17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. We will explain the reasons for our decision in more detail below.
Mr T discharged on 31 July with breathlessness, water retention and chest pain
18. Miss T explains that four to six days after his surgery in June, her father repeatedly informed clinicians about his symptoms until he was discharged at the end of July. Miss T says the Trust failed to investigate or treat her father for breathlessness, water retention or chest pain. Miss T believes these symptoms were an early indicator of her father’s heart failure which the Trust failed to act on.
19. In its response to Miss T, the Trust explained it measured Mr T’s fluid input and output during his admissions in May and July 2023. It said it stopped this practice on 17 August when Mr T was only receiving palliative care.
20. The Trust says before Mr T was discharged in July; he had consulted with its physiotherapy team. It said no obvious symptoms of pain or breathlessness were noted during this consultation. It explained to Miss T that some degree of pain was expected given the surgery Mr T had. It prescribed him with pain killers to help manage this and had weighed him regularly to check he was retaining fluid. The Trust said Mr T was discharged on 31 July and it planned for him to be followed up by his GP or a local hospital.
21. Mr T’s records show after his surgery, the Trust monitored him daily. We can see the Trust took Mr T’s observations, examined him, monitored his fluid retention regularly and adjusted his diuretic medication (commonly known as a ‘water pill’ this is used to help remove excess fluid from the body) dose on several occasions. For example, on 3 July the Trust increased Mr T’s diuretic dose as it found his legs to be swollen.
22. On 11 July, the Trust gave Mr T intravenous diuretics (given directly into a vein to faster) instead of administering this as a tablet. It also gave Mr T two units of blood transfusion. Our adviser explained this can help with fluid retention as it can help to improve a person’s overall blood volume and circulation, reducing fluid build-up. On 24 July, the Trust stopped giving Mr T diuretic medication because it found him to be urinating excessively after having his post-operative catheter removed.
23. We can see from Mr T’s records, the next day the Trust increased Mr T’s diuretic medication as it found him to be retaining fluid again.
24. Mr T’s records also show prior to his discharge in July, the Trust recorded his weight to monitor for fluid retention. For example, on 11 July Mr T’s weight was recorded as 94.8kg, on 21 July it was recorded as 92.4 kg and just prior to his discharge on 28 July it was noted as 91.2kg. Our adviser explained this showed an issue with where fluid was settling in Mr T’s body, rather than an overall increase in fluid. Our adviser also told us anaemia and low protein states can cause fluid to come out into the tissues from a person’s veins and sitting can cause the fluid to pool in a person's legs.
25. Mr T’s records also show the Trust took his observations daily, and repeatedly throughout the day. During observations of Mr T, clinicians noted his pain levels. We can see they asked Mr T about his pain both at rest, and on movement. The clinical records make no reference to chest pain reported by Mr T prior to his discharge on 31 July.
26. Our adviser explained that at the time of discharge, Mr T's records indicated he consistently maintained normal oxygen saturation levels on room air, had received physiotherapy, and showed no signs of chest problems. Clinicians closely monitored Mr T's kidney function, making necessary adjustments to medications and treatments to manage fluid retention and urinary issues.
27. We can see why Miss T is concerned the Trust could have done more to manage her father’s symptoms and why she has questions about the way it investigated his breathlessness, water retention and chest pain, given Mr T’s health worsened quickly after his discharge.
28. Based on the issues documented, the medical records for Mr T’s first admission indicate the Trust appropriately considered his symptoms. It managed and assessed them in line with GMC guidance, which says doctors must provide a good standard of practice and care when adequately assessing a patient’s condition and promptly arrange suitable investigations or treatment where necessary.
29. We recognise there is a significant difference between the information shared by Miss T and the Trust’s account of Mr T’s symptoms before his discharge in July, particularly in relation to Mr T’s symptoms of breathlessness and chest pain.
30. Based on what we do have, we have reached a view that it is more likely on balance of probabilities that Mr T did not disclose symptoms of chest pain and breathlessness prior to his discharge. We have reached this view based on the overall quality of the medical records and the issues documented within them during Mr T’s admission.
31. We do not have any reason to doubt the account Miss T has provided to us and thank her for being so forthcoming when describing difficult events to us. We think it likely that if Mr T did mention these symptoms prior to his discharge, they would have been noted in his medical records.
