32. Mrs O complains that the Trust made her husband wait too long for quadruple bypass surgery. She feels this should have happened sooner.
33. Our cardiac surgeon adviser said there are no specific guidelines that mandate the timing of cardiac surgery.
34. In lieu of specific guidelines, the GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.
35. The guidance explains doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer to another practitioner when this serves the patient’s needs.
36. Mr O first attended the emergency department with chest pain on 4 February 2019. He had collapsed the previous day after feeling dizzy. Doctors suspected he had atrial fibrillation (a condition that causes an irregular and often fast heartbeat) and admitted him to hospital.
37. On 7 February members of the cardiology, cardiac surgery and neurosurgery discussed Mr O in a multidisciplinary team (MDT) meeting. The team agreed Mr O needed a nonemergency coronary artery bypass graft (CABG) to treat his coronary heart disease.
38. During the MDT meeting, clinicians noted that a recent MRI showed evidence of an injury on Mr O’s neck. The neurosurgery team said Mr O would need to wait around two months for the injury to heal before staff added him to the waitlist for surgery. This meant Mr O could not go onto the waitlist for surgery until April.
39. GMC guidance makes it clear that doctors must only provide treatment when they are satisfied this serves the patient’s needs.
40. Performing surgery in February 2019 before Mr O’s neck injury had healed would have meant he was at high risk of bleeding that could have resulted in him being paralysed. Our cardiac surgeon adviser explained that having surgery at this point would not only have negatively impacted the outcome of surgery but may also have affected his recovery and rehabilitation too.
41. On balance, we consider it likely that performing surgery in February would have had the potential to severely negatively impact Mr O. Our adviser said that a deliberate delay of two months to allow his neck injury to heal was appropriate in this scenario. The evidence suggests performing surgery in February would not have met Mr O’s needs as it was likely this would have led to him experiencing a poor outcome. We consider the Trust’s decision to delay surgery by two months was in line with GMC guidance.
42. Mr O attended hospital again on 18 March with chest pain. During this admission staff asked a cardiac surgeon to expedite surgery. The cardiac surgeon explained it was not possible to perform surgery at this stage as they were still within the recommended twomonth delay period.
43. Mrs O says her husband became more unwell between February and March and feels staff should have expedited his surgery because of this. Our cardiac surgeon adviser reiterated it was appropriate to make him wait for surgery given the risks involved with doing this too soon. They said the surgeon handled the request to expedite surgery in line with clinical best practice and did not receive a further request after this.
44. As we explain above, the decision to delay surgery by two months was in line with GMC guidance. We do not consider doctors should have performed surgery in March.
45. On 9 April a cardiac surgeon wrote to Mr O explaining he was now on the waitlist for surgery. There is no specific guidance that specifies a timeframe for carrying out an elective CABG. Our cardiac surgeon adviser explained this typically takes place within three months of the patient going onto the waitlist. Meaning it was likely that Mr O would undergo surgery by July 2019.
46. Mr O returned to hospital for a third time on 17 May as he was experiencing chest pain. Staff admitted him to a ward as they suspected he had acute coronary syndrome.
47. On 24 May Mr O had an echocardiogram which showed deterioration since his last echocardiogram in February. In response to the result, that day staff made a cardiac referral to expedite surgery which resulted in a surgery date of 28 May.
48. The evidence indicates it was not possible for Mr O to be on the waitlist for surgery until April 2019. We can see the Trust added him to the waitlist as soon as the twomonth period had ended. This is in line with GMC guidance which says doctors must promptly arrange suitable treatment.
49. Mr O was on the waitlist for an elective CABG. Elective surgery is surgery that doctors schedule in advance as it does not involve a medical emergency. For this procedure surgery typically takes place within three months of a patient going onto the waitlist.
50. Mr O had been on the waitlist for around five weeks when he returned to hospital with chest pain. At which point staff noted he had deteriorated and urgently arranged surgery.
51. We recognise that Mrs O feels her husband should have received surgery much sooner. We understand her husband felt unwell whilst waiting for this and accept this was distressing to witness. Nowhere in guidance does it stipulate a timeframe for doctors carrying out elective cardiac surgery. The evidence shows that the earliest point staff could place Mr O on the waitlist was April.
