The Hillingdon Hospitals NHS Foundation Trust

4. Mr V complains on 29 August 2023 the Trust delayed admitting his father despite the GP’s letter and pre-arrangement for urgent admission. He complains it delayed taking CT head and CT angiogram brain scans, despite his father’s immediate and apparent signs of a stroke, and stroke symptoms being documented in the medical admissions proforma on 29 August.

5. Mr V says earlier action may have increased his father’s chances of survival. He says by the time the Trust took these scans on 30 August, his father was already unconscious, and it was too late. Mr V has experienced extreme distress since his father’s unexpected death on 2 September 2023, having traumatic flashbacks and nightmares. He suffers with anxiety and depression and cannot achieve closure about what happened.

6. To resolve his complaint, Mr V would like the Trust to acknowledge its failings and apologise for their impact. He seeks improvements at the Trust, to prevent this happening to others in future. Mr V would like a financial payment, in recognition of the impact caused by these Trust failings.

7. Mr V’s father was 74 years old at the time of these events. On 24 August 2023 Mr V took his father to the Trust’s accident and emergency department (A&E), reporting worsening shortness of breath in the last few days with intermittent chest pain.

8. Mr V’s father had a medical history including chronic kidney disease and acute coronary syndrome and congestive heart failure, two significant and chronic heart conditions. The Trust took a scan of his heart and requested blood tests and a chest X-ray. Later that evening, Mr V’s father indicated he did not wish to stay and self-discharged home.

9. Mr V says his father had a previously arranged GP appointment for 29 August about his arthritic knee. As his father was unwell, Mr V attended the appointment himself. He says he told the GP since the hospital attendance five days’ previously, his father remained very short of breath with chest pains, fatigue, urinary retention and kidney issues.

10. Mr V says he told the GP he had corresponded with a private cardiologist who his father would often seek advice from. He says this cardiologist suggested his father may need intravenous (IV) furosemide (a diuretic, medication to treat water retention and high blood pressure) and to contact the heart failure nurse to arrange this. He says he also told the GP he believed his father had started showing signs of stroke, as he was unable to raise one of his arms and had slurred speech with signs of confusion.

11. The GP contacted the Trust who advised Mr V’s father be admitted to hospital for IV diuretics and assessment from the heart failure nurse. The GP wrote a letter, giving this to Mr V, who took this along with his father to the Trust. Mr V told us he took his father to the ‘triage department’ and requested an urgent acute medical unit (AMU) admission, in line with what the GP had told him. Mr V says an hour was wasted waiting before they were advised they should be waiting in A&E.

12. A doctor first assessed Mr V’s father at 2.40pm and decided a plan, to give him IV furosemide pending chest X-ray, to discuss his case with cardiology, to take another heart scan and compare this with the one taken on 24 August, and to arrange a bed and cardiac monitoring. The plan commenced, and Mr V told us whilst waiting in A&E, nurses took a scan of his father’s heart and took blood tests. Mr V’s father was admitted onto the AMU later that evening.

13. At 6.15am the next morning the team made a cardiac arrest call. Records note that whilst Mr V’s father did not lose cardiac output, he had a rapid drop in his GCS (Glasgow Coma Scale, a measure of consciousness) and was unresponsive. A CT head scan was taken at 6.57am which questioned a basilar infarct (a stroke that occurs when blood flow is interrupted in one of the arteries into the brain). A CT angiogram was taken at 10.06am and confirmed findings of a stroke.

14. The Trust obtained input from the local specialist stroke centre at another hospital. Sadly, as this second scan showed a large area of clot affecting a lot of the brain, there was no intervention possible and palliative care was decided in his best interests.

15. Very sadly, Mr V’s father died in hospital on 2 September. Remaining unhappy with the responses received to his complaint, Mr V asked us to investigate.

Admission 19. We recognise that Mr V understood his father would not have to wait to be seen and admitted, considering the GP’s involvement.

20. Our adviser explains that patients who are referred into hospital by their GP in this way must still arrive and be triaged in A&E. A&E has responsibility for triaging any patient who arrives, whether they arrive independently or following GP referral. The A&E triaging process then determines where that patient needs to be sent or seen next.

21. We note Mr V’s concern is heightened by the GP’s letter, which states a need for urgent hospital review and admission. There is no specific guidance that stipulates what timeframe ‘urgent’ constitutes in this circumstance. Our adviser says the fact Mr V’s father was seen and admitted that same day is considered sufficiently timely to meet an appropriate level of urgency in his case.

22. The GP’s letter notes Mr V’s father was expected by the medical team in the A&E. It appears some confusion arose as Mr V took his father to another location rather than A&E, but was not long after redirected to A&E.

23. The GP letter includes the entry from GP records timed at 9.31am. Trust records note Mr V’s father was assessed by the medical doctor in hospital at 2.40pm and an immediate plan of care commenced. Whilst he was not admitted onto the AMU until several hours later, records show Mr V’s father was provided care and treatment from much earlier. Our adviser says this was timely, explaining admission onto a specific ward is not a requirement before care and treatment is given.

