Cardiac care and monitoring from September 2019 to April 2020 19. The heart has four chambers – two upper ones called the right and left atria, and two lower ones called the right and left ventricles. Blood passes through a valve before leaving each chamber of the heart. The aortic valve opens to let blood flow from the heart’s left ventricle (the main pumping chamber) to the rest of the body.
20. Mr G had mild to moderate aortic regurgitation (leak at the aortic valve) prior to his admission for chemotherapy on 16 October 2019. An echocardiogram on that October admission showed his aortic valve leak was severe.
21. The Trust carried out a CT pulmonary angiogram (CTPA, a scan of the lungs using X-rays). It found Mr G had pleural effusions (a build-up of fluid between a lung and the chest wall).
22. Point 15 of GMC ‘Good medical practice’ says doctors must adequately assess patients and promptly provide or arrange suitable advice, investigations or treatment where necessary. They must refer a patient to another practitioner when this serves the patient’s needs.
23. The aortic regurgitation guidelines say vasodilator therapy is indicated for long-term treatment in patients who have severe chronic aortic regurgitation and symptoms of left ventricular dysfunction but who are not candidates for surgery.
24. Our adviser said the findings from the CTPA should have prompted the Trust to prescribe a vasodilator medication to Mr G, such as Perindopril, in line with the aortic regurgitation guidelines. This medication is used to widen the blood vessels. This did not happen and we consider it a failing.
25. Spironolactone (used to treat fluid build-up due to heart failure) is indicated for symptomatic heart failure with reduced left ventricular function. Our adviser said this medication would also have helped to slow down the progression of his heart failure and improve his symptoms. Based on these comments, it would have been in line with the GMC guidance to prescribe this too.
26. Mr G went into hospital again in November. During that admission the Trust carried out a transoesophageal echocardiogram (‘TOE’, an endoscopy test to look at heart structure and function) to look into the aortic regurgitation.
27. The Trust concluded the aortic valve leak was due to degenerative valve cusps (flaps which open and close during each heartbeat) with no signs of endocarditis (infection at the aortic valve). Our adviser said the findings from the TOE were in keeping with severe aortic regurgitation and mildly reduced left ventricular function.
28. When the Trust discharged Mr G in November 2019, its intention was the cardiology team at the second hospital trust would follow him up. This did not take place until 26 April 2020.
29. The Trust says Mr G was under the care of the cardiology team at the second hospital trust between December 2019 and April 2020. The Trust’s decision to refer Mr G reflected point 15 of ‘Good medical practice’, about referring patients to other practitioners if this serves their needs. We understand the second hospital trust met to discuss his treatment options and management.
30. While Mr G was under the care of the cardiology team at the second hospital trust, he was also still having chemotherapy at the Trust. Our adviser explained in addition to Mr G’s heart condition, the Cytarabine chemotherapy he was having is recognised to cause cardiac complications especially heart failure.
31. This means the Trust should have ensured this risk to Mr G’s cardiac health was being monitored. We can see the Trust wrote to Mr G’s GP in February 2020 asking it to review the management of his heart valve disease.
32. Point 44 of the GMC guidance says doctors must contribute to the safe transfer of patients between healthcare providers. This means checking someone has taken over responsibility when their involvement has ended, and sharing relevant information with any clinicians involved in the care. The evidence shows the Trust acted in line with this.
Fluid overload on 18 December 2020 33. Fluid overload (also known as Transfusion Associated Circulatory Overload, TACO) is a type of acute transfusion reaction. This can happen when too much fluid is transfused or the transfusion is too rapid.
34. The JPAC guidance says TACO develops within 12 hours of transfusion. It can occur after transfusion of relatively small volumes if there are patient risk factors. The guidance says TACO is the leading cause of morbidity and mortality related to transfusion.
35. JPAC says ideally all patients, particularly those over 50, should have a TACO risk assessment before transfusion. Mitigating measures to reduce the risk include the use of diuretics (medication which helps get rid of extra fluid in the body) and transfusing slowly with closer monitoring.
