The Trust did not treat her ‘slipped’ S-ICD when she attended its emergency department on 19 March 2024
14. Mrs N said the Trust totally misdiagnosed her issue. She was frustrated she and her husband were not listened to when they insisted Mrs N was not having a cardiac event and her pain was because her device had moved and needed repositioning.
15. The Trust emergency department triage nurse took a good history from Mrs N when she went to it on 19 March 2024. The clinical record documents Mrs N’s recent surgery, and her pain starting after Mrs N attended her follow-up clinic.
16. NHS England guidance says Trusts ‘must have robust processes that match patients with the service most suited to meet their clinical need’. It says the main objectives of initial assessment are to:
• ‘identify patients with potentially life-threatening conditions and injuries to ensure those with the most time-critical conditions are prioritised, • accurately assess non-life-threatening conditions and injuries so that appropriate prioritisation occurs for these patients, and they are seen by the right service within appropriate timeframes’.
17. An emergency department doctor assessed Mrs N. They conducted an echocardiogram (ECG - to rule out the possibility of a sudden cardiac event), chest X-ray (to rule out a pneumothorax, where air can collect in the cavity outside the lung and can be a complication of Mrs N’s S-ICD surgery), and took a full blood count (FBC) and conducted a c-reactive protein (CRP) Test (to rule out infection and inflammation around the S-ICD device).
18. Mrs N has an S-ICD fitted as she has a serious underlying heart condition. The Trust ED’s immediate responsibility to Mrs N was to prevent or rule out a cardiac emergency (by way of an ECG). This is even if Mrs N has told the Trust her pain was not related to her heart. This what the Trust did. Our adviser said these were appropriate first line investigations to rule out a potentially life-threatening condition in line with the guidance above.
19. After the Trust ruled out a cardiac event it conducted additional investigations to rule out a pneumothorax or infection (by way of a chest X-ray, FBC and CRP test). Our adviser was satisfied the Trust accounted for Mrs N’s concerns about her device and conducted investigations to rule out urgent device related complications. The Trust conducted additional investigations and accurately assessed Mrs N’s non-life-threatening condition. This is in line with the guidance above.
20. RCEM Clinical Guidance says patients with non-traumatic chest pain should be reviewed by a senior clinician. Our adviser said this does not need to be in person. The clinical record shows the Trust discussed and agreed a plan for further management with an ED consultant.
21. The NHS England Guidance says patients ‘should be made aware of who is responsible for their care’. This guidance also talks about redirecting patients to an appropriate service after triage and says ‘redirection is a choice offered to patients with full awareness that there is no transfer or formal handover of care’.
22. The clinical record documents ‘reassure patient, TTO [to take home] Oromorph – patient says she has it at home, increase Lansoprazole to bd dose [twice per day] Patient declined, said she’ll speak with her cardiologist’.
23. This is in line with the guidance referenced at point above. The Trust made sure Mrs N was aware of who was responsible for her care. Mrs N’s documented response indicates some awareness there was no transfer or formal handover of care (happening at that time) and she would speak to her cardiologist.
24. We have seen no indication the Trust’s actions on 19 March 2024 in assessing and treating Mrs N were not in line with the guidance we have referenced above. The Trust ruled out an emergency requiring prioritisation or immediate action. It confirmed Mrs N’s problem was likely device related and better managed by her cardiologist. It confirmed Mrs N would contact her cardiologist. It treated her with strong pain killers.
25. There was no need to involve a cardiologist immediately on 19 March 2024 and Mrs N record shows she had indicated prior to her discharge that she would speak to her cardiologist. The Trust assessed Mrs N and matched her with the service that most suited her needs. We will take no further action here.
26. We were sorry to hear this was not properly explained to Mrs N or she was not reassured by this plan. We will look at the discharge in the next section.
The Trust discharged her without addressing her concerns about the S-ICD on 19 March 2024
27. Mrs N was still complaining of 10/10 pain and was in a wheelchair upon discharge. After Mrs N spoke with a Trust nurse, the nurse appropriately sought senior advice. Mrs N was very upset the senior doctor did not come and speak with her.
28. The GMC guidance says the exchange of information between medical professionals and patients is central to good decision making. It says doctors ‘must treat each patient as an individual’ and ‘not rely on assumptions about treatment options or outcomes a patient will prefer, or the factors they will consider significant’.
29. Mrs N would have preferred to have been seen by a cardiologist and she considered the device to be a significant factor in her continued pain.
30. There was no immediate need to involve a cardiologist and Mrs N did not need to be seen as an emergency patient. We note the subsequent specialist outpatient follow-up was at a different hospital. Mrs N had indicated to the Trust she would contact her specialist cardiology team.
31. Communication in line with the GMC guidance should likely have involved the senior doctor giving Mrs N reassurance and speaking with her about the Trust plan for management of her pain (with analgesia) and to check her understanding of what to do next (contact her cardiologist). This is what Mrs N did after returning home and was seen by her cardiologist on 26 March 2024.
32. There are indications the Trust did not communicate this effectively or reassure Mrs N sufficiently before her discharge on 19 March 2024.
33. The Trust has acknowledged communication fell below the standard it expected and apologised for the frustration and distressed caused. It was sorry the rationale for the decisions was not explained before her discharge and they assured Mrs N they had spoken with doctor involved who had reflected upon this.
34. Our severity of injustice scale describes Level 1 injustice to be one where the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. This would typically arise from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.
35. We acknowledge it was an upsetting situation for Mrs N and Trust communication could have been better. We were reassured to see Mrs N did contact her cardiology specialist team after returning home and was seen on 26 March 2024. When Mrs N says she remained in excruciating pain on discharge, we have no evidence to say this continued after she got home or that the Trust painkillers was inadequate. We were glad to see sought no further intervention before she saw her specialist cardiology team on 26 March 2024. We accept she was uncertain about her situation, but this uncertainty was of short duration until she saw her cardiologist.
36. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have seen no indication the Trust has not already done enough to put right the impact of these events by way of an apology.
37. We are glad to hear Mrs N was able to resolve her issues quite quickly once she saw a cardiologist. Up to that point it must have been a difficult few days while she waited for her device problems to be fixed. We thank her for telling us about what happened.