Hospital Trust
Failure to investigate 19. Mr R complains that the Hospital Trust failed to diagnose his father’s heart failure. He also complains the Hospital Trust failed to investigate his father’s swelling caused by fluid retention (oedema) and low sodium levels (hyponatremia).
20. NICE guidelines say that typical symptoms of heart failure are breathlessness, fluid retention, fatigue and light-headedness.
21. Mr R presented to the Hospital Trust’s ED on 1 January with swelling to his left leg and pain in his ankle, leg and knee. He had slipped two days before the attendance. The Hospital Trust carried out an X-ray which found no fractures and the swelling was thought to be due to a sprained ankle.
22. Patient.info website says that swelling in one leg could be caused by injuries, joint inflammation or deep vein thrombosis among other possible causes.
23. Our physician adviser explained that as Mr R presented with swelling of only one leg it was reasonable for the Hospital Trust to identify the fall as the reason for the swelling and there was no reason to suspect heart failure at that time. Therefore, it appears for this attendance the Trust did not fail to diagnose heart failure and did investigate his swelling and made a diagnosis based on how he presented.
24. Mr R attended the Hospital Trust’s ED again on 7 April with shortness of breath and pain on the left side of his chest, his leg swelling was also noted.
25. As explained above some of the typical symptoms of heart failure are breathlessness and fluid retention which Mr R was now presenting with. NICE guidelines on diagnosis of heart failure say clinicians should perform an Electrocardiogram (ECG), chest X-ray and blood tests. It says attempts should be made to exclude other disorders that present in a similar manner.
26. The Hospital Trust carried out a chest X-ray and blood tests. Nothing came back as abnormal. The Hospital Trust suspected his diagnosis was costal chondritis, which is an inflammation of the tissue between the ribs and breastbone. NICE guidelines say that typical symptoms for costochondritis include chest pain, difficulty breathing, breathlessness and dizziness.
27. Based on the evidence we have seen it appears the Hospital Trust carried out investigations outlined in the NICE guidelines to rule out heart failure and considered another disorder that presents in similar manner. It then made a diagnosis based on the most likely cause.
28. The patient.info website lists the treatment of costochondritis as use of relaxation techniques, painkillers such as paracetamol or ibuprofen, possible use of steroids or no treatment and monitor to see if the condition improves. The Hospital Trust advised Mr R that if the pain continued, he should speak to his GP or if pain became severe then he should return to the ED. It also asked his GP to consider investigation for heart failure if his symptoms continued.
29. Based on how Mr R was presenting at that time of this attendance it appears the Hospital Trust considered his symptoms and carried out investigations to make a diagnosis of costochondritis in line with the guidelines above. Clinicians will, in general, investigate the most common possible condition that covers the patients’ symptoms. Only after treatment for these conditions fail will they consider more unlikely conditions.
30. At this attendance the Hospital Trust also suspected Mr R’s swelling could be caused by deep vein thrombosis (DVT) or a pulmonary embolism (PE). This led the Hospital Trust to carry out a CT scan on 13 April as an outpatient, which identified his large artery going to the heart (ascending aorta) was enlarged (aneurysmal). As a follow up to this, the Hospital Trust carried out an ECG during an outpatient appointment on 20 April. This did not identify anything abnormal besides the enlarged artery. It planned surgery to repair the artery.
31. The ECG recorded Mr R’s left ventricle ejection fraction (LVEF), the function of the left side of the heart, was over the ECG and Echo Learning lower limit of 55%. Due to this it was not necessary for the Trust to carry out any further investigations at the time into heart failure or the swelling.
32. The Hospital Trust measured Mr R’s sodium levels at 126 mmol/l on 12 May during an appointment about his artery replacement. NICE guidelines define low sodium levels as below 135 mmol/l. It also says moderate levels of sodium are between 125-129 mmol/l. The guidance says to discuss with an endocrinologist whether referral is needed if the levels are moderate.
33. Mr R was admitted for surgery on 15 May in preparation for his surgery on 21 May. An endocrinologist assessed his low sodium levels and because they showed no symptoms the Hospital Trust decided this could be investigated further by Mr R’s GP and he did not need a referral that time.
34. Our physician adviser explained that referring the further investigations to Mr R’s GP was appropriate as he was not experiencing any symptoms, and it was not clear how his sodium levels would change over time.
