13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation complained about has got something wrong. We do this by comparing what should have happened with what did happen.
14. If we see signs something went wrong, we consider whether this had a negative impact which the organisation has not yet put right. If more needs to be done to put things right, we ask the organisation to do so. We do not investigate cases where a sufficient remedy has been provided.
Complaint about the delayed CT scan
15. GMC guidance says doctors must ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
16. When Mr Q was admitted to hospital doctors started treatment for his chest infection with antibiotics and steroids straight away. They then requested a CT scan on 24 March to rule out the possibility that his symptoms were caused by a tumour or a pulmonary embolism (PE - a blood clot in the lung).
17. The scan thankfully ruled out a PE and tumour, but it was delayed. It did not take place until 29 March, five days after it was requested. The Trust accepts there was delay here and said in its complaint response it should have been done within two days. The delay was not in line with GMC guidance.
18. We have therefore seen indications something went wrong here. Mrs W is concerned the delay affected her father’s chest infection treatment. Reassuringly we can see this is not the case, as he began treatment straight away when admitted and the timing of the scan did not affect this.
19. Although there was no clinical impact on Mr Q, we can see it caused Mrs W to worry this was the reason her father’s health got worse. She has told us this long standing worry has impacted her ability to grieve. We are sorry to hear this. At the end of this statement, we explain what the Trust has agreed to do to put this right.
Complaint about atrial fibrillation diagnosis and blood thinners
20. The GMC guidance says doctors must adequately assess patients. In practice, they should take account of clinical findings when reaching a diagnosis.
21. Mr Q was diagnosed with AF when he was readmitted to hospital in April. Mrs W thinks he likely had AF during the first admission too. In the first admission Mr Q received blood thinning injections due to the suspected blood clot. These were stopped when the blood clot was ruled out. Because Mrs W thinks her father had AF, she also thinks he should have stayed on blood thinners (as they treat AF too).
22. The medical records indicate doctors saw no signs of AF during the admission, for example when Mr Q was physically examined or when staff analysed his vital signs (particularly his heart rate, as a high heart rate can be a sign of AF).
23. Aside from manually testing the rate and rhythm of someone’s heartbeat, AF can be diagnosed during a test called an electrocardiogram (ECG). This is a test that detects the electrical signals from the heart via electrodes which are placed around the body.
24. The Trust did an ECG on 29 March. As far as we can tell from the medical records, this was the only ECG during the admission. Our physician adviser reviewed the ECG results and said they were suggestive of AF potentially indicating the GMC guidance was not met.
25. However, we cannot conclusively say Mr Q had AF during the first admission from this ECG alone. Our adviser also told us the ECGs done in April when AF was diagnosed show signs of AF much more clearly, meaning the diagnosis was also clearer and more obvious to staff.
26. Our adviser explained that if Mr Q did have AF in the first admission and this was diagnosed, he would likely have been prescribed blood thinners to take long term. The purpose of this medication would have been to reduce the risk of stroke, which is more likely to occur in people with AF as it increases the risk of dangerous blood clots forming.
27. In Mr Q’s case, he did not develop a blood clot or stroke. So, even if he did have AF and missed out on blood thinners, he was not worse off or negatively impacted by this.
28. We hope our explanations here give Mrs W some reassurance and help to resolve her worries. She became concerned about this issue more recently (she did not raise it during her initial complaint to the Trust) and therefore we do not think there is a specific longstanding injustice to Mrs W that needs addressing beyond the remedy provided by our decision itself.
Complaint about communication on 17 April
29. GMC guidance says doctors need to communicate effectively. They must give patients the information they want or need to know, in a way they can understand. In practice this means if there are significant changes to a patient’s condition or management plan, and the patient cannot update their loved ones themselves, staff caring for a patient should do this.
