North Cumbria Integrated Care NHS Foundation Trust

4. Miss L complains about the care and treatment the Trust gave to her father, Mr L. Miss L complains the Trust missed opportunities to diagnose Mr L’s coronary artery atherosclerosis (where arteries become narrowed, making it difficult for blood to flow through them) in June, October and December 2019, and in April 2020. She complains if the Trust did diagnose this condition, it did not tell Mr L or those involved in his care. Miss L considers the Trust overlooked the symptoms and the severity of the disease. She complains the Trust discharged Mr L from hospital nine weeks before his death and when he had severe symptoms and no care plan in place.

5. Miss L complains about the way her complaint was handled. She complains the Trust provided her with contradictory and conflicting responses, and that the consultant involved in Mr L’s care did not attend the Trust’s complaint handling meeting to answer her questions. Miss L also complains about the standard of the notes taken during the meeting and the Trust’s failure to make sure the recording equipment was working.

6. Miss L considers this led to Mr L’s health worsening and his unexpected death. She feels if the Trust had monitored her father’s condition appropriately, he would not have died. She tells us this has had a great emotional impact on her, which continues to affect her daily, and this has been made worse by the Trust’s handling of her complaint.

7. As an outcome to her complaint, Miss L wants to see service improvements in communication with patients and their families about diagnoses. She also wants service improvements in investigating and diagnosing diseases based on symptoms. Miss L also wants the Trust to accept the failings in Mr L’s care.

8. Mr L’s GP referred him to the cardiology department on 29 March 2019. Mr L had gone to his GP with increased episodes of angina (a type of chest pain caused by reduced blood flow to the heart and which is a symptom of coronary artery disease) over the previous six months. He had had a myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blockages in the arteries) in 2009 and likened the angina pain to this.

9. A consultant cardiologist saw Mr L on 6 June 2019. It was noted his condition had worsened. A plan was put in place for an echocardiogram (an ultrasound scan of the heart) and a myocardial perfusion scan (a scan to get pictures of blood flow through the heart at rest and during activity). Depending on the results, these were to be followed by a coronary angiography (an invasive diagnostic procedure which involves taking X-rays of the arteries in the heart). Mr L had an echocardiogram on 20 July 2019 which confirmed the functioning of his left ventricular (the heart’s main pumping chamber) was severely weakened.

10. Mr L had stressed and unstressed myocardial perfusion scans (to assess blood flow through the heart during activity and at rest) on 23 and 25 July 2019. The cardiologist referred Mr L to the heart failure clinic on 25 July 2019 so his medication could be reviewed. They also sent a letter to Mr L’s GP explaining they were waiting for the results of the myocardial perfusion scan.

11. The results showed evidence of a previous heart attack (in 2009), but no evidence that there was a significant lack of blood supply to any areas of the heart. The cardiologist explained they did not send Mr L for a coronary angiography because the results did not show any reversible ischaemia (a restriction of blood supply). A plan was put in place to review Mr L at the clinic.

12. Mr L was reviewed at the clinic on 17 October 2019. He reported poor sleep, chest pain and pain in his left shoulder. It was decided that he needed a coronary angiogram (a procedure that uses X-rays to look at the heart’s blood vessels). Mr L was referred to a consultant haematologist (a blood and bone marrow specialist) to determine if he required any pre-treatment.

13. Mr L had a coronary angiogram on 2 December 2019. The results showed no significant narrowing of the arteries requiring treatment and only minor atheroma (areas of plaque in the arteries). A plan was put in place to focus on treating Mr L’s heart failure and to review him at the clinic in six months’ time.

14. Mr L attended the heart failure clinic on 12 February 2020 for a review of his medication. Mr L reported increased breathlessness, reduced exercise tolerance (ability to do physical exercise), dizziness and palpitations (noticeable heartbeats). The clinic letter tells us Mr L was given advice about lifestyle factors (drinking and smoking). It says they discussed the heart failure diagnosis, management of Mr L’s condition, and signs and symptoms to be monitored.

15. Mr L was admitted to the emergency department (ED) on 31 March 2020 with shortness of breath and chest tightness. He had a chest X-ray and echocardiograms. Mr L was diagnosed with suspected bilateral pneumonia (a serious infection affecting both lungs) and treated with intravenous (IV) antibiotics. He was discharged on 4 April 2020.

16. Mr L was admitted to the ED again on 7 April 2020 due to sudden shortness of breath and chest pain. He had a computerised tomography (CT) pulmonary angiogram (a scan which produces images of the blood vessels from the heart to the lungs). This showed no evidence of any blood clots. No comment was made on any calcium in the blood vessels. Mr L also had a chest X-ray which showed bibasilar consolidation (a sign of a lung infection which blocks air flow through the lungs). Mr L also had raised d-dimer levels (d-dimer is only produced after a clot has formed and is being broken down).