35. Unfortunately, Mr R had a fall on 21 May which caused his surgery to be delayed.
36. The Hospital Trust considered heart failure on 23 May as blood test results during his admission were abnormal. Due to this it carried out a B-type Natriuretic Peptide (BNP) test to investigate. BNP is a hormone that indicates how hard the heart is working to pump blood. The test result from 24 May showed Mr R’s BNP level was 137 ng/l. NICE guidelines say heart failure is unlikely below 400 ng/l. At this time the Hospital Trust ruled out heart failure due to him not meeting this criteria.
37. Patient.info website lists diuretics as a possible treatment for swelling. The Hospital Trust discharged Mr R on 24 May with medications including Bendroflumethiazide, a diuretic as his leg was still swollen. The Hospital Trust also asked Mr R’s GP to assess whether he needed further investigations into possible causes of his low sodium levels.
38. By providing the diuretic the Hospital Trust has shown that it had identified, and was taking steps to try and relieve, Mr R’s leg swelling, given that again there were no indications he had heart failure.
39. Mr R attended the Hospital Trust again on 15 July in preparation for his artery surgery on 23 July. During this time the Hospital Trust tried to balance Mr R’s leg swelling and treatment for his low sodium levels. The Hospital Trust treated Mr R’s low sodium levels by restricting his fluid intake to one litre, started sodium chloride to maintain hydration and increase his sodium levels and stopped his diuretic which he was taking for the swelling.
40. Mr R’s sodium level was measured as 131 on 23 July, which was an improvement from May and classified as mild levels of sodium. During Mr R’s admission his sodium levels varied between 114 (following his operation) and 131, with it being 123 when he was discharged to the Partnership Trust for rehabilitation on 13 August. It was listed as 128 when the Partnership Trust discharged him on 20 August.
41. The Hospital Trust made the decision to stop the diuretic that Mr R was taking to manage his swelling. Our cardiologist adviser explained that it would have been preferrable for the Hospital Trust to continue the medication, however it had to make the decision that the treatment of Mr R’s low sodium level was of a greater importance.
42. From this we can see the Hospital Trust followed guidelines to treat Mr R’s symptoms during his admission from 20 July to 13 August, but he had two conditions that needed different treatments and impacted on each other. It appears to have used clinical judgement to decide which symptoms most needed treatment and continued to monitor this which is in line with the above guidance for these symptoms and GMC guidelines which say clinical judgement should be used to assess the effectiveness of different treatment options.
43. The Hospital Trust does not appear to have considered heart failure again during this admission as his swelling symptoms had not changed and he was in hospital for surgery for another condition. It did however prescribe Mr R with bisoprolol, a blood pressure and heart failure medication, on 28 July as a precaution following his surgery.
44. Our cardiology adviser explained that due to Mr R’s low sodium levels, bisoprolol would have been the only available medication to treat heart failure, had the Hospital Trust found that to be the case.
45. The Hospital Trust discharged Mr R to a community rehabilitation centre in the Partnership Trust on 13 August with amlodipine, a blood pressure medication, bisoprolol and sodium chloride to treat his low sodium levels. The Partnership Trust discharged him to his home on 20 August.
46. The Partnership Trust’s discharge plan asks Mr R’s GP to carry out a blood test in two to three weeks and to monitor his swelling. It did not recommend treatment for the swelling at that time as Mr R’s low sodium levels was the Partnership Trust’s primary concern.
47. Our physician adviser explained that the Hospital Trust’s actions were in line with the relevant guidelines above throughout this period. Once Mr R’s low sodium levels had been identified it made the decision to stop the diuretics in an attempt to find a balance between treating his swelling and low sodium levels. They explained this was especially important when Mr R was discharged home where constant observations could not be carried out.
48. Mr R attended the Hospital Trust’s ED on 2 September with chest pain and his swelling had progressed up to his scrotum. The Hospital Trust started diuretics again to try and treat his swelling in balance with treating his low sodium levels, which were measured at 130 so had increased. The Hospital Trust identified heart failure as a possible diagnosis whilst he was in the ED and provided him with another dose of bisoprolol.
49. The Hospital Trust completed another BNP test which showed level to be 3246 ng/l. NICE guidelines say levels above 2000 ng/l suggest heart failure is likely. The Hospital Trust prescribed Mr R with furosemide in an effort to relieve his swelling and improve his heart failure symptoms as these were now the most significant symptoms he was suffering from.
