West Hertfordshire Hospitals NHS Trust

4. Mrs N and Mrs A complain about aspects of care and treatment Mr A received while under the care of the Trust between 6 and 16 July. Specifically, they complain that staff: · inappropriately discharged Mr A on 7 July. They say staff should not have discharged Mr A because he had fluid in his lungs. They say staff should have provided him with medication for this · did not provide Mr A with good care or treatment in a timely way during his admissions (between 6 and 7 July, and 9 and 16 July).

5. They say the inappropriate discharge initially caused them distress as Mr A was in pain for two days more than he needed to be. They say Mr A may not have died if staff had given appropriate care, which has left them devastated and grieving. This has caused them significant distress.

6. They would like an independent investigation into the events they complain about, an acknowledgement of failings and service improvements.

7. Mr A had COVID-19 early in 2021 and required care in an intensive care unit.

8. Before his first admission in July, Mr A was suffering from swelling in both of his legs, shortness of breath and a cough which had lasted for two weeks. On 6 July, Mrs A took Mr A to see his GP. His GP believed he had fluid in his lungs and advised him to go to hospital for care.

9. Mr A attended the emergency department (ED) later that day. The ED doctor attended to Mr A about an hour later. The ED doctor noted his symptoms and medical history and did a physical examination of his chest and legs.

10. Based on this assessment, the ED doctor found Mr A had less air entering his lower lungs, which indicated his lungs were holding a lot of fluid. They also saw Mr A had swelling in his legs, which is caused by holding a lot of fluid (fluid retention).

11. Both symptoms indicate heart failure. This is where the heart does not pump enough blood to meet all the needs of the body. The ED doctor recorded a provisional diagnosis of heart failure and carried out blood tests, a chest X-ray and an electrocardiogram (ECG). An ECG measures the electrical activity of the heart.

12. After receiving a copy of the blood test results, the ED doctor saw Mr A had a high level of b-type natriuretic peptide (BNP). This is a hormone produced by cardiac cells in response to increased pressure within the heart. High BNP levels indicate the patient has heart failure.

13. The ED doctor referred Mr A onto the emergency admissions unit (EAU) team to assess if Mr A should be admitted onto a ward for further treatment. The EAU team reviewed Mr A the following morning.

14. The EAU team saw that Mr A had excessive fluid in his lungs and legs, but did not have any chest pains, or cough and was able to move independently. His temperature, blood pressure and oxygen levels were also all within normal ranges. At the time, Mr A said that he wanted to be discharged home and did not want to stay in hospital.

15. The EAU team gave Mr A bumetanide intravenously. This is a diuretic which is a type of medication that helps reduce fluid retention. Based on his clinical condition and desire to be discharged home, they decided that his suspected heart failure could be managed as an outpatient.

16. However, the EAU team were also concerned Mr A may have a blood clot in his lungs and wanted to rule this out before discharging him home. To check this, they did another blood test to specifically assess if Mr A’s D-dimer was raised. D-dimer is a protein in the blood that increases when there is a blood clot in the patient’s body.

17. Mr A’s blood test results showed that the D-dimer level in his blood was high. To confirm the diagnosis, the EAU team also carried out a CT pulmonary angiogram. This is a scan that looks for the presence of blood clots in the lungs. The results of the CT pulmonary angiogram showed Mr A did not have a blood clot.

18. Based on all the test results and clinical findings, the EAU team decided to discharge Mr A that afternoon. They prescribed Mr A with 1mg diuretic bumetanide to take orally daily to help with reduce his fluid retention. They also referred him to the heart clinic.

19. At home, Mr A continued to suffer from shortness of breath and his legs stayed swollen. Mrs A contacted Mr A’s GP again on 9 July, who advised Mr A needed hospital care. Mr A went to the Trust’s ED again and was admitted to the cardiology ward later that day.

20. The cardiologist consultant gave him the diuretic furosemide to help with his fluid retention. They also saw Mr A was suffering from low blood pressure, so gave him dobutamine and noradrenaline to help maintain this.

21. On 10 July, Mr A underwent an echocardiogram (ECHO). This is an imaging test which uses ultrasound to monitor the hearts’ function.

22. The ECHO showed a left ventricular ejection fraction (percentage of blood leaving the heart) of 48%. It also showed moderate mitral regurgitation (the heart valve not closing properly causing blood to leak) and showed the valve between the lower left heart chamber the main artery was not working properly.

23. On 11 July, the cardiologist reviewed Mr A’s ECHO results and increased his dosage of the diuretic furosemide.

24. On 12 July, Mr A had worsening shortness of breath, but was still able to mobilise independently. Staff carried out another chest X-ray which showed Mr A still had fluid in his lungs and had also developed pneumonia. Staff continued giving him diuretic furosemide and began giving him antibiotic co-amoxiclav to treat the pneumonia.

