Imperial College Healthcare NHS Trust

4. Mrs C complains about how doctors and surgeons from the Trust treated her brother Mr G between June 2021 and 3 January 2023. She specifically complains about:

• delays in arranging vascular surgery • use of codeine • treatment of a shoulder fracture on 17 October 2022 • discharge from hospital on 3 November 2022.

5. Mrs C says failings in treatment led to her brother’s death, which she believes was avoidable. She wants the Trust to acknowledge its failings and make changes to services so other patients do not have the same experience. She also seeks a financial remedy.

6. Mr G (who was aged 70 when he died) had a history of atrial fibrillation (an irregular and fast heartbeat) and peripheral vascular disease (a condition usually caused by a build-up of fat in the arteries of the legs). He was a heavy smoker and drank alcohol above the recommended levels. He had intermittent bouts of claudication (a lack of blood flow to the legs).

7. Mr G attended an appointment with his GP in June 2021. The GP noted Mr G had a large ulcer above his left ankle and discoloration of his feet and diagnosed type two diabetes. The GP made a referral to the Trust’s vascular department on 24 June 2021.

8. Mr G attended an elderly medicine clinic on 6 September 2021. During the clinic he told the doctor he was waiting for a vascular appointment. The doctor said there was no record of this on the Trust’s appointment system.

9. Mr G’s initial appointment with Mr A (Consultant Vascular Surgeon) was scheduled for 26 October 2021. This was then cancelled and rescheduled for 9 November because Mr A was on leave.

10. On 3 November 2021 Mr G attended the emergency department at West Middlesex Hospital. He had ongoing abdominal pain and doctors arranged a CT scan. This suggested he might have a tumour on his left kidney which needed further investigation. They decided to admit him to a ward. Doctors did not consider the tumour needed treatment at that stage and they suspected he had chronic liver disease, chronic pancreatitis (inflammation of the pancreas) and possibly a blockage linked to his gall bladder.

11. Doctors transferred Mr G to Hammersmith Hospital on 5 November 2021 to attempt to ease the blockage around his gall bladder. This procedure relieved his symptoms, and he went home the next day.

12. On 9 November 2021 Mr G had a telephone consultation with Mr A who said he needed to see Mr G in person.

13. On 18 January 2022 Mr G attended a face to face appointment with Mr A. Mr A was concerned about the ulcer on the left leg. He planned further investigations and recommended medication to try and prevent blood clots.

14. Mr G had an ultrasound of the arteries in his left leg (a duplex scan) at Charing Cross Hospital on 8 February 2022. His next appointment was with Mr A at West Middlesex Hospital on 14 March. The leg ulcer was still causing pain and discomfort for Mr G. Mr A recommended that Mr G should have vascular surgery for critical ischaemia (this is when the blood flow to the legs is significantly blocked). Mr G needed femoro-popliteal bypass surgery (where part of an artery is replaced using a section of a different blood vessel). Before that could happen scans of his legs were needed.

15. On 12 April 2022 Mr G had a CT angiogram (a test to assess the arteries to see whether they are blocked). This showed a long blockage of the artery in his left thigh.

16. Mr G attended the emergency department at West Middlesex Hospital on 17 April 2022. He had experienced episodes of vomiting blood. Doctors found that his digestive system was inflamed but the bleeding had stopped. They discharged him after three days and arranged for him to be followed up as an outpatient.

17. On 8 May 2022 Mr G wrote to the Trust. He was concerned about an episode of excessive bleeding from his leg. He complaint of sleeplessness, and in pain. He asked whether anything could be done to arrange surgery more urgently. He requested an appointment as soon as possible.

18. On 21 June 2022 a different vascular consultant, Ms E, reviewed Mr G and recent investigation results. She said she would request a scan of his veins to confirm whether he had one suitable for the planned surgery.

19. Mr G returned to the emergency department at West Middlesex Hospital on 22 July 2022. He had been struggling to eat and had abdominal pain and tiredness. Doctors did not consider he had any symptoms that needed him to be admitted at that stage. They noted he had other appointments planned and advised him to return if his condition changed.

20. Ms E saw Mr G again on 9 August 2022. She noted he was concerned about the delays in surgery because his leg felt much worse. She considered his atrial fibrillation needed to be controlled before surgery and recommended that his GP prescribe medication for that. She arranged an ultrasound scan of Mr G’s veins which took place on 15 August at Charing Cross Hospital.