50. The Hospital Trust spoke to Mr K and explained it believed Mr R had heart failure however it would not be able to confirm this until it had carried out an ECG. It completed a CT angiogram pulmonary, imaging of the pulmonary arteries, which identified Mr R’s heart had an enlarged right side and a build-up of fluid between his chest wall and lungs.
51. It also carried out an ECG on 11 September which identified an atrial flutter, an interruption of the regular heartbeat, moderate enlargements of both sides of the heart and a partial collapse of the vena cava, a vein that brings deoxygenated blood back to the heart.
52. The Hospital Trust increased Mr R’s bisoprolol dosage from 2.5mg per day to 10mg per day. BNF guidelines say 10mg a day is the highest dosage advisable to treat heart failure. The Hospital Trust also notes that it was able to control Mr R’s atrial flutter through medication and did not need to carry out an operation to fix this.
53. The Hospital Trust completed another BNP test on 17 September which showed Mr R’s BNP level was 2071 ng/l. This showed that the Hospital Trust’s treatment was improving his heart failure condition.
54. From the records that we can see the Hospital Trust did diagnose Mr R with heart failure when he had further new symptoms and these were investigated by 11 September at the latest. We cannot determine when Mr R developed heart failure, though we can say it was sometime between 24 May and 11 September.
55. We can see that the diuretics affected Mr R’s sodium levels as it had reduced to 113 by 15 September. In response to this the Hospital Trust reduced his diuretic dosage and restricted his fluids. An endocrinologist reviewed Mr R on 16 September and recommended further fluid restrictions. By 30 September the sodium level had recovered to 129 on 30 September and then 133 by 3 October.
56. Our physician adviser explained that although Mr R’s low sodium levels continued to be an issue, this did not mean that the Hospital Trust had failed to investigate and treat his sodium levels. His other health conditions made the management and treatment of both his low sodium levels and swelling more complicated than it would have been without the other condition.
57. It is unfortunate that the Hospital Trust was unable to relieve Mr R of his swelling or low sodium levels however we can see that the Hospital Trust made efforts to treat both conditions through the use of diuretics and sodium chloride when it could. Our adviser explained that the presence of the other health condition made the treatment for both very complicated, and the Hospital Trust did its best to balance the treatment of both conditions.
58. It is understandable that Mr K would be frustrated with the persistence of his father’s swelling and low sodium levels and that his heart failure was not identified earlier. We have not seen that the Hospital Trust did anything wrong regarding its investigations of Mr R’s leg swelling, low sodium levels or heart failure. It appears to have investigated, diagnosed and treated the symptoms as they presented during this time in line with the relevant guidelines as explained above. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Mr K some reassurance about what the Hospital Trust did.
Failure to diagnose 59. Mr K complains the Hospital Trust failed to identify a dislocation in his father’s shoulder on 21 May 2021. This was later identified after an X-ray on 24 May.
60. Mr R attended the Hospital Trust on 12 May in preparation for surgery that was due to take place on 21 May. Mr R had an unwitnessed fall on the morning of 21 May which forced the Hospital Trust to cancel the surgery. After the fall the Hospital Trust carried out a CT scan on Mr R’s head as he had hit his head. This scan did not identify anything of concern.
61. The notes say Mr R had pain in his left arm after the fall and an X-ray was requested on 21 May. At 6.55pm the notes say that he was due to have a 72 hour follow up CT scan and this mentions the X-ray again. It is not clear if this was to be completed at the same time as the CT scan or that it was requested at the same time.
62. GMC guidelines say that patients should be referred for treatment as it matches patient’s needs. By carrying out a CT scan and an X-ray we can see the Hospital Trust acted in line with these guidelines.
63. The Hospital Trust carried out the X-ray on 23 May and the report was completed on 24 May. This showed a type IV dislocation. This is a dislocation of the joint between the acromion, the shoulder blade, and the clavicle, the shoulder bone. It is unclear from the records when exactly the dislocation was identified however it was discussed before Mr R’s discharge on 24 May.
64. The discharge form from 24 May says that Mr R was due to be seen by the outpatient fracture clinic. The Hospital Trust asked Mr R’s GP to make sure this was completed. Our cardiologist adviser explained that a fracture clinic appointment would not be made unless the Hospital Trust had identified the dislocation.