25. On 13 July, Mr A had increased shortness of breath. Staff did another chest X-ray which showed excessive fluid in the lungs, and that his lungs had deteriorated significantly since 12 July. This indicated worsening heart failure but would have also been affected by his pneumonia, which can also cause fluid retention in the lungs.

26. The cardiologist continued to give Mr A the diuretic furosemide, changed his antibiotics to tazocin, and planned to carry out another ECHO to monitor Mr A’s heart function.

27. Staff carried out an ECHO later that day. This showed Mr A had a worsening left ventricular ejection fraction of 50-55% which indicated less blood was leaving the heart.

28. The BNP and troponin levels (proteins which are released from the heart into the blood stream when there is damage to the heart) had increased significantly. This showed worsening heart failure and myocardial necrosis (death of heart muscle cells).

29. Staff transferred Mr A to intensive care and gave him continuous positive airway pressure (CPAP) which supported his breathing. They continued giving him diuretic furosemide and antibiotic tazocin.

30. On 14 July Mr A’s blood pressure had increased. This was negatively impacting his heart and the arteries in the lungs. Staff reduced his blood pressure medication. He also had increased fluid retention in his lungs, which the diuretic furosemide was not easing. Staff inserted a chest drain into Mr A’s right lung to help ease the fluid retention.

31. Sadly, that same day, Mr A developed kidney failure. Staff considered if dialysis would be beneficial to Mr A, but because his blood pressure was now low, they decided he would not survive this treatment option. They kept giving him blood pressure medication to keep this at a stable level.

32. On 16 July, Mr A sadly developed sepsis and began to suffer from multiorgan failure. Sepsis is a serious infection of the blood stream which can cause a decrease in blood pressure, increased heart rate and fever. Multiple organ failure is when several of a patient’s organs begin to fail and significantly increases their likelihood of dying.

33. Staff informed Mr A’s family that he was approaching the end of his life later that same day. Mr A sadly died and his death was recorded as congestive cardiac failure, pneumonia, acute kidney injury, ischaemic heart disease, valvular heart disease.

Admission between 6 and 7 July

38. Mrs N and Mrs A are understandably concerned that staff may not have provided Mr A with appropriate care and treatment during this time, as he was admitted under the Trust’s care a few days later with the same symptoms. We have carefully considered if the care and treatment staff provided was in line with what should have happened.

39. GMC guidance says doctors must: · ‘Adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient · Promptly provide or arrange suitable advice, investigations, or treatment where necessary · Refer a patient to another practitioner when this serves the patient’s needs.’

40. NICE guidelines on heart failure also says doctors should: · ‘Take a history, perform a clinical examination and undertake standard investigations – for example, electrocardiography, chest X‑ray and blood tests · In people presenting with new suspected acute heart failure, measure a patients B‑type natriuretic peptide (BNP). To rule out the diagnosis of heart failure the BNP should be less than 100 ng/litre · In people presenting with new suspected acute heart failure, consider performing transthoracic doppler 2D echocardiography (ECHO) within 48 hours of admission.’

41. NICE guidelines on heart failure further recommend doctors prescribe the following medication: · ‘Intravenous diuretic therapy to people with acute heart failure · For people already taking diuretic, consider a higher dose of the diuretic than that on which the person was admitted.’

42. The ED doctor noted Mr A’s current symptoms, medical history and examined him. This indicated he had heart failure, so the ED doctor arranged further tests.

43. After considering the results of these tests , specifically the raised BNP levels in Mr A’s blood, the ED doctor referred Mr A to the EAU team to assess if he should be admitted onto a ward for further treatment for his heart failure.

44. We consider the ED doctor appropriately assessed Mr A’s clinical condition, in line with GMC guidance, by considering his symptoms and clinical history. They then promptly carried out further investigations for suspected heart failure. This was in line with GMC guidance and NICE guidance on heart failure.

45. After discovering Mr A had higher than normal BNP levels, which strongly indicated he was suffering from heart failure, they then referred Mr A to the EAU for further assessment and treatment.

46. Our ED adviser explained ED doctors do not decide if a patient should be admitted onto the ward. They carry out the initial assessment and arrange investigations accordingly. The medical admissions team then review the patient, decide on a treatment plan and if they should admit the patient for further treatment.

47. Based on our ED adviser’s advice and GMC guidance, our view is the ED doctor appropriately referred Mr A onto the EAU team to consider if they should admit him onto a ward. We have seen no failings in the care the ED doctor provided to Mr A while he was in the ED department.

48. As per the GMC guidelines and NICE guidelines on heart failure, the EAU team needed to assess Mr A again once he transferred into their care.