21. The vascular team offered Mr Murgan a date for surgery for 11 October 2022. The Trust then cancelled this and rescheduled it for 25 October.

22. The surgery did not take place on the planned date because Mr G had an accident and fractured his left shoulder. He attended the emergency department at West Middlesex Hospital on 17 October 2022. The orthopaedic team reviewed him and decided he did not need an operation on his shoulder, which would take up to two months to heal.

23. Mr G returned to the emergency department at West Middlesex Hospital on 24 October 2022. He complained of severe pain in his left arm and was not eating or drinking. Doctors were concerned about his observations, especially his low blood pressure, and decided to admit him for treatment.

24. On 3 November 2022 doctors decided Mr G was well enough to be discharged from hospital. However, he returned later that same day because he felt confused and nauseous. During this admission Mr G had pain in his left arm related to the shoulder fracture. He had episodes of breathlessness and doctors diagnosed and treated him for pneumonia. They also treated him for fluid on his lungs. Doctors discharged him from hospital on 21 November.

25. On 23 November 2022 Mr A wrote to Mr G’s GP. He said ‘we will reschedule him for the immediate future perhaps next week. He is still smoking, which is a problem, but he is aware that he is at higher risk of graft occlusion [a blocked artery] and limb loss. I will expedite his treatment.’

26. The Trust offered Mr G a new date for vascular surgery for 7 December 2022 at St Mary’s Hospital. Mr G attended for that date, but clinicians put it back to the following day because of issues with bed capacity. The surgeons could not complete the surgery because of difficulties getting access to the veins. They attempted instead to stretch some of the blood vessels to improve blood flow.

27. On 21 December 2022 surgeons attempted a further procedure, an angioplasty, to try and widen one of the arteries in Mr G’s leg. This worked well and they repeated the process in the following week.

28. On 1 January 2023 Mr G became increasingly unwell with pneumonia and COVID-19. Sadly, he died on 3 January.

29. The Trust sent two written responses to Mrs C’s complaint. In its final complaint response, on 6 March 2024, it included a list of Mr G’s appointments and cancellations. It said ‘the vascular department always had a long wait time of around 12 months’ but since then it now ensures appointments are booked without triage to try and speed up the process. Mrs C remained dissatisfied, so she complained to us.

Delays in surgery

33. Mrs C says her brother waited 18 months for vascular surgery. She says by the time surgery was offered her brother was too frail for the procedure. She says doctors and surgeons missed several opportunities to intervene at an earlier date.

34. The Vascular Society Guideline aims reduce serious health problems and death from peripheral arterial disease. It notes there is a regional variation in services for people with this condition within the UK.

35. The Vascular Society Guideline says early revascularisation (surgery to restore or improve blood flow) is necessary to prevent limb loss for patients who have critical limb ischaemia. It stresses that delay is best avoided. It says patients with critical limb ischaemia who are not in hospital should be seen within seven days of a referral and treatment should start within 14 days. It says assessment of patients requires input from a multidisciplinary team (MDT).

36. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.

37. Mr G’s GP referred him to the vascular team at the Trust on 24 June 2021. He had bilateral claudication (meaning pain in his legs when walking due to reduced blood supply). The referral letter also referred to a recently developed ulcer on Mr G’s left leg. It was on 9 November (20 weeks later) when Mr G had a review appointment with Mr A.

38. The Vascular Adviser said information in the GP referral alone should have raised the question of whether Mr G had critical ischaemia. This is a situation where the blood supply to the leg is so poor that tissues start to die with evidence of gangrene and ulceration. Mr G had a diagnosis of peripheral vascular disease from 2018 and reduced blood supply to his legs. The Vascular Adviser said, even if the vascular team made a bold assumption that the ulcer was not related to vascular disease, and only focused on claudication, a 20 week wait for an initial appointment is far too long. It was not timely treatment.

39. On 9 November 2021 Mr A had a telephone consultation with Mr G. The Vascular Adviser said this is an inappropriate way to review a patient who has peripheral vascular disease and a leg ulcer. We recognise this was only a short time after the COVID-19 pandemic and this was probably the reason a face-to-face appointment was not possible. It was clear from Mr A’s clinic letter that he was frustrated and needed to see Mr G in person.

40. There is limited information about what Mr A said during the consultation with Mr G on 9 November 2021. The Vascular Adviser said it would have been appropriate at that stage to arrange a duplex scan before the planned face-to-face appointment. This would have expedited the process because a further wait for the scan to take place afterwards would not have happened. Instead, there was a delay of eight weeks before Mr G could meet Mr A to discuss the scan results on 14 March 2022.

41. At the appointment on 14 March 2022 Mr G had critical ischaemia with pain when resting. The Vascular Adviser said this should have led to full investigations and treatment starting within 14 days. A CT angiogram and other investigations should have been requested as urgent. Instead, the CT angiogram took place on 14 April. This was not in line with the Vascular Society Guideline.

42. It was only on 21 June 2022 that Mr G had a clinic appointment to discuss the results of the angiogram. This was around one year from the date of the initial GP referral. The Vascular Adviser said this was far too long. There is also little evidence of MDT meetings taking place. The records refer to only one such meeting in December 2021. This was also not in line with the Vascular Society Guideline.

43. By August 2022 the vascular surgeons were concerned about Mr G’s atrial fibrillation. They were reluctant to operate because of the risks associated with this condition. When a date was offered for this procedure, this had to be cancelled due to a clinician’s illness. The rescheduled procedure then had to be cancelled because of Mr G’s accident when he experienced a shoulder injury. These were all unfortunate developments, but we cannot say they show doctors fell below the relevant standards.

44. After his accident it took until the end of November 2022 for doctors to consider Mr G was well enough for surgery. The clinical records show the vascular team managed him appropriately from this point onwards.

45. We find the vascular team delayed Mr G’s care and treatment for a year until June 2022. They did not give him timely and effective treatment and did not follow Good Medical Practice. The vascular team also fell below the standards required in the Vascular Society Guideline, in terms of the time they took to progress Mr G’s treatment and the lack of MDT involvement in decision making.

46. We asked the Vascular Adviser to explain what the impact of these failings in care and treatment was for Mr G.

47. The Vascular Adviser told us it is difficult to assess the impact delays in care had on Mr G’s health. This is because Mr G was consuming too much alcohol and had a history of chronic pancreatitis leading to chronic abdominal pain. He was also a heavy smoker and refused to take on board the lifestyle advice doctors gave to him. He had atrial fibrillation. He later developed narrowing of his bile duct and needed repeated surgery for that issue. In summary, he had a range of complex medical and lifestyle issues which would all have contributed to his worsening condition.

48. Mr G died from hospital acquired pneumonia, which was complicated by COVID-19. This was at a time when clinicians had attempted various procedures to try and improve his circulation. The Vascular Adviser said Mr G’s chronic vascular problems and lack of sleep would have contributed to his general deterioration. But all his other problems, along with his lifestyle, were also factors. It is possible these issues could have contributed to the fall he had, which also affected his general health.

49. The Vascular Adviser said it is unknown to what degree each of Mr G’s health problems contributed to his death. Their view was that delayed vascular treatment would only have played a small part in Mr G’s death. It is impossible to say whether he would have survived if the vascular issues had been treated more quickly.

50. The Vascular Adviser told us there is no doubt the delays from the vascular team had an impact on Mr G’s quality of life. There are repeated references to Mr G being unable to sleep because of the pain in his legs. Clearly, his mobility was also impaired. But, Mr G would have had pain and discomfort from his other health problems too. That said, it seems likely his pain and discomfort would have been reduced had the vascular team treated him quicker.

51. We cannot say the failings we have seen led to Mr G’s death. But we can say there was a small possibility that he could have had treatment that may have led to a different outcome. Unfortunately, Mrs C is left not knowing whether her brother would have survived if the failings had not happened. We find the doubts she is left with are a significant injustice to her. We also consider Mr G would have been in less pain and discomfort had the vascular team treated him promptly.

Codeine

52. Mrs C says doctors gave her brother codeine for pain in his legs. She said he was allergic to codeine, and this meant he could not eat without vomiting. She says doctors wrongly assumed he had pancreatitis.

53. The Pain Guideline explains how clinicians in emergency departments should assess the severity of pain and prescribe appropriate pain relief. For people with moderate pain, it recommends prescribing codeine. Good Medical Practice says doctors must prescribe medication only when they have an adequate knowledge of the patient’s health and are satisfied it serves the patient’s needs.

54. Records from the emergency department on 23 July 2022 show Mr G had been experiencing vomiting for three days with abdominal pain and weight loss. During his stay in the department his pain reduced, and he was ‘comfortable.’ The doctor who reviewed him noted he already had a prescription for co-codamol (medication that contains both codeine and paracetamol). There is no evidence clinicians gave him additional pain relief during this attendance.

55. Mr G attended the emergency department again on 17 October 2022 following the fall in which he injured his left shoulder. The ambulance records show he had already taken his own co-codamol before paramedics attended the scene. Doctors gave him morphine during his time in hospital and additional co-codamol to take home with him.

56. When Mr G returned in pain on 24 October 2022 the ambulance records again show he had been taking co-codamol. Hospital records show he was taking co-codamol regularly. Doctors at the hospital then gave him additional morphine for the pain, while continuing with co-codamol.

57. The Emergency Medicine Adviser told us codeine is an opiate painkiller that is used to treat moderate pain. Nausea and vomiting are common side effects associated with codeine. There is nothing in the clinical records to suggest Mr G was allergic to codeine. If codeine caused vomiting this would be considered an adverse effect rather than an allergy. There is no suggestion that Mr G had an allergic reaction to the codeine he took at home from July 2022 onwards.

58. The Vascular Adviser told us there were episodes of vomiting during two of Mr G’s emergency admissions, and one of these was associated with bleeding in April 2022. On that occasion doctors treated him and noted his symptoms settled despite him taking co-codamol. The cause of the vomiting was duodenitis (inflammation of part of the bowel). The Vascular Adviser said this could have been related to alcohol consumption. There were many occasions when Mr G took codeine or co-codamol without any evidence of nausea or vomiting.

59. We find doctors followed the Pain Guideline when giving Mr G medication containing codeine. It is a recognised treatment for moderate pain. There is no evidence to suggest codeine did not serve his needs or that he was allergic to it. Doctors also followed Good Medical Practice. We hope Mrs C is reassured we have seen no evidence of any failings in this respect.

Shoulder fracture

60. Mrs C questions whether doctors managed her brother’s shoulder injury appropriately.

61. The Fractures Guideline explains how doctors in an emergency department or orthopaedic clinic should assess and manage non-complex fractures. It specifically refers to proximal humerus fractures (which is the injury Mr G had). It says doctors should offer non-surgical management unless there are serious complications, such as open wounds, in which case they should consider surgery.

62. Mr G attended the emergency department at West Middlesex Hospital on 17 October 2022. An X-ray confirmed he had a proximal humerus fracture. The orthopaedic team reviewed him and recommended using a collar and cuff (sling). Mr G was in too much pain to use this to begin with and doctors gave him additional pain relief. Later that day he left the hospital, wearing the sling, with a plan for him to attend a follow up clinic in six weeks.

63. The clinical records show doctors treated Mr G with pain relief and a sling. The Orthopaedic Adviser told us this was appropriate. There were no signs of other complications relating to the fall. There were some issues with pain relief. The Orthopaedic Adviser said this is often this case with these types of injuries and it does not indicate poor practice.

64. We find doctors followed the Fractures Guideline. We have seen no evidence of any failings in this respect.

Discharge on 3 November 2022

65. Mrs C says doctors discharged her brother and then readmitted him later the same day. She questions whether he was well enough to be discharged.

66. The Discharge Guidance was published in 2024 but was initially introduced in 2016. The relevant section for this complaint was published before Mr G’s discharge in 2022. This is Annex D which explains how doctors should consider whether patients need to remain in hospital. If someone does not have any one of a list of different factors, doctors should consider discharging them.

67. The Medical Adviser told us doctors are encouraged not to keep people in hospital who do not need to be there. It is not the case that all patients who are unwell should remain in hospital. Only those who would benefit from continued admission should be there.

68. The clinical records show doctors reviewed Mr G daily from 1 to 3 November 2022. They did not record any signs that he was acutely unwell. His blood pressure was slightly lower than normal. The Medical Adviser said blood pressure measurements are sometimes unreliable in patients who have atrial fibrillation. Doctors would consider this in the context of other observations. They noted Mr G’s chest was clear.

