The coroner ruled that her death could have been prevented
The death of a 78-year-old grandmother could have been prevented if paramedics had transferred her to hospital rather than telling her to contact her GP. Following the death of Prabhabai Cangi, HM Senior Coroner Andrew Walker opened an investigation into the circumstances of the case which culminated in Ms Cangi’s death at Harefield Hospital on August 12, 2025.
She died from a cardiac arrest arising from the “late presentation” of a serious heart attack. The coroner concluded that Mrs Cangi died as a consequence of delayed hospital treatment.
According to the report, an ambulance attended Mrs Cangi’s home on August 7, 2025 – five days before her death. She had been experiencing burning chest pains for several days and was breathless, particularly when climbing stairs.
At the scene, London Ambulance Service (LAS) clinicians performed an electrocardiogram (ECG) and found an abnormal pattern known as ST elevation. This is an indicator of a severe type of heart attack where a coronary artery supplying blood to the heart muscle is completely or significantly blocked.
Instead of being taken immediately to A&E, clinicians discharged Mrs Cangi at the scene and advised her to contact her GP. Five days later, the grandmother was transferred to Harefield Hospital in an emergency state after her condition had deteriorated.
Despite receiving expert care, Mrs Cangi passed away on the same day. In his report, the coroner stated: “Had Mrs Cangi been taken to hospital, rather than being discharged to see her own doctor, it is likely that Mrs Cangi would not have died when she did.”
The coroner for North London identified a number of key concerns that require immediate action by the London Ambulance Service.
- He found that paramedics had no standardised process to consult a specialist doctor for advice when they decided not to transport Mrs Cangi to hospital after her abnormal ECG readings
- Serious symptoms did not result in an emergency hospital admission
- There was no clear instruction requiring paramedics to tell Mrs Cangi to bring a copy of her abnormal ECG to her GP
- There was a lack of standards or rules to ensure that photos of ECG records uploaded to official patient attendance logs were clear and readable to future care providers.
Dr Fenella Wrigley, Chief Medical Officer at London Ambulance Service, said: “We offer our sincere condolences to the family of Mrs Cangi and apologise for the delay in taking her to an emergency department for further assessment. London Ambulance Service is committed to continuously improving the care we provide and will reinforce guidance and best practice in relation to patients with similar symptoms.”
Training in the use of an ECG is a core component of paramedic education. This includes recognition of features consistent with a heart attack.
In response, the LAS noted that the ECG taken in Mrs Cangi’s home did not meet the specific criteria for direct transfer to a specialist Heart Attack Centre, they acknowledged that she should have been taken to A&E due to her persistent symptoms consistent with Acute Coronary Syndrome (ACS) – an umbrella term for conditions suddenly stopping blood flow to the heart.
The LAS has a number of key systems in place to ensure that clinicians can correctly interpret ECGs and share these with patients and healthcare professionals, however on this occasion fell short.
London Ambulance Service’s immediate action plan
The LAS formally responded to the Coroner on August 4, 2026, outlining several operational changes and improvements. To address the Coroner’s concerns, the LAS is implementing several measures:
- Actively reinforcing guidance and training on ACS presentations – particularly when symptoms such as chest pain and breathlessness are intermittent – through mandatory annual training and e-learning packages
- Later this year, the LAS will launch a pilot programme to share ECGs directly from the scene to specialist Heart Attack Centre clinicians
- During the 2026/27 financial year, LAS will launch a procurement process for new ECG monitoring equipment which will enable the direct upload of ECG date to the electronic patient record
- The LAS reaffirmed that standard policy requires leaving a physical copy of an ECG with patients, advising them to contact their GP. In this case, Mrs Cangi’s grandson confirmed that a copy was left with Mrs Cangi.
At the end of July, the NHS determined Mr X is eligible for full backdated funding for his care. This heavily reduced any financial loss. The council was ordered by the Ombudsman to apologise, pay Mr Y £150, and issue training reminders to staff.
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