12. When looking at whether there have been failings in the service provided, we consider what should have happened. We look at what did happen, and if this was different. If it was, we consider if it fell so far short of what should have happened to amount to a failing. If there was a failing, we look at what impact this had. If it caused a negative impact to the individual concerned, and the organisation has not done enough to put that right, we can make recommendations for it to take further action.
13. Miss E complains, the Practice failed to diagnose Mr N’s symptoms stemmed from a heart problem, and in turn it failed to refer him for emergency or urgent treatment.
14. The NICE Guidance explains how the Practice should have investigated the cause of Mr N’s symptoms on 29 April 2022. It says the initial aim of an assessment is to identify or exclude a serious cause of chest pain which needs immediate hospital admission, such as heart related problems.
15. To determine the cause of chest pain, GPs should take a detailed medical history to determine the cause of chest pain.
16. GPs should ask patients about: the nature, onset, duration, site, and radiation of chest pain. Sudden onset of central chest pain which radiates to the person's jaw, arms, or back, suggests a cause linked to heart problems. Chest pain worsened by exertion also suggests heart problems. Persistent and/or localized chest pain, or chest pain linked to breathing suggests a lung or musculoskeletal cause.
17. GP’s should also assess patients for cardiovascular risk factors such as older age, male sex, increased cholesterol, and a family history of cardiovascular disease which increase the likelihood of significant coronary artery disease. GP’s should organise appropriate investigations based on the suspected cause, unless immediate hospital admission is necessary such as for heart problems.
18. We looked carefully at Mr N’s medical records from on 29 April 2022 to establish what happened during his consultation with the Practice’s GP. The GP noted, Mr N complained of chest pain for around five weeks.
19. The GP recorded Mr N had reflux disease and was taking lansoprazole, which mostly controlled his symptoms. He had travelled to Italy around 15 April 2022. His pain worsened at night after alcohol consumption. Mr N called an Italian ambulance whose clinicians assessed him and considered he had inflammation and prescribed him Brufen, a pain relief and anti-inflammatory medication. Whilst Mr N said Brufen relieved his pain temporarily, it can aggravate reflux symptoms.
20. The GP examined Mr N and found chest pain was localised and not worsened by exercise. His chest was clear, he had normal heart sounds, and he did not complain of breathlessness. He had no chest or abdominal tenderness. The GP found Mr N had mildly raised blood pressure, he had a regular pulse, and he was a healthy weight. The GP recorded, Mr N’s physical examination was normal with only a mildly raised blood pressure of note.
21. The GP added, Mr N was passing black stools which indicated he had a bleeding ulcer potentially caused by reflux problems.
22. The GP did not record Mr N’s cholesterol or family history.
23. In line with the NICE Guidance, we expect to see the GP refer Mr N to hospital had their assessment suggested heart problems caused his pain.
24. Chest pain caused by heart problems normally has a sudden or severe onset. Mr N had chest pain for 4-5 weeks, rather than a sudden onset. Exercise normally worsens chest pain caused by heart problems. We see exercise did not worsen his pain. Breathlessness may also indicate a heart problem. Mr N did not report he had bouts of breathlessness. Mr N’s chest pain was relived temporarily with Brufen which suggests a musculoskeletal cause for his pain.
25. The GP considered Mr N’s chest pain stemmed from his reflux disease. The GP changed Mr N’s medication from lansoprazole to omeprazole which he may have been able to tolerate in higher doses. The GP also scheduled a blood test and Electrocardiogram (ECG) which records the hearts electrical activity which may identify heart problems.
26. We carefully reviewed Mr N’s records to establish what happened on 29 April 2022. We compared the records against the NICE Guidance which tells us what should have happened.
27. Miss E says, the GP failed to consider Mr N had high cholesterol and a family history of heart problems which increased his risk of heart attack.
28. As we explained earlier, the purpose of the GP’s assessment was to identify or exclude a serious cause of Mr N’s chest pain which required immediate hospital admission. We appreciate what Miss E told us about Mr N’s heart attack risk. We see the GP was aware heart problems may have caused Mr N’s chest pain.
29. We appreciate Mr N died from heart problems 10 days after he presented to the Practice. We understand how the circumstances around Mr N’s death may lead Miss E to feel the Practice misdiagnosed Mr N on 29 April 2022.
30. We found the GP appropriately questioned and thoroughly examined Mr N in line with the NICE Guidance. The GP found no indication Mr N had a heart problem which required immediate hospital admission. The GP considered his chest pain stemmed from reflux problems. Based on the evidence, we agree with the GP’s conclusion. The GP changed Mr N’s medication and referred him for further investigation elsewhere.
31. We found nothing to suggest the GP should have referred Mr N for emergency treatment. We found no evidence of maladministration by the Practice. For this reason, we do not uphold Miss E’s complaint.