32. We have also considered whether the Trust’s decision to discharge Mr T at the end of July was correct.
33. Guidance for NHS England on discharging patients outlines when it is safe and appropriate to discharge someone from the hospital. According to the guidance, hospitals should review patients twice daily to assess their needs. If a patient does not require intensive care, or hospital level care, they should be considered for discharge.
34. Mr T’s records show during his first admission he was seen by a heart surgery specialist every day and reviewed at least two times a day by other Trust staff. We can also see he received care from physiotherapist and nurses. Mr T was able to move around in hospital. Our adviser also explained his vital signs were stable prior to his discharge. Mr T underwent an ultrasound of his heart after surgery, and this showed he was doing well and recovering. Our adviser told us it was sensible for the Trust to discharge Mr T when it did in July.
35. Based on the records and the evidence we have seen, including the views of our adviser, the indications are the Trust acted in line with guidance for NHS England on discharging patients. We have already considered Mr T’s symptoms of chest pain and breathlessness and explained why we believe the Trust considered these appropriately prior to his discharge. We have not seen any indications of failings with the Trust’s decision to discharge Mr T at the end of July.
Failure to give Mr T a pacemaker
36. Miss T says the Trust discussed fitting a pacemaker for her father after his surgery in June. She believed Mr T needed rest but was making progress. She expected the pacemaker to be fitted, but the Trust later decided that end-of-life care was more appropriate for Mr T.
37. In its response, the Trust explain Mr T was noted to have a slow heart rate during his stay in the Intensive Care Unit (ICU) (this is a specialised department in hospitals designed to provide intensive treatment and monitoring for patients with severe or life-threatening conditions). It acknowledged discussing a pacemaker but said this depended on Mr T’s recovery once he had his breathing tube removed.
38. The Trust explained clinicians involved (ICU, cardiology and general surgery) felt Mr T was not improving despite maximum care and so, the Trust determined palliative care (end-of-life care) should be started. It said a pacemaker was not in Mr T’s best interest as it would not have improved his quantity or quality of life and was therefore not appropriate.
39. ESC guidelines on cardiac pacing gives a very specific set of circumstances where a pacemaker would be recommended. Our adviser said Mr T did not meet the criteria for a pacemaker.
40. Mr T’s records show he had continuous cardiac monitoring and on 14 July he had a 24 hour heart monitor. Our adviser said this showed no heart block and continuous monitoring did not detect a heart block either. Mr T’s records show during his second admission on 14 August, he was found to have a normal heart rate. Our adviser explained there was no indication for Mr T to have a pacemaker.
41. Taking into account the guidance and the views of our adviser, we cannot see any indication of failings on the part of the Trust in relation to its decision not to provide Mr T with a pacemaker.
Ward placement
42. Miss T told us she was concerned about the Trust’s decision to place her father on a non-cardiac ward when was readmitted to the Trust in August. She said this was not a suitable ward given his known heart condition and it meant he did not get the treatment he needed.
43. In its response, the Trust said Mr T did not need cardiac monitoring at that time and was appropriately transferred to a ward for treating his water retention. The Trust clarified that the ward Mr T was moved to is a general cardiology ward, primarily focused on treating patients with water retention.
44. GMC guidance says when providing clinical care, doctors must provide effective treatment on the best available evidence.
45. The National Heart Failure Audit publication explains many patients with heart failure are treated on general medical wards. It explains some patients with heart failure may have multiple health issues which may be more appropriately cared for by other clinicians with specialist input from the heart failure team.
46. Mr T’s records show on his readmission in early August he was initially assessed on an Acute Cardiac Unit (ACU). Mr T was then transferred to a general medical ward. A few days later the Trust decided to transfer Mr T back to the ACU for cardiac monitoring. This was because it had obtained an ECG which appeared to identify Mr T’s heart had a junctional rhythm.
47. Considering Mr T’s records, we can see he did have specialist care needs which were not just limited to his heart. Mr T's medical records indicate along with his heart failure, he had several health conditions, including a past diagnosis of type 2 diabetes, anaemia, and chronic kidney failure.
48. Due to Mr T’s comorbidities, our adviser explained it was reasonable for him to be on a general medical ward rather than the cardiac ward, they explained many patients with heart failure are treated on such wards because heart failure is a relatively common condition which general wards are well-equipped to manage effectively.
49. Upon his readmission in August, Mr T’s records note he was reviewed by a cardiologist who gave appropriate advice. They found him to have fluid overload and planned to treat this with diuretics.