52. We do not know how long the waitlist was at the point staff added Mr O. But Mr O received surgery around one month and three weeks after he went onto the waitlist. Meaning the Trust provided this within expected timeframes.
53. Whilst we understand Mrs O disagrees with the timing of surgery, we have seen no evidence that Mr O experienced a delay in receiving surgery. We consider the Trust arranged suitable treatment in line with GMC guidance. We have found no failing in this aspect of the complaint.
Water tablets before surgery
54. Mr O complains the Trust delayed providing her husband with water tablets before surgery.
55. Our cardiac surgeon adviser said there are no specific standards or guidelines that recommend the use of water tablets (diuretics) prior to cardiac surgery.
56. In lieu of specific guidance, the GMC guidance says doctors must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
57. In this context, doctors would typically use diuretics to treat excess fluid build-up. Our cardiologist adviser explained that echocardiograms are used to detect this. Clinicians performed an echocardiogram on 7 February. Our cardiac surgeon adviser said there was no indication from that test that Mr O had any excess fluid at this time, meaning there was no need for doctors to prescribe diuretics.
58. Mr O returned to hospital on 18 March feeling generally unwell and short of breath. During this admission doctors examined Mr O and felt that his symptoms were linked to his beta-blockers as Mr O said he felt better when he was not taking a beta blocker.
59. Clinicians discontinued his beta blocker and arranged for a trial of isosorbide mononitrate (also known as ISMN, a drug used to prevent chest pain in patients with coronary artery disease) to see if it improved his symptoms. They discharged Mr O the following day back to the care of his GP.
60. Mrs O says she feels doctors should have performed an echocardiogram in March and prescribed her husband diuretics. Our cardiac surgeon adviser said an echocardiogram would only be necessary if clinicians had concerns about Mr O’s cardiac function.
61. There is no documentation of any change in cardiac function in the clinical records between 18 March and 19 March. This means we cannot say an echocardiogram should have taken place, nor can we say doctors should have prescribed Mr O with diuretics during this admission.
62. The first mention of excess fluid in the clinical records is from a physiotherapy review on 4 June. This was after Mr O had surgery. There is no evidence that Mr O had any excess fluid until after he had surgery. Meaning there was no indication he needed water tablets before the surgery.
63. GMC guidance says doctors must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs. The evidence suggests that there was no clinical need for staff to prescribe Mr O with diuretics before surgery. We find no failing in this aspect of the complaint.
Monitoring on waitlist
64. Mrs O complains the Trust did not monitor her husband whilst he was on the waitlist.
65. Both our advisers explained there are no specific standards or guidelines for monitoring patients whilst on the waitlist for cardiac surgery. Again, we refer to GMC guidance which says doctors must adequately assess the patient, examine where necessary and provide or arrange suitable advice, investigations, or treatment.
66. Our advisers said that both cardiologists and cardiac surgeons would be expected to be responsive to any changes in a patient’s condition.
67. The Trust added Mr O to the waiting list on 9 April where he remained for around five weeks. We have seen no evidence that he reported any deterioration to his GP or the cardiology team during this time. Meaning clinicians were not aware of any change in condition or need for further care whilst he waited for a surgery date.
68. It is not clear from Mrs O’s complaint to us what monitoring she feels should have taken place. Mrs O says her husband was becoming increasingly unwell whilst on the waiting list. We have been unable to support this with evidence from the clinical records which suggests he did not report those symptoms to his treating clinicians.
69. The NHS constitution says individuals have a responsibility to take care of their own health. It says they should provide accurate information about their health to healthcare providers. We have not been able to establish whether Mr O’s condition changed whilst on the waiting list as he did not attend hospital or report any change in condition to his GP between 9 April and the admission in May.
70. When Mr O attended hospital on 17 May staff promptly identified his condition had changed and arranged surgery. We consider it likely staff would have arranged suitable investigations or care had Mr O attended hospital or reported a change in condition to his GP between April and 17 May.