30. Mrs W says she heard nothing from the Trust on 17 April when her father deteriorated. The medical records show his vitals signs were very abnormal (showing he was seriously unwell) and a doctor felt he needed to be urgently treated with fluids to help correct this. He was prescribed fluids, but no one got in touch with Mr Q’s family.
31. The Trust has accepted it made a mistake here. In one of its complaint responses it said the ward team missed an opportunity to keep Mr Q’s family informed, and to give them a potential early warning that he might become more unwell.
32. In another response the Trust said Mrs W ‘should have been contacted when Mr Q became poorly on 17 April, this was a missed opportunity for you to be together and we are very sorry. This was shared with the ward team who are committed to improving communication between patients and their families when someone becomes unwell’.
33. Mrs W tells us that knowing she missed an opportunity to see her father, or at least know about his deterioration, has added to her grief. We are very sorry to hear this and understand how difficult this must have been for her.
34. We are satisfied the Trust has already acknowledged and apologised for its mistake and has addressed this with the ward. However, later in this statement we set out what else the Trust has now agreed to do to further put matters right for Mrs W.
Complaint about communication on 18 April
35. Mrs W says sometime after 7am on 18 April her mother called the ward for an update and was told to call back at 12pm. Mrs W also tried calling the ward around this time. We understand she and her mother must have been very worried. Mrs W says staff reassured her they would let her know if there was a problem with her father.
36. Mrs W says she received a call a short time later saying her father was very unwell and had deteriorated at 7.30am. Mrs W says the staff knew this when she and her mother called for an update, but this information was withheld.
37. According to Mr Q’s medical records, he deteriorated at 10am and not 7.30am. Things were stable up until 10am, when he suddenly became very unwell and staff put out a medical emergency call (an alert to specialist staff to rapidly attend to a patient with emergency needs). There is an entry in the notes from 10.20am where one of the doctors who attended to Mr Q called Mrs W to update her on the recent situation.
38. Therefore, it appears the Trust contacted Mrs W promptly when Mr Q deteriorated on 18 April. This was in line with what GMC good medical practice says (as set out above) about communicating effectively. There are no indications anything went wrong here. We hope this explanation helps to resolve this important matter for Mrs W.
Complaint about the death certificate
39. After Mr Q’s death, one of the Trust doctors completed his death certificate and said his primary cause of death was ‘COVID-19 infection’. They said ‘new atrial fibrillation and acute coronary syndrome’ were contributory causes of death.
40. In the Trust’s various complaint responses it explained that AF and ACS were listed because they had recently been diagnosed or were suspected, they were present at the time of death, and may have contributed. From the complaint responses it appears some Trust doctors feel it was acceptable for AF and ACS to be listed, and others disagree.
41. Our adviser told us it is difficult to be conclusive about what should be included on a death certificate. Doctors use their best judgement to determine what should be listed, and opinions may differ between doctors.
42. The death certificate guidance accepts that causes of death and contributory causes of death are not always completely irrefutable. It says ‘doctors are expected to state the cause of death to the best of their knowledge and belief; they are not expected to be infallible’.
43. AF and ACS were recorded in section 2 of the death certificate, which is where conditions that were present at time of death that may have contributed are listed. This would be a reasonable place to record these things, if the doctor completing the form felt they were relevant factors.
44. Given AF and ACS were included based on the doctor’s judgement and belief at the time, and taking into account what we know about this not being an exact science, we cannot say there are any indications of a failing here. We know this was a serious concern for Mrs W and we hope we have helped her understand why these things were listed.
Further steps the Trust has agreed to take to put matters right for Mrs W
45. The Trust has already accepted it made mistakes with the delayed CT scan and poor communication on 17 April. To further put matters right for Mrs W it has agreed to write an apology letter that acknowledges how these issues have caused her worry and impacted her ability to grieve and pay her £600 in recognition of this injustice. It will do this within four weeks of this decision.
46. We think these additional actions are enough to put things right for Mrs W, and we will therefore not consider the complaint further.