49. This means the EAU team should have reconsidered Mr A’s symptoms and clinical history. They should have also done a clinical examination and reviewed the results of the investigations the ED doctor had ordered. This is what happened.

50. The EAU team considered Mr A’s symptoms, clinical history and carried out an examination of his chest and legs. After considering this and the investigation results, the EAU team felt his heart failure was the likely cause the excessive fluid retention in his body, which would have also led to his breathlessness. They gave him bumetanide to help with this.

51. We have considered what our physician adviser told us and what we saw in Mr A’s records. Based on this, our view is the EAU team appropriately considered Mr A’s symptoms, test results and gave him medication in line with NICE guidelines on heart failure. We have seen no failings in the way the EAU team investigated or managed Mr A’s symptoms.

52. However, we can see the EAU team were also concerned Mr A may have had a blood clot. This can contribute to breathlessness. Our physician adviser explained that this is a significant diagnosis and the EAU team had to ensure Mr A did not have this before discharging him.

53. NICE guidelines on blood clots recommend that for suspected pulmonary embolism, staff should carry out a blood test to check a patient’s D-dimer levels. If the D-dimer level is raised, they should then carry out a CT pulmonary angiogram to confirm if there is a blood clot.

54. As we have noted above, Mr A’s blood test results showed he had raised D-dimer levels. The EAU team recognised this and requested a CT pulmonary angiogram to confirm the diagnosis. The results of the CT pulmonary angiogram confirmed that Mr A did not have a blood clot.

55. We can see staff followed NICE guidelines on blood clots in checking Mr A’s D-dimer levels and carrying out a CT pulmonary angiogram. This excluded the diagnosis of a blood clot, which in turn meant his breathlessness was likely caused by heart failure. We have not seen any failings in the actions staff took here.

Discharge on 7 July

56. Mrs N and Mrs A are concerned Mr A was discharged from hospital, even though he had suspected heart failure and his symptoms were not yet treated. We have carefully considered if staff should have discharged Mr A below.

57. We can see Mr A did not want to stay in hospital and was upset at the thought of this. In line with the GMC guidelines, the EAU team should have considered his view here, which it did.

58. Our physician adviser explained that staff had already identified the cause of Mr A’s breathlessness (heart failure) and had provided him with treatment (diuretic bumetanide) for this, in line with NICE guidelines on heart failure.

59. To support relief of Mr A’s symptoms, even after discharge, the EAU team also prescribed Mr A with 1mg of diuretic bumetanide to be taken orally after discharge. This is in line with BNF guidance on bumetanide which recommends 1mg of oral bumetanide for the treatment of oedema (fluid retention).

60. Also, Mr A’s observations at the time were stable and staff had ruled out a pulmonary embolism. This meant that he did not need to stay in hospital for urgent treatment.

61. Our physician adviser explained that, taking the above into consideration, staff acted as we would expect them to in discharging Mr A home at the time. Mr A did not want to stay in hospital, nor was there any requirement to keep him there as his condition could be treated as an outpatient.

62. Our view is that it was appropriate for the EAU team to discharge Mr A on 7 July. We have seen no failings here. We hope this reassures Mrs N.

Admission between 9 and 16 July

63. Mrs N and Mrs A are concerned Mr A was still suffering from his symptoms during his admission between 9 and 16 July. They would like to know if the care and treatment staff provided during this time was appropriate. We have carefully considered this below.

64. Our cardiologist adviser explained Mr A’s fluid retention was likely caused by his heart failure. The only treatment staff could have given to Mr A to help with this were diuretics, while continuing to investigate the cause of his heart failure to see if any long-term treatment would have helped.

65. Staff gave Mr A the diuretic furosemide upon admission and continued to give Mr A this throughout his admission. They also increased the dosage of the diuretic furosemide to try to reduce the fluid retention in his lungs.

66. Mr A also had two ECHOs and further X-rays of his chest. These helped staff monitor the progress of his heart failure.

67. We can see staff actions are in line with the NICE guidelines on heart failure and our cardiologist adviser’s advice. Staff treated Mr A’s heart failure appropriately while monitoring its progress.

68. Unfortunately, Mr A’s clinical condition was poor, and he developed several other co-morbidities (other conditions that are present at the same time). He also sadly developed severe infections. These all contributed to his rapid decline.

69. Firstly, it is important to note that Mr A had low blood pressure. This was likely caused by his heart failure. Low blood pressure restricts the amount of blood flowing to the brain and other organs in the body, which effects their ability to function effectively.

70. To increase his blood pressure to a suitable level, staff had given Mr A dobutamine and noradrenaline.

71. BNF guidelines on dobutamine and BNF guidelines on noradrenaline confirm that staff should give these medications to a patient who is suffering from low blood pressure. This is to help increase and maintain the patient’s blood pressure, which in turn will help their organs function effectively.

