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The blood sample had to be repeated on 16 December2019 showing a BNP of 353 and the recommendation from the Pathology Laboratory was an echocardiogram referral which is the usual recommendation when BNP marker is between 100 and
400. The referral for echocardiogram was made on 17 December 2019. It was further noted that Mr Murphy's haemoglobin was 99 and so in addition to the referral for echocardiogram, an urgent referral was also made to the Colorectal Team. Mr Murphy was seen by the Colorectal Team on 6 January 2020 and gastroscopy, flexible sigmoidoscopy and CT thorax abdomen pelvis organised: On January 2020 Mr Murphy had spirometry identifying that he had Chronic Obstructive Pulmonary Disease (COPD): By 22 January 2020 Mr Murphy had completed all of colorectal examinations and was discharged as colorectal cancer had been excluded: On the 6th February 2020, the echocardiogram report was available, which showed moderate to severe Left Ventricular systolic dysfunction: Dr saw Mr Murphy the same and noted him to have gone upstairs in the surgery as he had been under the impression that Dr was in an upstairs consultation room, despite which he had not appeared breathless. Mr Murphy reported no breathlessness on walking his every There was no orthopnoea, no breathlessness on Iying flat, his oxygen saturation was 96%, pulse was 76 beats per minute and his blood pressure was 135/80. It was also noted that there was no ankle swelling: Mr Murphy was referred to cardiology for his heart failure. Dr was Saddened to note that Mr Murphy was admitted to hospital a few days later, on 12 February 2020 and that he passed away o 17 Febtuary 2020. I have reviewed Mr Murphy's pathway and also looked at the timings here and I am satisfied that the patient's care was managed appropriately and in timely manner_ The correct investigations were undertaken in the right order based on the presenting symptomb and were in line with current guidance. question is whhether the echocardiogram or any of the othlr investigations referred to should have been ordered on more urgent basis but I lam satisfied that the GP responded appropriately to the presenting circumstances, ordered the correct tests and that all results were acted on in accordance with agreed patient pathways. Had the BNP marker been reported as above 400 then this would have generated an urgent referral to the heart failure team and would have arranged the echocardiogram and follow up direct: his day dog day. key they

The test has subsequently changed to NTpBNP for which the values are different: - BNP Marker Action Level Under 400 Unlikely to be heart failure 400 2000 Refer for echocardiogram followed by routine referral to Heart Failure Clinic if heart failure identified on echocardiogram Above 2000 Heart Failure Clinic referral as urgent clinic to then arrange for the echocardiogram and follow Up as urgent Your report asks for an account of steps that we will be taking in relation to cardiology investigation timescales in order to reduce potentially avoidable deaths: I find in an unusual position in that whilst I am to respond appropriately to your request, my review identified that there were no delays in this case ad that the correct processes and pathways were followed from the point of consultation with the GP through to the ordering of the echocardiogram and referral to specialist cardiology services. Therefore whilst I can very much appreciate that from the family's perspective there may appear to have been delay from the point of consultation to the referral into specialist cardiology services, this was not the case. This is because it is necessary for initial investigations to be completed prior to referral, all of which were in this case completed in timely manner. I do not though under estimate the worry the perceived delay will have caused this family ad I am sorry if the investigation process and timeline was not explained at the time: I hope the above information is helpful to you but if you require any further information please do not hesitate to contact me: