Surrey and Sussex Healthcare NHS Trust

3. Mr A complains about the care provided to his mother, Mrs B, by the Trust from 31 March to 20 October 2022. Specifically:

• the cardiology care that Mrs B received from the Trust between 31 March and 20 October 2022 • how the Trust handled Mr A’s subsequent complaint in terms of the content of the complaint response including a lack of empathy, delays in the response, and a corrupted recording of the local resolution meeting.

4. Mr A believes that if his mother’s heart disease had been identified through an angiogram when she was being investigated by the Trust, the outcome would have been different for her. Mrs B’s death was unexpected, and Mr A says the impact of this event never becomes any easier as she was so young. The family have been ripped apart by this event and every day is a struggle. Mr A says he has since been prescribed sleeping tablets due to the constant questions about what happened to his mother. Mr A is also concerned that the Trust’s recording of a local resolution meeting that he and his family attended is now corrupt.

5. As an outcome, Mr A wants a financial remedy from the Trust for him and his family.

6. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

7. Mrs B was 61 years old. She had a background of heart problems, high Body Mass Index (BMI), poorly controlled diabetes, and elevated cholesterol. Mrs B was also a smoker and recovering from recent abdominal surgery. She was referred to the Trust by her GP in December 2021 due to breathlessness. Mrs B had her first appointment with the Trust’s cardiology team via a telephone consultation on 31 March 2022. Her breathlessness was thought to be related to her recent surgery which may have caused lung problems or an infection. Mrs B was under the cardiology team’s care until 20 October 2022 during which time various tests were carried out, but this did not include a coronary angiogram.

8. Unfortunately, Mrs B had to be admitted to hospital (part of a separate Trust that is not part of our investigation) on 2 December 2022 after suffering a heart attack. On admission, Mrs B was given a stent, but it became evident that she had chronic heart disease despite being discharged by the cardiology team at the Trust a few weeks earlier.

9. Mrs B became very unwell whilst she was in hospital during December 2022 and therefore open-heart surgery was carried out to try and save her life. Unfortunately, the surgery was unsuccessful, and Mrs B sadly died on 8 December 2022. The causes of her death were Multi-organ failure, Post Infarction ventricular septal defect (complicated by cardiac tamponade during intervention 04/12/22), Myocardial infarction and Type 2 diabetes, hyperlipidaemia.

Cardiology care

14. Mr A is concerned that the cardiology care provided to his mother by the Trust from 31 March to 20 October 2022 was inadequate. In particular, Mr A is concerned that his mother was never offered a coronary angiogram which he expected to be a key part of her care. Also, some of her consultations with cardiology were by telephone rather than face-to-face. It is noted that Mrs B sadly died on 8 December 2022 just a few weeks after being discharged by the Trust on 20 October 2022.

15. We have considered the cardiology care provided to Mrs B during this period by the Trust, based on the relevant evidence highlighted earlier in this report, and with support from our adviser.

16. Our adviser says that Mrs B’s presentation was with breathlessness, but no chest pain. In a patient that had the risk factors Mrs B had, in particular her poorly controlled diabetes mellitus which may mask chest pain, breathlessness must be explored as angina equivalent and investigations arranged to clarify the situation. Another risk factor is that females often present with atypical symptoms for cardiac problems which can mask their true diagnosis.

17. As for the investigations that could have been carried out, our adviser says a CT coronary angiogram (an imaging test that looks at the arteries that supply blood to the heart) or a stress perfusion scan (an imaging test to show how well blood flows through the heart muscle, as well as how well the heart muscle is pumping) could have been offered and carried out by the Trust. This was even more relevant given that Mrs B’s echocardiogram (a scan to look at the heart and blood vessels) on 27 June 2022 was not entirely normal and therefore a further risk factor. It showed regional wall motion abnormality (septal motion abnormality that was put down to the difficulty in image acquisition). Therefore, our adviser says the overall picture painted should have triggered a suspicion of coronary artery disease by the Trust, and additional investigations should have been offered. This is supported by the NICE guidance on Cardiac causes of breathlessness which indicates that breathlessness can be a sign of coronary artery disease. It is also supported by the ESC guidelines which highlight the diagnostic approach that should be taken including further investigations being offered.