71. We understand Mrs O feels the Trust should have monitored her husband whilst he was on the waitlist. Nowhere in guidance does it stipulate that clinicians must monitor patients for potential deterioration whilst on the waiting list for surgery. We have not found a failing in this aspect of the complaint.
Discharge
72. Mrs O complains that the Trust discharged her husband when he was not well enough on four occasions.
73. There are no specific standards or guidelines on discharging a person with cardiac issues from hospital. As we have explained, GMC guidance on good medical practice says doctors must adequately assess a patient, carry out a physical examination where necessary and promptly provide or arrange suitable advice, investigation, or treatment where necessary.
Discharge - first admission
74. Mr O first attended the emergency department on 4 February 2019 with chest pain. His GP had referred him following a fall the day before. During the admission staff carried out an echocardiogram and decided he needed a CABG. Staff also carried out an MRI which identified the presence of an injury on his neck. The multidisciplinary team recommended a two month wait to be added on the waitlist to allow this to heal.
75. As we explain in an earlier section of this report, the decision to delay adding Mr O to the waitlist for an elective CABG was in line with GMC guidance. Our cardiac surgeon adviser confirmed that clinicians assessed Mr O, carried out suitable investigations and arranged follow up. They said this was in line with clinical best practice and therefore in line with GMC guidance.
76. We have not seen any evidence that Mr O required any further hospital treatment at this time and therefore the decision to discharge him on 8 February was clinically appropriate. We have not found a failing in this aspect of the complaint.
Discharge - second admission
77. Mr O returned to hospital on 18 March following a GP referral for generalised weakness. During this admission doctors assessed him, identified his symptoms were likely related to medication and made changes to his prescription. Our cardiac surgeon adviser confirmed this was clinically appropriate and in line with GMC guidance.
78. Mrs O feels staff should not have discharged her husband in March. From her conversations with us, it is clear she feels staff should have performed surgery before discharging him. We have already explained above why surgery was still not appropriate at this time.
79. Mr O went into hospital with generalised weakness. The evidence suggests that staff assessed him and arranged treatment in line with GMC guidance. Notes from the admission state he was stable, and staff discharged him back to his GP’s care to wait for surgery.
80. Mrs O says her husband was unwell in March. We do not doubt what she says, and it must have been difficult seeing her husband unwell. We recognise Mr O was not a well man as his heart function was poor enough to require quadruple bypass surgery. This is a major and serious operation. During the March admission it was not possible for staff to arrange this surgery as Mr O was still within the two-month waiting period.
81. Our cardiac surgeon adviser confirmed they had seen no issue with the decision to discharge Mr O in March as there was nothing to suggest he needed any further treatment in hospital at that point.
82. The evidence shows staff assessed Mr O and provided suitable treatment. This was in line with GMC guidance. We find no failing in the Trust’s decision to discharge him on 19 March.
Discharge – third admission
83. Mr O underwent surgery on 28 May. After which he had pleural effusion which is an excessive collection of fluid in the space surrounding the lungs.
84. Our cardiac surgeon adviser explained that pleural effusion is common after bypass surgery and usually resolves without issue. Chest X-rays from the admission in May are missing from the clinical records, so they could not comment on the full extent of Mr O’s effusion. However, staff documented the effusion was small directly after surgery.
85. The same adviser explained doctors treat small effusions with diuretics which Trust doctors did prescribe prior to discharge. They use X-rays and echocardiograms to assess the level of effusion. They confirmed the doctor’s decision to treat Mr O’s small effusion with diuretics was clinically appropriate and therefore in line with GMC guidance.
86. On 5 June staff noted Mr O was medically fit for discharge and discharged him shortly after. He returned to hospital the following day. Our adviser said the fact that he returned to hospital so soon after discharge suggested he was not well enough to go home the day before.
87. At the point of discharge, doctors were treating Mr O’s small effusion with diuretics. On 10 June tests showed that this had progressed to moderate/severe.
