12. Mr B says the Trust identified his father had tricuspid regurgitation during the surgery on 7 April, but did not treat this. The Trust’s complaint response explained it felt that in this case the risk of treating the condition would have outweighed the benefits.
13. The Trust did an echocardiogram before the operation. This is an ultrasound scan, used to look at the heart and nearby blood vessels. Our adviser told us this showed moderate tricuspid regurgitation.
14. The ‘Guidelines for the management of valvular heart disease’ say surgical intervention is for patients with severe tricuspid regurgitation. The guidance also says this is in cases where patients are symptomatic.
15. Our adviser told us Mr W did not fall into this category and to operate would have presented greater risks to Mr W. This is because of the longer time taken for surgery and the increased risk of death. He explained there would have been little or no advantage to doing this procedure as there was no evidence it was causing Mr W any symptoms. The surgery the Trust did was to treat the symptoms caused by the coronary heart disease and not the regurgitation.
16. The records show the surgeon discussed the decision to not undertake corrective surgery on the tricuspid regurgitation with a colleague. This collaborative decision making is good practice and is in line with the GMC guidance, which says ‘consult colleagues […] where appropriate’.
17. For these reasons we find the actions of the Trust were in line with the guidance in relation to the decision to not treat the tricuspid regurgitation during the surgery.
18. Our adviser said the records show the surgery provided an improvement to the symptoms of tricuspid regurgitation, without the additional risks of a longer and non-essential procedure.
19. Mr B told us the Trust delayed changing his father’s dosage of ramipril and in putting him on blood thinners (anticoagulant medication). He questioned why this did not happen on the day of the follow up appointment on 6 June.
20. The GMC guidance explains what doctors should do when making decisions about medications. It says:
‘propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs’ and ‘you should consider the overall impact of the patient’s treatments, and whether the benefits outweigh any risk of harm’.
21. Our adviser explained there was nothing to show the Trust needed to change the dosage of ramipril (a drug which widens blood vessels making it easier for the heart to pump blood around the body) at that appointment. He explained the Trust weighed up all the medication Mr W was taking and considered the effect of these in relation to each other, and in relation to what was needed to manage his symptoms. This decision was in line with guidance quoted in paragraph 20.
22. In relation to the blood thinners, the consultant wrote to Mr W’s GP to ask him to prescribe apixaban (an anticoagulant medicine which makes the blood flow through the veins more easily and prevents clots).
23. Our adviser explained this was because Mr W had atrial fibrillation (AF, a heart condition that causes an irregular and often abnormally fast heart rate) and the Trust planned to carry out cardioversion (giving the heart a controlled electric shock to try to restore a normal rhythm) in four weeks time.
24. AF can increase the likelihood of a blood clot, and the ‘Guidelines for the diagnosis and management of atrial fibrillation’ recommend not less than 3 weeks of adequate anticoagulation before cardioversion.
25. We consider this was a reasonable approach, in line with the guidance in paragraphs 20 and 24. Our adviser explained the problem was not acute and did not require the Trust to issue an immediate prescription for the medication.
26. We have not identified any failings in the care and treatment the Trust gave Mr W. We find the actions of the Trust were in line with the relevant guidance and Mr W sadly died despite, not because of, the care and treatment by the Trust. The Trust completed a technically successful operation, but sadly this was not enough to counter Mr W’s severe ischaemic heart disease.
27. We thank Mr B for sharing his concerns with us. We hope this report fully explains the reasons for our decision and provides the family with reassurance about the care the Trust gave Mr W.