65. A physiotherapist note from 27 May says that Mr R was for conservative, non-operative, management.
66. It is unfortunate that the Hospital Trust did not carry out an X-ray before 23 May however once it became clear that the pain in Mr R’s left shoulder was not going away, it arranged for an X-ray to be completed. As the Hospital Trust arranged for an outpatient clinic appointment and did not intend to carry out any operational intervention, we can see that the delay did not alter the Hospital Trust’s treatment decision and therefore there was no loss of treatment.
67. It is unfortunate that Mr R had a delay in the diagnosis of his shoulder dislocation however he was already receiving paracetamol to treat his pain, and he did receive an outpatient appointment. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Mr K some reassurance about what the Hospital Trust did.
Lack of services 68. Mr K says his father was a vegetarian however he was given non-vegetarian food. He says the Hospital Trust failed to provide vegetarian food leading to his father not being able to eat properly during his admissions. He says this contributed to his father’s low sodium levels.
69. Mr K has provided us with a food diary of what his father was provided with between 3 September and 1 October. During this time the Hospital Trust provided him with non-vegetarian meals on 12 occasions.
70. NMC guidelines say that nurses should recognise diversity and individual choice. Our physician adviser explained they would expect alternative meals to be available for patients depending on their food preferences.
71. From the records it appears the Hospital Trust did not follow appropriate guidelines in providing food to Mr R.
72. In the Hospital Trust’s response, it apologised that Mr R was not given vegetarian options and said it has spoken to staff to make sure appropriate options are always available to meet patient’s needs.
73. From the records we can see that the Hospital Trust was providing treatment to balance Mr R’s sodium levels with treatment for his leg swelling. Due to this it is unlikely that Mr R missing a meal would have had an impact on his sodium levels.
74. It is unfortunate that the Hospital Trust failed to provide Mr R with meals at times during his admission however we cannot link this to the impact that Mr K is claiming. We can also see that the Trust has apologised and implemented learning from this failing, which is what we would expect the Hospital Trust to do. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Mr K some reassurance about what the Hospital Trust did.
Incorrect reporting of death 75. Mr K complains the Hospital Trust said other factors, such as bowel perforation, were the main contribution to his father’s death, rather than the heart failure. He believes that his father’s heart failure was a big part of his death and the failure to recognise this was to cover up its failings.
76. The Hospital Trust’s death certificate lists Mr R’s causes of death to be:
77. a) Large bowel perforation b) Ischaemic bowel c) Atrial flutter
78. Congestive cardiac failure (another term used to describe heart failure.)
79. The Hospital Trust’s complaint response says ‘Having said that, Mr R developed several other problems (sternal infection, bowel perforation) which were not related to his heart failure and also contributed to his death directly’.
80. Reading this it appears that the Hospital Trust does acknowledge that Mr R’s heart failure contributed to his death however it was not the only cause.
81. Mr R developed abdominal distension (swelling) around 1 October, and he complained this was causing him pain. The Hospital Trust carried out a CT angiogram on 1 October that did not identify any bleeding from blood vessels in the abdomen.
82. NICE guidelines say a CT scan should be offered within 24 hours of acute diverticulitis, inflammation of the intestines, which can be indicated by swelling of the abdomen. The Hospital Trust acted in line with these guidelines by providing a CT scan on 1 October.
83. This pain continued on 2, 3 and 4 October so the Hospital Trust carried out a CT scan of his abdomen on 4 October. This scan identified gas in the abdomen, but it could not identify the site of the bowel perforation. Three different consultants gave their opinions, and it was decided that an operation to fix this would not provide a positive outcome.
84. The Hospital Trust prescribed Mr R with IV gentamicin, an antibiotic. This is in line with the antibiotics suggested by the NICE guidelines.
85. Our physician adviser explained that the bowel perforation likely occurred due to lack of blood supply (ischaemia) to the bowel, which combined with Mr R’s other conditions caused the perforation.
86. Unfortunately, Mr R continued to deteriorate so he was admitted to the critical care unit (CCU) on 5 October. The Hospital Trust then put Mr R on end-of-life care on 6 October. A palliative care review believed he was likely dying due to co-morbidities including the ischaemia of his bowel. Mr R passed away at 8pm on 6 October.
87. As the Hospital Trust was primarily treating Mr R for bowel perforation at the time of his death this was listed first in his causes of death.