36. NHS Blood and Transplant funds clinical audits to help improve patient care. Following 2017’s Transfusion Associated Circulatory Overload Audit, it recommended Trusts include a formal pre-transfusion risk assessment for TACO in hospital transfusion policies. It also recommended the use of a checklist highlighting risk factors, including being over 50.
37. Its other recommendations say in patients at risk of TACO clinicians should: • Monitor fluid balance • Prescribe one unit at a time and consider prescribing according to body weight • Transfuse at a slower rate • Consider use of a prophylactic diuretic • Monitor the observations closely, including oxygen saturations • Review the patient following each unit.
38. Mr G’s echocardiogram from April 2020 showed he had heart failure secondary to severe aortic regurgitation and moderate left ventricular dysfunction. He was also over 50. This indicates the Trust should have considered his risk of TACO and whether mitigating measures were necessary. We consider it a failing there is no evidence of this.
39. Our adviser explained for a patient with a history of heart failure, like Mr G, the intravenous fluid and blood transfusion should have been given extremely cautiously. This is because the likelihood of heart failure decompensation (worsening signs and symptoms) in those patients is high. In practice, this means administering them only if necessary, at a slower rate and with additional diuretics.
40. In looking at this, we have taken account of the records. The information the Trust provided does not reflect points 19 and 21 of GMC ‘Good medical practice’. They say clinical records should be made at the same time as the events being record or as soon as possible afterwards. They should include any drugs prescribed or treatment.
41. We have seen no contemporaneous records from the Trust. The Trust has provided no evidence it acted in line with the JPAC recommendations about transfusing slowly. We consider there is a failing, on balance, in the administration of the infusion based on the evidence we have seen.
42. The third hospital trust carried out a CT pulmonary angiogram (CTPA, a scan of the lungs using X-rays) on 20 December. Our adviser said Mr G’s lungs showed features of pulmonary oedema (a condition caused by too much fluid in the lungs) which are likely due to fluid overload.
43. Our adviser explained the records say Mr G was short of breath and needed oxygen. This indicates fluid overload had affected his lung function. In this situation, intravenous diuretics would be given in sufficient dosage to help the lungs.
44. Our adviser noted pulmonary oedema was a complication Mr G had previously experienced, in an earlier period of care. This should have prompted a joined up approach to managing chemotherapy and transfusion complications between haematology and cardiology at the Trust.
45. We therefore consider there was a failing in the care the Trust provided after the infusion too.
46. Mr G’s cardiac enzyme NT-proBNP, a marker for heart failure, was very elevated on 26 December. Unfortunately, Mr G deteriorated and his chest X-ray on 2 January 2021 showed signs of pulmonary oedema.
47. NICE NG106 says very high levels of NTproBNP carry a poor prognosis. A level of 2000 is considered very high.
48. Our adviser explained Mr G’s level, 7766, indicated heart failure decompensation. This is a common and potentially serious cause of acute respiratory distress, and symptoms can be severe enough to require urgent care.
49. Our adviser said Mr G had also been treated with antibiotics for chest infection and was COVID-positive too. This may have caused an overlap of signs in his lungs and chest X-ray with pulmonary oedema.
50. We have seen there was an issue with planning, risk assessing and taking appropriate measures to mitigate the risk of the blood and fluid transfusion. We consider this a failing.
51. We recognise Mr G’s clinical condition was complex. Our adviser explained both chest infection and pulmonary oedema were possible differential diagnoses. That said, there are enough features on his lung images and blood tests to indicate the way in which the Trust carried out the transfusion likely affected his heart failure decompensation. Our adviser said it is likely this made a major contribution to his deteriorating respiratory failure and death.
52. Our adviser said if the Trust had given the blood transfusion (and intravenous fluid) cautiously knowing Mr G was a high-risk transfusion patient, this would have had a greater than 50% chance of preventing his death from heart-related issues during that admission.
53. In thinking about the impact of the failings we have seen, we have taken into account Mr G’s leukaemia. We recognise this would have affected his longer term prognosis.
54. Whilst we cannot say exactly how much longer Mr G would have lived for, what we can say is, on the balance of probabilities, it is likely he would have survived longer than he did had the Trust acted in the way it should have done. Knowing this, and the way in which Mr G spent his final weeks, has compounded Mrs C’s grief.