18. In terms of the telephone consultations that Mrs B had during this episode of care, our adviser says this has become standard practice over recent years since the Covid-19 pandemic. If there is any suspicion that further assessment is required, a consultant can arrange a face-to-face consultation as and when it is necessary. This is supported by GMC guidance on remote consultations which indicates they are appropriate in certain circumstances.

19. Mrs B had a mixture of telephone and face-to-face consultations. Patients do not always need to be seen face-to-face and there is no indication from our consideration of Mrs B’s records that telephone consultations had a negative impact on her care.

20. As for Mrs B’s discharge from the Trust on 20 October 2022, our adviser says she was discharged as there was no appropriately documented consideration or suspicion of underlying coronary artery disease. As above, coronary artery disease should have been considered and investigated in accordance with all Mrs B’s stated risk factors.

21. In summary, we consider this indicates some failings in Mrs B’s management due to a lack of appropriate investigations being offered by the Trust. This is contrary to the ESC guidance for the diagnosis and management of chronic coronary syndromes and the NICE guidance on the cardiac causes of breathlessness. We appreciate this will raise some concern and uncertainty for Mr A about the care that his mother received from the Trust. We have made some recommendations about this.

Impact

22. Given this, we have considered at what point between 31 March and 20 October 2022, should Mrs B have been offered further investigations for potential coronary artery disease. We have also considered what further investigations may have shown, what treatment Mrs B could have had, and what difference this could have made for Mrs B.

23. As we have said, Mrs B had an echocardiogram on 27 June 2022. Our adviser says this showed a regional wall motion abnormality (septal motion abnormality that was put down to the difficulty in image acquisition). This should have raised the suspicions of the cardiology team at the Trust and led them to investigate Mrs B further.

24. Initially, this could have been through a CT coronary angiogram and/or a stress perfusion scan. Unfortunately, once the doctor had not considered the abnormal finding on Mrs B’s echocardiogram as a potential sign of coronary artery disease, our adviser says she was not going to be subject to these further investigations for her condition when she should have been due to the findings of the echocardiogram and her other risk factors as highlighted earlier in this report.

25. If Mrs B had had a CT coronary angiogram (which can also provide functional assessment with a CT Fractional Flow Reserve procedure FFR) followed by a stress perfusion scan, our adviser says, on the balance of probabilities, coronary artery disease (which Mrs B had) would have been diagnosed more promptly. This is because both tests help in the diagnosis of this condition. Appropriate treatment could then have been considered. FFR is a non-invasive procedure which uses HeartFlow Analysis to provide a 3D model of the coronary arteries to identify any potential blockages.

26. Our adviser says that the treatment for coronary artery disease, depending on the symptoms and the location and extent of the disease, could have been either medical treatment, a stent or heart surgery, depending on which procedure was considered most appropriate for Mrs B. At the very least, Mrs B would have been started on Aspirin and a statin as prevention measures. As for the urgency of this, our adviser says Mrs B had stable angina so her situation (in terms of having one of these procedures) was not necessarily urgent. It would have been dependent on her clinical circumstances at the time and the pattern of the disease.

27. Again, it would depend on the pattern and extent of Mrs B’s heart disease as to how much impact a stent or surgery would have had on her prognosis. Our adviser says that if surgery or stenting of the left main stem or proximal left anterior descending artery would have been found to be the right treatment then, on the balance of probabilities, it would have at least had a positive impact on her condition assuming she had the treatment before she suffered a heart attack. Nevertheless, as we do not know the pattern and extent of Mrs B’s disease, we cannot say with any certainty if such treatment would have saved or even extended her life. As we understand it, there was no post mortem to help us verify the pattern and extent of her disease.