88. Our cardiology adviser explained the bowel perforation was likely caused by a blood clot due to arrhythmia, an irregular heart rhythm. The risk of arrhythmia is increased by the presence of heart failure. In this sense Mr R’s heart failure may have contributed to the bowel perforation. However, we can see that the Hospital Trust was treating Mr R’s heart failure, as explained above, and there was nothing further it could have done to treat it.
89. Our physician adviser also explained they did not think that alternative management would have produced a different outcome.
90. While it is likely that Mr R’s heart failure did contribute to the development of his bowel perforation, we can see that the Hospital Trust provided all possible treatment for both his heart failure and bowel perforation.
91. As the Hospital Trust did diagnose Mr R’s heart failure, provided treatment and included it on his death certificate, we cannot say that the Hospital Trust has tried to cover up the causes of his death.
92. It is understandable that Mr R’s death would have caused Mr K distress and that he was frustrated by what he saw as a lack of action by the Hospital Trust. We have not seen that the Hospital Trust did anything wrong regarding its reporting of Mr R’s death. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Mr K some reassurance about what the Hospital Trust did.
Partnership Trust
Discharge 93. Mr K complains that his father was not discharged appropriately by the Partnership Trust on 20 August. He believes this because his father attended the Hospital Trust on 2 September and was diagnosed with heart failure.
94. The Hospital Trust discharged Mr R to a rehabilitation unit in the Partnership Trust on 13 August as part of a step down for an overall discharge. Mr R was deemed not to need acute care however the Hospital Trust asked the Partnership Trust to improve Mr R’s sodium levels before he could be discharged home.
95. Blood test results show that Mr R’s sodium level was 123 on 13 August, shortly before his transfer to the Partnership Trust.
96. NHS discharge guidelines say that patients can be considered for discharge if they do not meet a set criteria. This criteria includes a need for oxygen, intravenous (IV) fluids or medication, functional impairment or surgery with 72 hours. Mr R did not meet any of these criteria.
97. Blood test results show that Mr R’s sodium levels was 127 on 16 August. The Partnership Trust reviewed Mr R on 19 August and explained that if his sodium level had improved to at least 128 then he would be considered for discharge. Blood test results show his sodium level was 128 on that day.
98. During the review the only other concerns Mr R raised were regarding his swelling and a rash he had recently developed. The doctor explained that if his sodium levels continued to improve then diuretics could be considered at a later time to treat the swelling. They also prescribed antihistamines to treat the rash as no new medication had been started recently, so that could not be the reason for the rash.
99. The discharge summary explains to Mr R’s GP that he should continue to take the sodium tablets and restrict his fluid intake to one litre. It asks the GP to complete another blood test in two to three weeks to monitor his sodium levels and to monitor his swelling.
100. From the records we can see that the Partnership Trust acted in line with relevant guidelines in its decision to discharge Mr R as he did not need treatment that required hospital admission at that time.
101. Although Mr R was deemed to be medically fit for discharge this does not mean that he was fully fit and did not require further treatment and monitoring. His sodium levels appeared to be improving, and it was not presenting any side effects at this time, and it was hoped with continued treatment it would eventually reach the normal range.
102. Unfortunately, Mr R’s health deteriorated, and he was admitted to the Hospital Trust on 2 September. It is understandable that Mr K may see this as a failure of the Partnership Trust however he was medically fit for discharge at the time and did not require hospital intervention at the time. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Mr K some reassurance about what the Partnership Trust did.
103. It is unfortunate that Mr K had to witness Mr R’s deterioration and pain, and it is understandable that he found this distressing. We have not seen that the Hospital Trust did anything wrong in how it investigated Mr R’s heart failure, swelling and low sodium levels, how it investigated Mr R’s dislocated shoulder, the food it provided to Mr R and the reasons it gave for Mr R’s death. We also did not see that the Partnership Trust did anything wrong with its discharge of Mr R. Therefore, we will not be taking further action to investigate this complaint and apologise for any distress this decision may cause him.
104. We can clearly see from what he told us how distressing events were for Mr K and his family. We hope our explanations have given Mr K some reassurances that nothing went wrong with Mr R’s treatment and provide him with some closure on the events. Mr R was suffering from a number of conditions, and he deteriorated over several months despite different treatment being given. We hope Mr K is reassured that based on what we have seen it does not appear that his father’s death was caused by the Trust failing to take action.