88. Our adviser said it is unlikely Mr O’s effusion had progressed significantly between discharge on 5 June and readmission on 6 June. They said the fact that Mr O was experiencing breathlessness towards the end of the third admission suggested the effusion had progressed. Our adviser explained doctors should have carried out an X-ray and echocardiogram to assess the level of effusion before discharging Mr O on 5 June.
89. During a local resolution meeting on 1 November 2019 a cardiac surgeon said Mr O had X-rays on 4 June and 5 June. They said the results of these showed Mr O’s effusion had progressed, and they recommended inserting a drain. The cardiac surgeon said Mr O was strongly opposed to a chest drain and asked them to continue treating his effusion with water tablets.
90. We have been unable to support the above account of events with information from the clinical records. During our detailed investigation we repeatedly engaged with the Trust to ask for more information. Specifically, notes from the cardiology and cardiac surgery teams showing what they thought was happening with Mr O in the third admission, or the discussions they had with him at the time. The Trust has confirmed it has sent us everything it has.
91. Staff should have carried out an X-ray and echocardiogram to assess the level of Mr O’s effusion prior to discharging him on 5 June. Whilst we recognise the Trust said this took place, and the meeting transcript suggests staff had records to support this during the local resolution meeting, it has been unable to supply us with these records meaning we cannot verify this.
92. There is not enough evidence to say what the Trust did to assess and manage Mr O’s effusion during the third admission. The gap in records means we cannot say he was well enough for discharge on 5 June. This lack of evidence means we must reach a decision on the balance of probabilities. This is where we reach a view on what is likely to have happened using the evidence available.
93. Given what we know about Mr O’s clinical condition upon readmission on 6 June, on balance of probabilities we consider it is likely that his effusion was no longer manageable with diuretics by the end of the third admission and a change in treatment should have occurred prior to discharge. Specifically, doctors should have arranged an X-ray and echocardiogram to confirm the extent of the effusion before inserting a chest drain to treat this.
94. We acknowledge what the Trust said about Mr O’s wishes around the chest drain. But we have been unable to locate documentation of this conversation in the clinical records, meaning this has limited weight as evidence.
95. GMC guidance makes it clear that doctors must arranged suitable investigations and treatment. The absence of scans and notes on decision making from cardiology and cardiac surgery teams means we cannot say the Trust did enough to assess and treat Mr O’s effusion prior to discharge. This was not in line with GMC guidance.
96. We have found a failing in this aspect of the complaint. We go onto consider the impact of this in a later section of this report.
97. The above three sections of this report covered Mrs O’s concerns around discharge. We have chosen to address her complaint around the timing of the chest drain next as this applies to both the third and fourth admissions. We go on to consider her concerns around the fourth discharge after this.
Chest drain
98. Mrs O complains that doctors delayed inserting a chest drain after surgery.
99. There are no specific standards or guidance around the insertion of a chest drain after surgery. Again, we refer to GMC guidance which says doctors should promptly arrange suitable treatment.
100. Our cardiac surgeon adviser said in this context doctors would use a chest drain to treat moderate to severe effusion.
101. As we explain in the previous section of the report, the evidence suggests that Mr O’s effusion progressed from small to moderate or severe during the third admission. Gaps in the records have prevented us from establishing when this occurred or at what specific point staff should have changed his treatment.
102. The clinical records note Mr O was experiencing breathlessness between 5 and 7 June. This is a symptom of moderate to severe effusion, meaning staff should have arranged an Xray and echocardiogram instead of discharging him on 5 June and inserted a chest drain once results confirmed the effusion had grown.
103. Mr O returned to hospital on 6 June. As with other sections of this report, we are missing records documenting what the cardiology and cardiac surgery teams thought was happening with him during this admission.
104. The records suggest clinicians ordered an X-ray and echocardiogram within 24 hours of Mr O returning to hospital. Our cardiac surgeon adviser said this would be considered prompt and in line with GMC guidance that says doctors must promptly arrange suitable investigations and treatment.
105. Staff ordered the X-ray and echocardiogram on 7 June. The records show it took three days for these tests to be complete and results came back on 10 June. These showed Mr O now needed a chest drain as his effusion had progressed from small to moderate/severe.