17. Mr L was discharged on 10 April 2020 and sadly died in June 2020. The post mortem determined coronary artery atherosclerosis as the cause of death. Atherosclerosis is a build up of plaque in the arteries which causes them to harden and narrow, restricting blood flow and oxygen supply to vital organs.

Diagnosis

21. Miss L complains that the Trust missed opportunities to diagnose Mr L’s coronary artery atherosclerosis in June, July, October and December 2019, and in April 2020, and that it ignored the symptoms and severity of the disease.

22. We have reviewed this aspect of the complaint with our cardiology adviser and we see no signs that the Trust ignored Mr L’s symptoms or the severity of his disease or missed an opportunity to diagnose him.

23. Mr L had been diagnosed in 2009 following his myocardial infarction. His heart muscles had been damaged by a loss of blood supply due to blockages in the arteries. So, we understand Mr L had narrowing of his arteries for a long time. We understand this was being treated medically and Mr L had a coronary angioplasty (a procedure used to widen blocked or narrowed coronary artery/arteries) at the time.

24. When the cardiology team reviewed Mr L in June and October 2019, they found his left ventricular function had significantly worsened. In response to this finding, there are signs the Trust conducted appropriate investigations to confirm or rule out a significant blockage in the arteries, including a stress myocardial perfusion scan and a coronary angiogram. This is in line with NICE Clinical guideline 95 concerning investigating chest pains and deterioration. It is also in line with the GMC’s Good Medical Practice guidance on assessing the patient’s condition and history, examining them and quickly arranging suitable advice and investigations, if necessary.

25. Following the angiogram on 2 December 2019, atherosclerosis was identified, but was not significant enough for treatment. A plan was put in place to focus on treating Mr L’s heart failure and to review him at the clinic in six months’ time. He was also referred to the heart failure clinic for medication review. This is in line with the GMC’s Good Medical Practice guidance on referring a patient to another practitioner, when required, and providing effective treatments based on the best available evidence.

26. Mr L attended the heart failure clinic on 12 February 2020. He reported increased breathlessness, reduced exercise tolerance, dizziness and palpitations. The clinic letter tells us Mr L was given advice about lifestyle factors (drinking and smoking). It also says they discussed the heart failure diagnosis, management of Mr L’s condition and signs and symptoms to be monitored. A plan was made to discuss Mr L’s case with the consultant cardiologist and to follow up with Mr L at the clinic.

27. There are signs Mr L was receiving the appropriate medication, with the aim of reducing his risk of having a heart attack, and that he was given appropriate advice about his symptoms and lifestyle changes. This is in line with NICE Guideline 106 concerning giving information to people with heart failure, treating heart failure and ongoing management and monitoring.

28. For the reasons given above, we do not see any signs that the Trust missed opportunities to diagnose Mr L’s condition. We also do not see any signs that the Trust ignored his symptoms or the severity of his heart failure.

Discharge

29. Miss L complains her father was discharged from the Trust nine weeks before his death and when he had significant symptoms and no care plan in place. In response, the Trust explains that the scans showed Mr L had mild atheroma in some areas of his heart. So, he was given medical therapy to prevent blockages and medication to treat his impaired heart muscle function.

30. We have discussed Mr L’s discharge on 10 April 2020 with our cardiology adviser and we see no signs this discharge was inappropriate. This is because the records show Mr L’s condition had been stabilised and he had been medically optimised.

31. A plan was put in place for Mr L’s GP to monitor his renal (kidney) function and follow up appointments were made for a repeat chest X-ray, an outpatient CT scan of the thorax (the area between the neck and the stomach) and an outpatient echocardiogram to continue monitoring his heart failure.

32. The occupational therapy team had planned for Mr L’s discharge from hospital, were arranging support in the community for Mr L and were corresponding with his social worker.

33. This is in line with NICE Guideline 106 concerning the ongoing monitoring and management of heart failure, and NICE Guideline 27 concerning discharge planning and arrangements for ongoing support and care. So, we do not see any signs of service failure relating to this part of the complaint.

Communication

34. Miss L complains that if the Trust did diagnose Mr L with coronary artery atherosclerosis, it was not tell him or those involved in his care.

35. During the Trust’s complain handing process, it accepted there were some areas where communication could have been better. It confirmed it would take this up with the cardiology team to improve future communication.

36. When looking through Mr L’s records, we can see the Trust reviewed and monitored him, and sent him for tests. It also sent correspondence about his symptoms and the ongoing care plan to his GP and the heart failure clinic. The clinic letters detail his diagnosis, his symptoms and the worsening of his condition, and suggest this was discussed with him during his appointments.

37. We consider this is in line with NICE Guideline 106, which explains a patient’s prognosis should be discussed in a sensitive, open and honest manner. Clinicians should be honest about the uncertainty involved in predicting the course of heart failure and should continue to discuss this as the condition develops. There are signs such conversations took place during Mr L’s reviews when it became his heart failure had worsened. For this reason, we see no signs of service failure relating to this part of the complaint.

