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Bedfordshire Hospitals NHS Foundation Trust

P-002734 · Statement · Decision date: 13 June 2024 · View Bedfordshire Hospitals NHS Foundation Trust scorecard
Treatment Transfer, discharge and aftercare Care plan failures Delayed Recognition of Deterioration
Complaint (AI summary)
Ms L complained the Trust failed to act on her father's angiogram results in April 2020 and did not perform a follow-up, delaying heart surgery and potentially affecting his survival.
Outcome (AI summary)
Closed. An ongoing investigation is expected to achieve the desired outcomes, so further action by the Ombudsman is on hold.

Full decision details

The Complaint

3. Ms L complains in April 2020 Bedfordshire Hospitals NHS Foundation Trust (the Trust) did not act on an angiogram (a heart scan) of her late father (Mr E). Ms L said the angiogram showed Mr E had a moderate to severe leaky heart valve.

4. She also complains the Trust did not perform a follow-up angiogram six months afterwards, as she believes it should have done.

5. She says this meant her father missed an opportunity for earlier heart surgery. She says if the surgery had happened sooner then he would have had a better chance of survival and not experienced the stress of an emergency operation.

6. As an outcome to her complaint Ms L would like service improvements.

Background

7. Mr E visited the Trust in April 2020 for a routine angiogram. It showed his heart had a leaky valve, but because Mr E had no other symptoms the heart specialist decided not to investigate further.

8. In September 2022 Mr E visited his GP complaining of shortness of breath and fluid retention. The GP arranged another angiogram which happened in November. Mr E was admitted to hospital immediately and listed for an operation on his heart.

9. Mr E moved to another hospital and the operation went ahead in January 2023. Sadly, Mr E died 13 days after his heart surgery.

Findings

11. Ms L told us a coroner is currently investigating her father’s death. A coroner is responsible for investigating what happened when the circumstances of someone’s death are unclear.

12. Ms L understands the investigation will look at two areas. Firstly, the possible missed opportunity for earlier intervention and follow-up angiogram in April 2020. She also believes it will look at the operation and aftercare Mr E had in early 2023.

13. The coroner’s investigation might find shortcomings in the care given to Mr E before he died. If the coroner finds areas where the care could have been better then they have an obligation to report their concerns to the relevant organisation. They do this to identify areas where improvements can be made to prevent future deaths.

14. With this in mind, it is possible the coroner’s investigation could result in the service improvements Ms L wants as an outcome to her complaint.

15. Furthermore, Ms L says her father’s death might have been avoided if the follow up happened and the operation went ahead sooner. There are also questions about her father’s condition at the time of his death and the impact this had.

16. The impacts of what happened can be complex to figure out. A coroner is well placed to unpick these issues and reach a view on how Mr E died. If we did investigate further then we would rely on our own consideration of independent evidence. That said, information from the coroner might be relevant to our own work.

17. The report was initially due at the end of May 2024. However, this has been delayed because the medical expert needs further records from the Trust and from the hospital where Mr E had his operation.

18. As the coroner’s investigation is currently underway, it is appropriate we allow it to finish before taking any further action on Ms L’s complaint. It would be unsuitable to keep the case open whilst this work is ongoing.

19. If the coroner does not resolve all of Ms L’s concerns, or does not look at the issues she complained about, then she can return to us. We will then decide if any further action is necessary.

20. If Ms L does return to us then it is important she does so promptly. This is because we have a 12-month time limit from the date someone knew they had a reason to complain. We can set this time limit to one side in certain circumstances but not if there is undue or excessive delay.

21. Although we will not consider Ms L’s complaint at this time we acknowledge how upsetting these events have been for her. We hope the ongoing investigation brings some closure to the sad experience she has gone through.

Our Decision

1. We have carefully considered Ms L’s complaint. We understand how concerning these events have been and acknowledge the overwhelming upset she has experienced.

2. We have decided there is an ongoing investigation into what happened which might achieve the outcomes she wants. It is therefore appropriate to let this finish before we decide if we should take any further action.

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