106. We can see doctors inserted the chest drain on 11 June (within 24 hours of receiving the results). Again, our adviser said this would be considered prompt and in line with GMC guidance. There is no indication that Mr O experienced a delay in receiving a chest drain in the fourth admission.
107. The main period of delay relates to the third admission. The evidence suggests that staff should have arranged an X-ray and echocardiogram on 5 June. Given that it took three days for both scans to be complete and for staff to receive the results, we consider Mr O should have received a chest drain no later than 9 June.
108. The evidence shows Mr O received a chest drain on 11 June, meaning he experienced a delay of up to two days in receiving treatment in line with GMC guidance. We have found a failing in this aspect of the complaint. We go on to consider the impact of this in a later section of the report.
Discharge - fourth admission
109. Mrs O complains that the Trust discharged her husband when he was too unwell on 23 June. During the local resolution meeting she told staff that by 6 July his health was deteriorating. She explained he was vomiting, struggling for breath, and was not eating or sleeping.
110. Mr O returned to hospital on 6 June as he was breathless and lethargic. As we explain in the above section, doctors carried out investigations that showed he had moderate to severe effusion which they treated by inserting a chest drain.
111. The chest drain was in place until 14 June. On 16 June a doctor reviewed Mr O and noted that whilst his effusion was now very small and could be managed with diuretics, he had abdominal pain and confusion. The doctor felt this was likely due to heart failure. The doctor asked the team to consider a referral to the heart failure team.
112. On 19 June an echocardiogram showed Mr O’s LV systolic function was severely impaired. This is when the heart’s ability to pump blood is greatly reduced.
113. Between 19 June and 23 June staff treated Mr O with diuretics and colchicine. During this time staff reduced Mr O’s prescription for diuretics as it was negatively impacting his kidneys and liver. His kidney and liver function improved after this.
114. By 22 June Mr O’s effusion was minimal, and his NEWS remained between 0 and 2. National Early Warning Scores (NEWS) is a system doctors use to quickly assess a patient’s health. It helps doctors identify patients with may be deteriorating and need closer monitoring or medical attention. A NEWS score between 0 and 2 means a patient’s condition is stable. A score of 5 or more would trigger urgent clinical review.
115. Doctors felt he was stable and medically fit for discharge and did so on 23 June.
116. As with other sections of this report, the clinical records contain minimal documentation of the cardiology and cardiac surgery teams thinking around what was happening with Mr O. We have been unable to locate any documented discussions between Mr O and clinicians.
117. We have had to make a balance of probabilities decision based on the information available to us. During this admission we can see doctors:
• assessed Mr O • identified his effusion had progressed • treated this with a chest drain • identified diuretics were affecting his kidneys and liver • reduced his diuretic prescription • confirmed he was stable before discharging him.
118. Our adviser reviewed the clinical notes and confirmed doctors assessed Mr O, provided clinically appropriate treatment, and arranged follow up by asking his GP to review him on and ongoing basis. Our adviser said the records suggest Mr O was medically fit for discharge and there is no indication he needed further hospital treatment as of 23 June. Therefore, the decision to discharge was in line with GMC guidance. We find no failing in this aspect of the complaint.
Medication after surgery
119. Mrs O complains that doctors provided her husband with the wrong medication after surgery. She says the medication her husband received caused him to experience kidney issues, constipation, fatigue, and sickness.
120. Our cardiologist adviser said there are no specific standards or guidelines on the provision of medication after cardiac surgery. They explained that any medications clinicians prescribed would be based on the patient’s clinical condition, diagnosis, and needs.
121. We can see doctors prescribed Mr O the following medications after surgery:
• furosemide (medication that helps the body get rid of excess fluid) • iron tablets (medication to treat iron deficiency anaemia) • colchicine (medication to treat inflammation) • bisoprolol (a beta blocker that blocks the effects of stress hormones such as adrenaline on the heart which helps control heartrate).