28. Our adviser says that Mrs B suffered a heart attack on 2 December 2022 which was complicated by ventricular septal defect. This is an uncommon complication when there is a hole between the pumping chambers (ventricles) in the heart. We cannot comment on the care provided to Mrs B by another Trust in the days after her heart attack until she sadly died on 8 December 2022, but we recognise that her death was unexpected and must have been a terrible shock for Mr A and his family. We note that this devastating event happened just a few weeks after Mrs B had been discharged by the Trust.

29. While we consider there is insufficient evidence for us to say that Mrs B’s death was avoidable, we recognise that the management failings we have identified by the Trust leave Mr A and his family with concerns and considerable uncertainty about Mrs B’s care which is emotionally distressing for them.

Complaint handling

30. Mr A is concerned about how the Trust handled his complaint in terms of the content of the complaint response including a lack of empathy, delays in the response, and a corrupted recording of the local resolution meeting.

31. Having considered the Trust’s complaint responses dated 31 July, 20 September, and 28 December 2023; we consider that all three contain some examples of empathy by the Trust. For example, the first letter passes on condolences to Mr A and apologises that he has had cause to use the complaints service. The second letter also passes on condolences from some of the doctors involved in Mrs B’s care. The third letter apologises for the corrupted recording of the local resolution meeting. It also contains written notes of the meeting (they also contain some empathy examples) which replaced the corrupted recording.

32. The NHS complaints regulations 2009 indicate that complaints should receive a substantive reply within 6 months of submitting the complaint. Mr A made his complaint to the Trust on 30 July 2023. Within the next approximately 5 months, he received three written responses including a final response to his complaint as highlighted above and had a local resolution meeting. Therefore, we cannot say there were any unreasonable delays in the Trust’s response to his complaint contrary to the NHS regulations.

33. As for the audio recording of Mr A’s local resolution meeting, this was an unfortunate technological event which the Trust apologised for in its complaint response. We appreciate that written notes of a meeting may not be as comprehensive as an audio recording but, having considered the notes, they are detailed and act as an adequate record of the meeting. In summary, we consider the Trust took appropriate action in the circumstances to rectify matters after the audio recording became corrupted.

34. Overall, we have not identified any failings in the way in which the Trust handled Mr A’s complaint.

1. We have seen failings by the Trust regarding the management of Mrs B’s cardiology care due to the lack of appropriate investigations offered. This meant that Mrs B was denied the opportunity to be diagnosed with coronary artery disease more promptly so appropriate treatment could be considered. We consider this causes Mr A some concern and uncertainty about the care provided to his mother by the Trust. We have not seen any failings in the way in which the Trust handled Mr A’s complaint.

2. Therefore, we will partly uphold Mr A’s complaint about the Trust. These are our recommendations:

• the Trust should acknowledge the failings in Mrs B’s management, as summarised in paragraph 21, and apologise to Mr A for the concern and uncertainty this causes him about his mother’s care • the Trust should develop an action plan to address the failings summarised in paragraph 21. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored • the Trust should pay Mr A £550.00 as a personal remedy in view of the concern and uncertainty these failings in his mother’s care have caused him.

35. In considering our recommendations, we have referred to the ‘NHS complaint standards.’ The Complaint Standards support organisations to provide a quicker, simpler, and more streamlined complaint handling service. They have a strong focus on:

• early resolution by empowered and well-trained people • all staff, particularly senior staff, regularly reviewing what learning can be taken from complaints • how all staff, particularly senior staff, should use this learning to improve services.

36. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the Trust should pay Mr A £550.00.

37. Therefore, in accordance with this and the NHS complaints standards, we recommend the following action by the Trust within the next six weeks:

• the Trust should acknowledge the failings in Mrs B’s management, as summarised in paragraph 21, and apologise to Mr A for the concern and uncertainty this causes him about his mother’s care • the Trust should develop an action plan to address the failings summarised in paragraph 21. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored • the Trust should pay Mr A £550.00 as a personal remedy in view of the concern and uncertainty these failings in his mother’s care have caused him.

38. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.