Complaint handling

Contradictory responses

38. Miss L complains the Trust has given her conflicting responses as it changed its answers in the different responses she received. We have reviewed the responses the Trust sent to Miss L on 26 October 2020, 15 February 2021 and 24 June 2021.

39. Our principles explain that public bodies should investigate complaints thoroughly and fairly, basing decisions on the available facts and evidence.

40. We do not see any instances of contradictory information in the Trust’s responses and it appears to have responded to the complaint in a consistent way which is based on the evidence. The information in the Trust’s responses is in line with the timeline we see in Mr L’s medical records and with the clinical advice we have received. For this reason, we see no signs of fault relating to this part of the complaint.

The Trust’s complaint handling meeting

41. Miss L complains the doctor who looked after her father and was responsible for his care was not present at the meeting.

42. In response, the Trust explains that the meeting it offered was with the then clinical director for cardiology. As Miss L accepted this meeting, the Trust understood she was agreeing to the people attending the meeting. It has no record of Miss L asking for another consultant to attend the meeting.

43. Our principles say that complaints should be investigated fairly and objectively, and by a member of staff who was not involved in the events leading to the complaint.

44. We have reviewed the complaints file and do not see any evidence showing Miss L specifying who she wanted at the meeting. Also, the consultant who attended the meeting was the clinical director for cardiology, which is the specialism most relevant to this complaint.

45. Involving the clinical director rather than the consultant responsible for Mr L’s care allowed the investigation and complaints response to be objective and have a degree of independence, which is in line with our principles. So, we do not see any signs of fault relating to this part of the complaint.

Meeting notes and recording equipment

46. Miss L complains about the standard of the notes from the Trust’s complaint handling meeting. She says she received a poor copy of the notes. Miss L also says the Trust failed to record the meeting. It began recording but, at the end of the meeting, it was clear that the equipment had failed to record.

47. In response, the Trust explains that the usual process during a complaint handing meeting is to electronically record the meeting and give the complainant a copy of the meeting recording along with the Trust’s response, outlining what was discussed and any agreed actions. Written notes are not normally provided when a meeting has been recorded. The Trust explains it only discovered the equipment was not working at the start of the meeting, so the service manager took notes.

48. Our principles say public bodies should create and maintain reliable and usable records as evidence of their activities.

49. We do not consider there are signs of service failure relating to the failure of the recording. On this occasion, the error was due to the digital equipment failing, which could not be avoided.

50. We have reviewed both the written and typed versions of the notes taken at the meeting. As we do not have a recording of the meeting, we cannot comment on whether they provide an accurate summary but they show that Miss L’s concerns were discussed.

51. The letter the Trust sent after the meeting is short on detail but confirms that Miss L was able to raise her concerns and receive detailed explanations in response. The letter says Miss L was satisfied with the outcome of the discussions and did not need any further information. It also summarises the outcome of the meeting and an action point, which was followed up.

52. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 requires a complaint is responded to in writing.

53. We asked the Trust why the letter did not detail what had been discussed at the meeting. The Trust says it did not always include such details at that time but letters now include details of what is discussed in complaint handling meetings, including any agreed actions. If possible, the complainant receives the recording and a copy of the written notes.

54. We have also considered Miss L received two written responses to her complaint, answering her questions, before the meeting. The Trust offered the meeting so Miss L could discuss any outstanding questions and concerns with the clinical director for cardiology.

55. While the Trust’s response following the meeting could have given more detail, it is clear the Trust has accepted this and has updated its practices to ensure complainants receive all the information required. Miss L would normally have received a copy of the recording but this was not possible due to a technological failure.

56. Based on the evidence, we do not see any signs of fault with regard to the notes taken at the meeting. The Trust created usable records as evidence of its complaint handling meeting and had already given detailed responses before this in line with our principles.

1. The Parliamentary and Health Service Ombudsman has carefully considered Miss L’s complaint about the North Cumbria Integrated Care NHS Foundation Trust (the Trust). We are sorry to hear how Miss L and her father have been affected by the concerns she raises. It is evident they have had a difficult and upsetting time and, understandably, Miss L is seeking an outcome to put things right.

2. After considering the information provided by Miss L and the Trust, and getting advice from a cardiology (heart) adviser, we do not see any signs that Mr L’s care fell below the expected standards. We have also considered the way the Trust managed Miss L’s complaint, and we do not see any signs that the complaint handling fell below the expected standards.

3. We explain the reasons for our decisions in this statement. Complaints give us valuable insight into the organisations we investigate, so we thank Miss L for sharing her experience with us. It is important to recognise that finding no signs of service failure in relation to Mr L’s care or the complaint handling does not detract from Miss L’s experience or the impact this has had on her and her family.