10. Mrs A complains the Trust have not recorded a correct medical diagnosis for her heart in her records following an echocardiogram on 3 April 2023. She says a BAV and HFpEF should be included in her records.
11. A BAV is an aortic valve that contains only two cusps (or flaps) instead of three. HFpEF is a complex clinical syndrome in which patients have symptoms and signs of heart failure, with left ventricular ejection fraction less than 50%.
12. The Trust did not uphold Mrs A’s complaint. The Trust explained the echocardiogram on 3 April showed stable results and a mild leakage in the mitral valve. The mitral valve is a small flap in the heart that stops blood flowing the wrong way.
13. The records show on 1 November 2022 Mrs A’s GP requested an up to date echocardiogram from the Trust. On 3 April 2023 Mrs A attended the Trust.
14. The medical records say Mrs A had mild bileaflet mitral valve prolapse and mild mitral regurgitation. It noted she had normal left and right ventricular size (lower chamber of the heart) and systolic function (the pressure when your heart pushes blood out around your body).
15. The Trust’s echocardiogram report dated 3 April notes the normal range for each measurement next to Mrs A’s measurement. We have reviewed the British Society of Echocardiography, Reference Intervals & Functional Assessment guidance. We can see the normal range listed on the Trust’s echocardiogram’s report is the same normal range listed in the British Society of Echocardiography’s guidance.
16. An example of this is the left ventricle internal diameter (LVID) diastole (the phase of the heartbeat when the heart muscle relaxes) normal range for a female is 3.5 to 5.1cm. This is the same as the Trust’s report. Mrs A has a LVID diastole of 3.6cm.
17. Our advisor told us the Trust’s diagnosis is sound. Mrs A’s echocardiogram showed mild mitral valve prolapse and mild mitral regurgitation. Our advisor says the echocardiogram showed normal function and measurements.
18. On 25 May the Trust wrote to Mrs A’s GP. The Trust confirmed no further action was needed.
19. GMC Good medical practice sets out, ‘You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.’
20. We can see on 25 May the Trust explained to Mrs A and her GP there was no further action to be taken. Mrs A’s diagnosis of mild bileaflet mitral valve prolapse and mild mitral regurgitation were included. This is in line with GMC guidance.
21. We acknowledge Mrs A’s concern she was not given a correct diagnosis. We understand this has caused her distress and frustration. We have considered the medical records. The Trust have recorded its findings within the echocardiogram report. Its description of the findings are in line with the British Society of Echocardiography. We are also persuaded by the clinical advisor the Trust’s diagnosis is sound. The Trust have given Mrs A the information she needs to know in line with GMC guidance. There is no indication of a failing.