122. The clinical records show that after surgery Mr O had excess fluid, anaemia and an irregular or fast heartrate. During the fourth admission Mrs O told a consultant she was concerned that beta blockers were causing her husband’s fatigue. The consultant explained it was unlikely this was the case, and it was essential Mr O took the beta blocker to control his heartrate.
123. Our cardiac surgeon adviser reviewed Mr O’s clinical records from after surgery to the time of his death on 24 July 2019. This included all medications doctors prescribed during the period. They said the medication Mr O received after surgery was appropriate for each of his symptoms as they occurred, and the dosages were in keeping with normal clinical practice.
124. GMC guidance says doctors must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
125. We recognise Mrs O says that the medication her husband received caused him unpleasant side effects. We recognise this was distressing for Mr O to experience and worrying for his family to witness. Unfortunately, all medications can have side effects.
126. The medications doctors prescribed Mr O after surgery were clinically appropriate for his symptoms. This means that doctors prescribed medication that served his needs. This was in line with GMC guidance. We consider Mr O received the medication he needed after surgery. We find no failing in this aspect of the complaint.
Communication
127. Mrs O complains about a lack of communication from senior doctors whilst her husband was on Ward L16.
128. GMC guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. Nowhere in guidance does it specify which doctor should keep family members updated.
129. At the beginning of the admission Mr O’s condition had deteriorated to an extent that staff had to urgently arrange surgery. He then spent several days in intensive care before remaining in hospital for around three days whilst staff managed fluid build-up around his heart and lungs.
130. Mr O’s condition was complicated and there was a potential for problems to develop because of his fluid build-up. He was on Ward L16 for almost three weeks. We have been unable to identify any documented conversations between doctors and Mrs O between the date of admission and 4 June. Meaning we cannot establish what communication took place or whether this was in line with GMC guidance.
131. The only record we have been able to identify is on 5 June which was the day staff discharged Mr O. The notes indication a consultant cardiac surgeon spoke to Mrs O for around five minutes before they had to leave for surgery. A junior doctor continued this conversation and largely discussed medication.
132. Mrs O says she did not understand what was happening with her husband’s care whilst he was on Ward L16. She says she did not become aware her husband’s left ventricle was compromised or truly understand how unwell he was after surgery until a local resolution meeting after his death.
133. Mrs O says she did not find out her husband had heart failure after surgery until the Trust told her this during a local resolution meeting after his death. She feels doctors should have made it clear Mr O was experiencing heart failure during the third admission.
134. Our cardiac surgeon adviser said they could not properly comment on doctors’ communication during the third admission due to gaps in the records. There is little documented communication either from the consultant or junior doctors. They said given Mrs O’s continued lack of understanding of her husband’s care during the local resolution meeting it is likely that staff on ward L16 did not give her enough information to ensure she fully understood the situation.
135. Whilst it is clear Mr O began to decline after surgery, we have been unable to identify any documentation of him having heart failure during the third admission. The earliest reference to heart failure in the clinical records is during the fourth admission.
136. On 16 June a doctor noted Mr O was experiencing abdominal pain and confusion. The doctor felt this was likely due to heart failure and asked the team to consider a referral to the heart failure team.
137. We cannot say doctors should have informed Mrs O about her husband’s heart failure during the third admission as we cannot see he was diagnosed with heart failure whilst on Ward L16. We recognise this will be disappointing to Mrs O as she strongly asserts her husband had heart failure during his third admission.
138. Nowhere in guidance does it stipulate how often updates should take place. But on the balance of probabilities, we consider it likely that doctors should have provided Mrs O with updates throughout the admission. Given how complicated Mr O’s condition was and the fact that he had surgery followed by time in intensive care, we do not consider that a singular update at the end of the admission was in line with GMC guidance to be considerate to those close to the family. We find a failing in this aspect of the complaint. We go on to consider the impact of this in a later section of this report.
Impact
139. We will now consider what impact the failings we have identified had on Mr O and Mrs O. To aid clarity we have split that into two sections. We will first consider whether the Trust’s failings had any physical impact on Mr O. We will then go on to consider any emotional impacts on Mrs O.