50. Mr T’s records also show during his stay on the general medicine ward he was regularly monitored, including weighing and fluid status checks as well as receiving his diuretic medication. Our adviser explained by monitoring his weight and fluid status, the medical team could detect any changes that might indicate worsening heart failure and adjust treatment if needed.
51. Our adviser said Mr T's overall treatment plan was tailored to his specific health needs, addressing not only his heart failure but also his other health issues. We can see from Mr T’s records that during his readmission in August cardiac specialists treated him and he was also reviewed by other specialist teams including urology and a diabetic nurse.
52. Although Mr T was not on a cardiology ward, his records show he continued to receive input from cardiology and cardiac surgery specialists. Our adviser said this ensured he had access to expert advice and treatment plans, essential for managing complex conditions like heart failure.
53. Taking this into account, we have not found any indications of failings in the ward the Trust cared for Mr T on, or that it meant he did not get the treatment he needed.
54. We are of the view the Trust acted in line with the GMC guidance mentioned in paragraph 46.
Monitoring of Mr T’s fluid levels
55. Miss T says the Trust did not monitor her father’s fluid input and output during the times he was an inpatient at the Trust. She said she and her mother were constantly encouraging him to drink, and they were bringing drinks in for him.
56. In its response to Miss T, the Trust sought to assure her it had monitored Mr T’s fluids. It said this was being measured and is reflected on the fluid balance chart records for Mr T.
57. ESC guidelines for heart failure emphasise the importance of careful fluid management in heart failure patients to prevent fluid overload as the body tends to retain fluid which can worsen the condition.
58. Mr T’s records show the Trust took daily observations of his fluid levels during his admissions to the Trust between May and August. For example, Mr T’s records evidence the Trust monitored his fluid levels via daily logs between 16 May and 18 May and 10 July to 31 July, and again during his further admission from 8 August. We can see from Mr T’s records that on 14 August he was transferred to a critical care unit and by the 17 August the Trust determined it was no longer appropriate to monitor Mr T’s fluid levels as sadly, the Trust decided to start end of life care.
59. Mr T’s records show the Trust took regular note of his body weight. Our adviser said this is an appropriate way to monitor Mr T’s fluid status as it helps assess fluid retention and indicates thorough monitoring by the Trust. As we have already explained in the decision above, we can see the Trust adjusted Mr T’s care based on observations and examinations, including changing his diuretic medication and dosage to help balance his fluid levels.
60. Our adviser also explained the difficulty with heart failure is a person’s body wishes to retain fluid, so generally the less fluid taken in, the quicker the person gets better. Our adviser said it is important to manage fluid input in patients with heart failure. Considering the evidence we have seen and our clinical advice we think the Trust staff monitored Mr T carefully and in line with ESC guidelines mentioned in paragraph 62.
Communication surrounding decision to withdraw treatment and start palliative care
61. Miss T told us the Trust decided to withdraw treatment and transferred her father to a ward for palliative care without discussing this with her or her family.
62. GMC end of life guidance emphasises the importance of involving patients and their families in decisions about their care. Clinicians are advised to communicate clearly, providing information in a way that is understandable, ensuring all relevant people are informed about this decision.
63. Mr T’s records show on 15 August staff at the Trust updated Mr T’s wife and Miss T about his condition and prognosis. Staff explained Mr T’s kidney function worsened and his kidneys appeared to be failing, along with his heart failure. They told Mr T’s family he remained on a ‘knife edge’ and was unfortunately deteriorating. The records note Mr T’s family were understandably upset and in agreement that resuscitation was not in Mr T’s interests, as it would not save his life.
64. On 17 August Mr T’s records refer to a discussion that took place with his family regarding his treatment plan. Sadly, at this stage, clinicians identified that Mr T’s health was not improving, and no critical care or active treatment interventions would reverse his condition. Staff said it was appropriate to start palliative (end of life) care for Mr T. We can also see from the same record entry that this had been discussed with Mr T’s family.
65. Our adviser reviewed Mr T’s records and said the discussions around the Trust’s decision to withdraw treatment for Mr T and start palliative care were appropriate and in line with the GMC guidance referenced in paragraph 64. We have not seen any indications of failings. We can see from Mr T’s records that staff at the Trust spoke with his family before it started palliative care or transferred him to its palliative care ward. This means, based on the evidence we have seen we have not seen any indications of failings for this part of the complaint.
66. We recognise that Miss T continues to be profoundly affected by what happened. We are very grateful to her for sharing this experience with us and hope this statement fully explains the reasons why we will not take further action on her complaint.