Should an ECHO have been done in hospital, between 4-8 May 2023?
8.Mr P was admitted with symptoms which were promptly and correctly identified by the Trust as possibly being related to heart failure. He was appropriately assessed on admission and the Trust made a reasonable diagnosis (of heart failure) based on the results of his initial investigations. There does not appear to have been any unreasonable delay in making the correct diagnosis. Our adviser indicated Mr P was then promptly, and appropriately, treated for heart failure with diuretics and beta blockers, pending further investigations.
9.Mrs P believes her husband should have had an ECHO before being allowed to leave hospital. The Trust’s own response acknowledged that it would have been preferable to do the test while Mr P was in hospital and we agree with that, so did understand Mrs Walters’ concern about this.
10.While we agreed it would have been beneficial to do the test sooner, while Mr P was still an inpatient, especially with the benefit of hindsight given the subsequent events, we think the Trust’s plan to perform the ECHO a few days later, on an outpatient basis, was also reasonable.
11.One of the relevant pieces of guidance in this context is NICE (NG106): ‘Chronic heart failure in adults: diagnosis and management’, published in September 2018. NG106 at section 1.2.8 states that echocardiography should be undertaken to exclude significant valvular disease. That means it was an appropriate test to do in Mr P’s case. But the guidance sets out no specific time scale for this to happen. The timing is therefore usually a question of assessing the clinical need/urgency and balancing that with availability. We say more about this in the next paragraph.
12.Another piece of relevant guidance is NICE (NG208): ‘Heart valve disease presenting in adults: investigation and management’, which was published in November 2021. NG 208 at section 1.1 describes when there is a need for echocardiography. Mr P met this criterion with him having symptoms and a murmur. So, an ECHO was appropriate. Section 1.1.3 of NG 208 covers the timing and describes when an urgent ECHO should be undertaken. Mr P did not meet the criteria for an urgent referral at that time as he did not have syncope (fainting or passing out), nor severe symptoms. However, urgent in this context is described as within 2 weeks and the plan was to arrange it for Mr P within that timeframe anyway.
13.That means the plan to do an ECHO was correct. There was no pressing need, clinically, for it to be done urgently, though the plan was to do it within the ‘urgent’ timeframe anyway. The correct clinical diagnosis of heart failure had already been made (following clinical assessments which we think were compliant with the General Medical Council’s ‘Good Medical Practice’ guidance)) and appropriate heart failure treatment had already been started. It is not disputed by the Trust that it would have been better to do the test while Mr P was in hospital, but our view is that the Trust’s plans for follow up were reasonable too. Mr P was to be referred to cardiology for further assessment, with a suggestion that he be seen in the same day emergency medicine service for follow up and echocardiography and that was a reasonable plan.
Discharge from hospital
14.Mr P was admitted with shortness of breath on exertion which had lasted for two weeks prior to his admission. He was treated for a lower respiratory tract infection with oral antibiotics. On the day he was discharged, his observations were stable, and his oxygen saturation level was 96% on air, which indicated he was no longer suffering with shortness of breath. His blood test results were within normal ranges, and he was noted to be alert and orientated. In summary, his records indicated that his overall and respiratory condition seemed to have improved so there was no pressing need to keep him in hospital.
15.NEWS2 (National Early Warning System) is a tool widely used in the NHS to detect and respond to any clinical deterioration in adult patients. It is a key element of patient safety and improving patient outcomes. Mr P’s NEWS2 charts for 6-8 May 2020 show that all his scores were between 1 and 3 (meaning ‘low risk’). That means there was nothing in the way he was presenting that called for any escalation in his care. Having looked at Mr P’s records, our adviser indicated there was no indication of any worsening in his clinical condition.
16.Mrs P told us Mr Walters was still ‘very poorly’ when they went home. She questioned whether he was ‘alert and orientated’ and commented that he needed a wheelchair, assistance to get to the car and help to get upstairs when they get home. We do not question what Mrs P told us.
17.People are not kept in hospital just because they are unwell, or very poorly. People only remain in hospital when they cannot safely be discharged, or when they require treatment that can only be delivered in a hospital setting. Neither of those things appear to have applied in Mr P’s case, when the decision was made to discharge him on 8 May 2023. His notes show that he was independent of all activities of daily living while on the ward and was keen to go home. There is nothing to suggest that when Mrs P came to collect him any concerns were raised with the Trust about their ability to cope if he was discharged, although Mrs P commented to us that no one asked her about that.
18.The available evidence suggested to us that Mr P’s condition was stable, he was not being actively treated, he was keen to go home and there appeared to be no obstacle to that happening. The appropriate follow-up referrals had been made (to cardiology and respiratory), so we concluded there was no pressing clinical reason to keep him in hospital.