72. Therefore, it was appropriate and in line with the guidelines for staff to give these blood pressure medications to Mr A.

73. On 12 July, Mr A sadly developed pneumonia. Staff gave him the antibiotic co-amoxiclav intravenously (into the veins) to help with this. Pneumonia can also contribute to fluid retention in the lungs.

74. NICE guidelines on pneumonia say co-amoxiclav should be given as a first-choice oral antibiotic for adults, when the patient’s symptoms are not severe.

75. Even though staff gave Mr A co-amoxiclav intravenously and not orally, BNF guidance on co-amoxiclav confirms it can also be given intravenously. Our physician adviser confirmed this .

76. NICE guidelines on pneumonia also say tazocin should be given intravenously when symptoms of pneumonia become more severe.

77. We can see that on 13 July, Mr A’s clinical condition began to deteriorate, and he now had excessive fluid in his lungs. As pneumonia may have contributed to this, to help alleviate Mr A’s symptoms, staff changed Mr A’s antibiotics to tazocin. They gave him this intravenously.

78. We can see that staff promptly changed Mr A’s antibiotic to tazocin in line with NICE guidelines on pneumonia, as they should have done, when his condition became more severe. We have found no failings in the way staff managed or treated Mr A’s diagnosis of pneumonia.

79. On 14 July, staff saw that Mr A’s higher blood pressure was negatively affecting his heart and the arteries in his lungs, so they reduced the dosage of his blood pressure medication. This was in line with BNF guidelines on dobutamine and noradrenaline, which say staff should adjust the dosage according to the way the patient responds to treatment.

80. Staff also decided to insert a chest drain in Mr A’s right lungs to help improve the excessive fluid retention.

81. BTS guidelines say that a chest drain should be inserted into the larger area of where fluid is being retained to help drain it. We found staff did drain the right area of Mr A’s lungs. This is in line with BTS guidelines. Our physician also explained that staff managed this as they should have done.

82. On the same day, Mr A also developed kidney failure. Our physician adviser explained this usually happens when a patient has developed infections, has low blood pressure and has been on continuous diuretics. These all reduce the blood supply to the kidneys, which impacts their ability to work normally, causing them to fail.

83. Our physician adviser explained the best support that can be provided in this case is to help make sure the kidneys get enough blood supply, without affecting the patient’s other conditions.

84. Our physician adviser explained that in Mr A’s case, the only ways staff could have done this was to help reduce symptoms of the infection and to maintain a patient’s blood pressure. In some cases, treatment like dialysis can also be provided to support the kidney’s function.

85. We have already seen staff were appropriately giving Mr A blood pressure medication to manage his blood pressure and antibiotics to support his body in fighting pneumonia.

86. NICE guidelines on acute kidney failure also say staff should only refer a patient for dialysis treatment if this would benefit the patient.

87. In this case, our physician adviser explained Mr A’s naturally low blood pressure would have meant he would not have survived dialysis. The NCBI study on dialysis also shows us patients with low blood pressure before undergoing dialysis are at an increased chance of dying.

88. Taking into consideration our adviser’s advice and the NCBI study on dialysis, we consider it would not have been beneficial to offer Mr A dialysis at the time.

89. Staff’s actions here were in line with NICE guidelines on acute kidney failure. We would not have expected staff to give Mr A treatment which would have not benefited his condition or been damaging to his health.

90. On 16 July, Mr A sadly also developed sepsis. At this point, he began to suffer from multi organ failure. He died later that same day. Our physician adviser explained that once a patient begins to develop multi organ failure it is likely they will sadly die. The NCBI study on organ dysfunction also explains that sepsis, along with multiple organ failure, increases a patient’s risk of death.

91. To summarise, we have seen that staff provided Mr A with the care and treatment they should have done throughout his admission. We have not identified any failings in the care and treatment Mr A received.

92. Unfortunately, Mr A’s clinical condition deteriorated unusually rapidly which led to his untimely death. We recognise this would have been very difficult for Mrs N and Mrs A. We hope our report reassures them that staff provided Mr A with appropriate treatment and goes some way in providing answers to their concerns.

93. As we have not found any failings in the care provided, we are not upholding this complaint.

1. Mrs N and her mother, Mrs A, have concerns about the care and treatment their father and husband, Mr A, received during his hospital admissions in July 2021 before his sad death. Mrs N is representing Mrs A in this complaint.

2. We carefully considered their concerns and have found staff at the Trust provided Mr A with care and treatment that was in line with national guidelines. This means we have not found any failings in the care provided to Mr A in July. Therefore, we will not uphold this complaint.

3. We would like to thank Mrs N and Mrs A for giving us the opportunity to consider their concerns and we hope our report will provide them with some reassurance that the care and treatment Mr A received did not contribute to his death.