69. Nurses also recorded physiological observations. These were consistent and showed no signs of increased breathing rate or low levels of oxygen, which would be indicators that someone was developing a chest infection.

70. Mr G’s blood test results from 1 to 3 November 2022 were also normal. While his level of CRP (a protein that is used to identify inflammation in the body) was slightly high, on its own it was not significant enough to be of concern. There was no evidence of any raised temperature or a productive cough. There were no clues during this time that Mr G was developing an infection.

71. Mr G returned to the hospital by ambulance later that same day. Paramedics noted he had episodes of vomiting at home. This was a new development. Some of his observations were worse than they were before he left the hospital. For example, his rate of breathing was slightly raised along with lower levels of oxygen in his blood and lower blood pressure. The Medical Adviser said these findings may all have been linked to the vomiting but may have been linked to a developing chest infection. The paramedics were right to be cautious and to take Mr G back to the hospital.

72. Doctors assessed Mr G on his return and found crackles at the base (lower part) of one of his lungs. This, together with the increased breathing rate and lower oxygen levels, were sufficient for the team to suspect a chest infection and start antibiotics. But Mr G did not have a cough, sputum or other chest symptoms. He had a normal white blood cell count, mildly raised CRP and a normal chest X-ray, which did not suggest a chest infection. A CT scan of the abdomen, which incidentally captured the lung bases, ruled out pneumonia, despite the crackles heard at the lung bases that had initially raised suspicion. The Medical Adviser said it is unlikely Mr G had pneumonia on 3 November 2022 either when he left the hospital or when he returned.

73. We find doctors followed the Discharge Guidance when they decided to discharge Mr G from hospital on 3 November 2022. He did not have any of the factors stated in the Discharge Guidance that would have needed him to remain in hospital. We can see why Mrs C has questioned the decision given that her brother returned soon afterwards. We cannot say doctors fell below the required standards in this respect.

1. Mrs C complains about the treatment doctors from the Trust gave to her brother, Mr G, at West Middlesex Hospital. Vascular surgeons working for the Trust also gave Mr G treatment at Charing Cross Hospital and St Mary’s Hospital, which are part of a different organisation. We can see how devastating these events have been for Mrs C and her family. We offer our sincere condolences to them for their loss.

2. We find there were delays in arranging Mr G’s vascular surgery. We cannot say his death would have been avoided if the delays had not happened. But we can see there was a possibility that earlier treatment could have led to a different outcome. We can also see how Mr G experienced pain and discomfort that could have been reduced. This has led to a significant and ongoing injustice for Mrs C.

3. We do not find failings in the other areas of Mrs C’s complaint. We partly uphold her complaint. We recommend the Trust acknowledges its failings and apologises for the impact they had. We also recommend a financial remedy and an action plan to try and ensure there is learning from the complaint.

74. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

75. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

76. In line with this we recommend the Trust should acknowledge its failings relating to delays in providing Mr G with the vascular treatment he needed. Within two months of this report the Trust should acknowledge these failings and apologise to Mrs C for the impact they had. We also consider it should pay a financial remedy to Mrs C.

77. To decide on a level of financial remedy, we review cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, our current thinking is the organisation should pay Mrs C £1,000 in recognition of the injustice she has been left with.

78. Our complaint standards say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

79. Within three months of this report, the Trust should produce an action plan to describe what it has done or will do to improve the specific issues relating to treatment delays we have seen in this investigation. The action plan should, where possible, identify the reasons for the failings. It should explain the learning the Trust has taken from these issues; what it will do differently in future; who is responsible and timescales for each action; and how it will monitor these. The Trust should provide a copy of this action plan to us, Mrs C, the Care Quality Commission (CQC) and NHS Improvement.

Conclusion

80. Mrs C believes failings in care and treatment contributed to her brother’s death. Clearly, the last months of her brother’s life and the way he died were incredibly distressing for her. We hope she is reassured that we have carefully considered all the relevant evidence.

81. In most of the areas Mrs C complained about we have not seen any evidence of failings. The exception were the significant delays in vascular treatment. We can see how these have left her with doubts about whether her brother would have survived if the failings had not happened. We can also see how Mr G’s pain and discomfort would have been reduced and his quality of life was affected. This knowledge will continue to be a source of distress to her and her family.

82. We partly uphold Mrs C’s complaint and to make recommendations to the Trust.