24. We are satisfied these were timely actions in line with GMC Guidance. This says health practitioners must adequately assess the patient’s conditions, promptly provide or arrange suitable advice, investigations or treatment, and refer a patient to another practitioner when this serves the patient’s needs.

25. We recognise the frustration and worry caused by any person having to wait to receive care. We acknowledge Mr V’s distress, knowing of the arrangement made for his unwell father to be seen, and on an urgent basis. We hope to assure him the timing of events appears reasonable, and we do not see any clinical need to have expedited his father’s care once he arrived at the Trust.

CT scans 26. We know Mr V is concerned that CT scans were not taken sooner, and this is understandably amplified considering the events that occurred the following day.

27. The GP’s letter makes clear Mr V’s father was presenting with heart failure. This aligns with the information from his short A&E attendance five days beforehand, on 24 August. His presentation at that time indicated concern of worsening of heart failure and a possible acute cardiac event. These were the symptoms Mr V was presenting with on this occasion, 29 August.

28. Following assessment of Mr V’s father at 2.40pm on 29 August, the medical doctor determined the differential diagnosis (the root cause of a patient’s symptoms) as due to his heart problems. Considering his recent medical history and signs and symptoms on presentation, our adviser confirms this was an appropriate basis for the clinical concern. Heart problems were the documented reason for his admission.

29. We know Mr V is concerned because of what the doctor recorded about his father. The record includes information about his recent medical history that was clearly gained from speaking with Mr V. It is noted: ‘son concerned RE stroke’. We know Mr V considers this significant and feels on this basis, more should have been done.

30. We think it clear that what is recorded is the doctor reporting what Mr V thought. We do not see that this was a record of the doctor’s clinical observation or opinion. This is further supported by what is recorded over the page: ‘son believes he has dementia asking where toilets are’, and ‘son says ++ fatigue, worse since Thursday’. We think it clear these are also records of what Mr V thought, rather than the doctor’s own assessment.

31. The doctor makes no further comment about stroke, just as they make no comment on dementia. This leads us to conclude that stroke was not felt to be a clinical concern. We do not find issue with this, as we do not find evidence to suggest any apparent stroke symptoms at that time. In turn, we do not find any clinical indication for a CT head scan.

32. We considered guidance for CT head scanning. NICE Guideline 232 explains CT head scanning is indicated for people who have suffered a head injury. This did not apply here, as Mr V’s father did not have any such injury. NICE Guideline 128 says brain imaging with CT should be done as soon as possible and within 24 hours of symptom onset, in people with suspected acute stroke. As we have explained, Mr V’s father had a presentation indicative of heart problems, not stroke. CT head scanning was therefore not indicated.

33. Our adviser says the symptoms Mr V reported did not clinically indicate a stroke, but they could have indicated a transient ischaemic attack (TIA). Whilst commonly known as ‘mini-strokes’, TIAs present very differently. Much of the information reported by Mr V suggests a short-term impact, or where his father suffered an event which had since resolved. Our adviser explains this would not be indicative of a stroke but could have been the result of a TIA.

34. In line with NICE Guideline 128, the test for TIA would be a magnetic resonance (MR) scan, and not a CT head scan. Even considering the possibility of TIA, CT head scanning would still not have been indicated. MR scans are more challenging tests to undergo, particularly when a person is acutely unwell as Mr V was. They take more time than a CT scan and the person must lay flat for up to an hour. Our adviser says performing such a test for Mr V would not have been a priority at that time.

35. We hope to assure Mr V the clinical rationale for the timing of the CT scans was appropriate in line with NICE Guideline 128. The CT head was clinically indicated on the morning of 30 August because of the change in Mr V’s father’s condition. Having previously been speaking with nursing staff, he is noted to have become very drowsy and was not responding to voice commands. His pupils were fixed and dilated, he had an observable right sided facial droop, and he became incontinent of urine.

36. Due to this change in his condition, CT head was clinically indicated, in line with NICE Guideline 128. There was no clinical indication to perform this scan at any earlier time. The CT angiogram was only performed because the CT head scan was taken. It would not be considered a first line investigation nor again indicated any sooner.

37. We know how important this issue is to Mr V. To give further assurance, our adviser provides agreement with the Trust’s explanation, that given CT head results on the morning of 30 August, a CT head taken the day before would not have resulted in any earlier diagnosis. We do not see any evidence of service failure, as there was no earlier indication for either scan.

1. We have carefully considered Mr V’s complaint about the time it took the Trust to admit his father on 29 August 2023 and to take CT scans. We were sorry to hear of his concerns that these constituted delays and may have affected his father’s chance of survival.

2. We do not see any evidence of failings on the part of the Trust. On the evidence we have seen, we have not upheld this complaint.

3. We recognise the significant emotional distress Mr V has experienced, and hope this report provides him assurance and fully explains our decision.