The Trust failed to carry out the appropriate investigations to accurately diagnose the cause of her father’s condition
9. The NICE guidance provides information to help clinicians diagnose and managing acute heart failure or possible acute heart failure. It aims to improve the immediate care of someone who is acutely unwell as a result of heart failure. The NICE guidance says:
‘1.2 Diagnosis, assessment and monitoring
1.2.1 Take a history, perform a clinical examination and undertake standard investigations – for example, electrocardiography, chest X‑ray and blood tests – in line with the NICE guideline on chronic heart failure.
1.2.3 In people presenting with new suspected acute heart failure with raised natriuretic peptide levels (see recommendation 1.2.2), perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities.’
10. Mr S attended A&E on 22 March 2023 with breathlessness and reported that he had been unwell for the previous 3 days. The records show Mr S described experiencing reduced tolerance to physical activity and difficulty lying flat. Our clinical adviser said such symptoms are highly suggestive of heart failure.
11. The records indicate the Trust carried out an initial physical examination including respiration rate, oxygen saturation levels, blood pressure, temperature and carried out an electrocardiogram (ECG, a test that records the electrical activity of the heart). During the examination the Trust identified lung crackles (abnormal lung sounds whilst breathing caused by air passing through fluid or secretions in the airways) and sent samples of his blood for testing and arranged a chest x-ray and CT scan.
12. The chest x-ray and CT scan confirmed Mr S was suffering with pulmonary congestion (excessive fluid build-up in the lungs) and pleural effusions (excessive fluid build-up in the space between the lungs and the chest wall). Our adviser said in light of these findings and the symptoms reported by Mr S the Trust appropriately confirmed the diagnosis of heart failure.
13. To establish the cause of Mr S’ heart failure the Trust arranged an echocardiogram (an ultrasound scan of the heart) however the records indicate Mr S declined this. Following discussions between the Trust, Mr S and his family an echocardiogram was carried out on 28 March 2023. The report of the echocardiogram identified severe aortic stenosis (narrowing of the heart’s aortic valve) and very poor function of the left ventricle (the main pumping chamber of the heart).
14. The records indicate from the tests undertaken by the Trust the diagnosis was fully established and confirmed when Mr S was reviewed by the Trust’s cardiology team on 30 March 2023. Our adviser said the investigations undertaken by the Trust were appropriate, in line with the NICE guidance and established the diagnosis of heart failure due to severe aortic stenosis clearly.
15. We carefully considered Mrs R’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust failed to carry out the appropriate investigations to accurately diagnose the cause of her father’s condition. We found the investigations carried out by the Trust were in line with the NICE guidance and enabled a clear and definitive diagnosis to be made in a reasonable timeframe.
The Trust failed to provide the appropriate care and treatment for her father’s condition during his admission
16. The NICE guidance says:
‘1.3 Initial pharmacological treatment
1.3.3 Offer intravenous (IV) diuretic therapy to people with acute heart failure. Start treatment using either a bolus or infusion strategy.
1.3.5 Closely monitor the person's renal function.’
17. The ESC guidance says:
‘Prosthetic heart valve durability is a key consideration in younger patients at low surgical risk and SAVR (surgical aortic valve preplacement which is open chest surgery to replace the aortic valve) if feasible, is the preferred treatment option. Conversely, durability is a lower priority in older patients (≥75 years), or those who are inoperable or high risk for surgery, and TAVI (transcatheter aortic valve implantation, a procedure where a narrow flexible tube is passed through a blood vessel in the leg or chest to the aortic valve in your heart to fix a replacement valve over the top of the old one) is preferred.’
18. The records indicate as soon as the diagnosis of heart failure was made on 23 March 2023 the Trust started treatment with IV diuretics and fluid restriction to help remove the excess fluid that had built up in Mr S’ chest and ease the pressure on his heart. The records indicate Mr S was very unwell at this time and the priority for his management was for the Trust to stabilise his heart failure before considering any definitive management of the aortic stenosis.
19. Our adviser said the records indicate his clinical situation was made more complicated by his acute renal impairment (the decline in his kidney function) which was being caused by his heart failure, and the severity of his aortic stenosis. This prevented the Trust from using any alternative drug therapies to treat heart failure as they may have had a further impact on his already reduced renal function.
20. Our adviser said the combination of his heart failure, poor left ventricular function and severe aortic stenosis made Mr S extremely vulnerable from the point he was admitted to hospital. This combination of conditions carries a poor prognosis and medication alone would not be sufficient to enable Mr S to fully recover from his illness.
21. The definitive treatment would be replacement of the aortic valve (SAVR or TAVI) however it is very clear in the records that there was no point during this admission where Mr S was fit to be considered for either procedure due to his cardiac and renal failure. Our adviser said unfortunately his aortic stenosis was severe and when a patient with such a condition is acutely unwell and suffering with poor heart function there is a risk of sudden death which cannot be predicted.
22. We carefully considered Mrs R’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing this period was for Mrs R and the impact the sudden death of her father has had on her and her family.
23. We found no evidence to indicate the Trust failed to provide the appropriate care and treatment for her father’s condition during his admission. The treatment options were limited by the severity of his condition and the treatment the Trust did provide to attempt to stabilise his condition was in line with the NICE guidance.
24. Sadly Mr S’ cardiac condition was advanced when he was admitted to hospital on 22 March 2023 and we found no evidence to indicate the further deterioration he suffered following his admission to hospital was due to any failings in care from the Trust.
25. Mr S was at risk of a sudden deterioration during this admission. We found no evidence to indicate his cardiac arrest or his death on 3 April 2023 could have been predicted or prevented by the Trust.