and pension	£49,968.00
Future loss of services	£22,302.38
Total:	£119,048.13

96. Conclusion

The Claimant's claims succeed. Negligence on the part of the paramedics is established and I award damages in the sum of £119,048.13.