Physical impact
140. We have found a failing in the Trust’s decision to discharge Mr O from hospital on 5 June. Specifically, we have found that staff should have carried out an X-ray and echocardiogram to check the progression of his effusion before deciding to discharge him.
141. Our cardiac surgeon adviser said that had staff arranged further testing on 5 June, it is likely the results would have shown worsening effusion. Our adviser explained this would have needed treating with a chest drain and staff would likely not have discharged Mr O.
142. Mr O returned to hospital on 6 June and staff arranged a chest X-ray and echocardiogram by 7 June. We have not found any failing in the care Mr O received in his fourth admission. The evidence shows that staff promptly identified his worsening effusion and arranged for a chest drain to be placed.
143. The evidence we have seen suggests that staff would have arranged for Mr O to have a chest drain up to 48 hours earlier if they had identified his worsening effusion during the third admission instead of discharging him on 5 June. The Trust did not do this meaning Mr O experienced up to 48 hours delay in receiving the treatment he needed. Our cardiac surgeon adviser explained worsening effusion can cause breathlessness which is uncomfortable.
144. Mrs O feels the Trust’s actions caused her husband pain, suffering and contributed to his death.
145. Our adviser noted that after surgery Mr O was increasingly having issues with heart failure, atrial fibrillation and then had a stroke. He went back into hospital for a fifth time on 10 July despite receiving clinically appropriate care and treatment during the fourth admission.
146. Our adviser said the fact that Mr O could not manage at home shows he was experiencing terminal decline. This is decline in health a person cannot recover from. They explained that whilst earlier placement of a chest drain would have alleviated Mr O’s discomfort sooner, it would not have prevented his decline and eventual death.
147. It is clear from Mrs O’s account of events that her husband’s death came as a shock to her, and she feels mistakes on the Trust’s part led to this. We have not been able to link Mr O’s death with any failing on the Trust’s part. We do not find Mr O’s death would have been preventable had the delay in chest drain not occurred. We recognise this will be disappointing to Mrs O as she strongly asserts the Trust failed her husband on all counts. We recognise Mr O was increasingly unwell after surgery and this was distressing for Mrs O and the family.
148. We have seen evidence that the Trust’s actions during the third admission caused Mr O discomfort for around two days. Whilst we cannot link the failings with the exact impact Mrs O claims, we consider the failings we have identified did have a physical impact on her husband.
Emotional impact
Discharge from third admission
149. Mrs O says staff made Mr O feel lazy as they attributed his discomfort to him being unwilling to mobilise. She says the decision to discharge her husband on 5 June caused him distress as he could not cope at home. She says she felt powerless, and it was distressing to see him struggling.
150. It is clear from Mrs O’s account of events that the incorrect discharge caused worry and distress for the family. Whilst we would reasonably expect this distress to diminish over time, it is clear this continued beyond Mr O’s death on 24 July and that this formed part of the loss and bereavement experienced. We find the Trust’s actions caused additional worry and distress.
Communication
151. Mrs O says a lack of communication from senior doctors on Ward L16 meant she did not know his left ventricle was compromised or truly understand how unwell he was after surgery until a local resolution meeting.
152. Mr O was on Ward L16 for almost three weeks. During this time, he underwent major surgery, spent several days in intensive care and remained in hospital for around three days whilst staff managed fluid build-up around his heart and lungs.
153. Our cardiac surgeon adviser explained that Mr O was very unwell after surgery, his condition was complicated and there was a potential for problems to develop because of his fluid build-up.
154. As we explain in an earlier section of this report, we have only seen evidence of one conversation between a doctor and Mrs O during this admission. We do not consider this conversation was sufficient as it is clear from Mrs O’s account of events that she did not understand what was happening with her husband’s care.
155. The Trust did not do enough to help Mrs O understand what was happening with Mr O’s care and how his condition had progressed. This in turn meant she did not understand how unwell he was.
156. Whilst we recognise it may not have been possible to fully prepare Mrs O for her husband’s death, we consider better communication may have given her more realistic expectations and made Mr O’s death less of a shock. The failings we have found impacted Mrs O’s ability to prepare for her husband’s death on 24 July.