Delays in transferring Mr D and operating on him 29. Mrs K is concerned Rotherham delayed transferring her father to Sheffield so he could undergo cardiac surgery. She is also concerned once her father was at Sheffield, it delayed operating on her father.
30. She says her father’s death could have been avoided had Rotherham and Sheffield acted sooner.
31. Mr D was diagnosed with endocarditis in July and was given a six-week course of antibiotics. Sheffield says due to this infection, Mr D was not a suitable candidate for surgery at this time.
32. Rotherham says doctors monitored Mr D in September and there was indication his endocarditis had resolved, and his moderate aortic valve stenosis and regurgitation was not a cause for concern. Its doctors decided they would continue to monitor Mr D in an outpatient capacity.
33. Following Mr D’s further admission to Rotherham in October he was transferred to Sheffield for a coronary angiography. Sheffield considers he was not suitable for surgery at this time either.
34. Sheffield’s cardiac surgeon says as Mr D had just suffered a heart attack, it was too risky to operate. They explain Mr D’s heart needed time to recover before surgery could be considered so he was transferred back to Rotherham.
35. Rotherham initially planned to transfer Mr D to Sheffield on 22 November for cardiac surgery. However, due to Mr D’s COVID-19 status and a pleural effusion (fluid between the lung and chest wall), this transfer was delayed.
36. There was a further planned transfer to Sheffield on 6 December which was also delayed because of air becoming trapped in Mr D’s lungs when it drew fluid from the pleural effusion to check for infection.
37. Rotherham says it needed to wait to see if the air dispersed. It made the decision to transfer Mr D to Sheffield on 16 December as he was stable.
38. Sheffield’s doctors discussed Mr D’s condition with Mrs K on 20 December. They set out Mr D was too frail to survive an operation.
39. During the complaints process Sheffield’s cardiac surgeon added that Mr D would never have been suitable for surgery and was palliative, but they could not know when he would die.
40. Mrs K disputes Sheffield’s doctors gave her any indication her father was palliative. She says throughout his admission doctors gave the impression he was not suitable for surgery but may be following rehabilitation.
41. ESC guidance explains a patient’s condition should be evaluated and managed with access to immediate surgical facilities under a multidisciplinary ‘endocarditis team’, which includes cardiothoracic surgeon, cardiologist and microbiologist input among others.
42. BMJ guidance says cardiac patients, like Mr D, should be designated a cardiothoracic surgeon following multidisciplinary team meeting (MDT).
43. GMC guidance, Section 15, says doctors must adequately assess a patient and promptly arrange suitable advice, investigations or treatment where necessary.
44. Our cardiologist adviser explained July would have been best time for Rotherham and Sheffield to have evaluated Mr D for surgery.
45. They found evidence to indicate Mr D’s aortic regurgitation (aortic heart valve leaking blood backward in the heart) may have been worse than first thought, which adds weight to the potential benefit for earlier surgical evaluation.
46. Our cardiologist adviser explains that the transoesophageal echocardiography scan (TOE) dated 25 July, which uses sound waves to probe the structure of the heart, did not give any measurements to quantify the degree of Mr D’s aortic regurgitation.
47. The TOE also stated he had moderate mitral regurgitation (mitral heart valve leaking blood backward in the heart) but again does not appear to have quantified the amount.
48. Our cardiologist adviser says the trans-thoracic echocardiograms (TTE), dated 15 July and 24 August, which also use sound waves to probe the structure of the heart, both reported there was mild mitral regurgitation and prominent flow reversal in the aorta (backward blood flow into the heart during its relaxation phase, or diastole).
49. They note these findings could be consistent with severe aortic regurgitation, rather than moderate, as Rotherham thought.
50. If the degree of aortic regurgitation had been underestimated during his initial admission at Rotherham, and Mr D’s condition was more serious than first thought, his subsequent MDTs may have picked up on this and prompted earlier surgical evaluation from Sheffield.
51. We can see an MDT discussed Mr D on 20 July, but this was before the TOE. This MDT also does not document whether it reviewed his 15 July TTE.
52. There was a further MDT on 28 July but, due to ‘cardiology staffing issues’ it did not discuss Mr D. Following this, Rotherham confirmed there were no further MDTs in July or August.
53. Therefore, there were no MDT discussions after 20 July. As such, Mr D’s TOE and later TTE do not appear to have been reviewed at this stage, so Rotheram carried out no MDT consideration of his overall condition and potential for cardiac surgery.
54. This represents a missed opportunity to get a better understanding of Mr D’s condition at this earlier juncture and may have allowed for earlier surgical opinion.
55. Even if we set our cardiologist adviser’s concerns to one side, Rotherham’s actions do not appear to be in line with both ESC guidance and BMJ guidance. We see this as a failing.
56. We will consider what impact this had upon Mr D and Mrs K later in our report where we will also consider what remedy will put it right.
57. Mr D’s condition had deteriorated by the time he was readmitted to Rotherham in October.
58. As set out at paragraph 41, ESC guidance says a patient’s condition should be evaluated and managed with access to immediate surgical facilities under a multidisciplinary endocarditis team.
59. Mr D does not appear to have been under an MDT following his initial discharge on 10 August.
60. Rotherham’s cardiology team saw him in its outpatient clinic on 22 September and discharged him. We recognise this review suggested Mr D’s endocarditis had resolved, but he was still at risk of deterioration.
61. Our cardiac surgeon adviser says Mr D had complicated endocarditis. This is because there was evidence of splenic infarction. Therefore, in line with ESC guidance, Rotheram should have referred him to Sheffield at the earliest opportunity, as it had had access to immediate surgical facilities.
62. Not doing so is a failing. We will consider what impact this had upon Mr D and Mrs K later in our report where we will also consider what remedy will put it right.
63. Rotheram diagnosed Mr D with COVID-19 in November after returning following his coronary angiography. This appears to have led to further delays in obtaining surgical evaluation.
64. Ultimately, Rotheram did not transfer Mr D to Sheffield for surgical evaluation until 16 December.
65. We acknowledge Mr D was Rotherham’s patient so was transferred back following his coronary angiography at Sheffield in October. We can see this move appears to have led to a series of emails between Rotherham’s doctors and Sheffield’s surgical team.
66. These emails concerned Mr D’s condition and his readiness for transfer back to Sheffield for surgical evaluation.
67. As set out earlier in this final report, following Mr D’s transfer back to Rotherham in October his condition deteriorated, and it took some time to medically optimise him enough to be sent back to Sheffield.
68. ESC guidance, set out at paragraph 41, emphasises the need for early action in patients with complicated endocarditis and for plans to be put in place. This would be particularly important for Mr D as he had serious and worsening cardiac problems by this stage.
69. We must also bear in mind that Sheffield was the surgical centre and had in person access to cardiothoracic surgical opinion, which Rotherham did not. As such, there was a missed opportunity for Mr D to have received earlier and more timely surgical evaluation at Sheffield following his coronary angiography in October.
70. This is because Sheffield appears to have been aware of Mr D’s serious cardiac problems. Owing to the potential for further deterioration, this would have justified surgical evaluation.
71. Had this taken place, it may have allowed Sheffield’s staff to more fully consider whether Mr D may be a candidate for surgery at this earlier point and form an appropriate plan in response.
72. It may also have allowed both Rotherham and Sheffield to more effectively manage Mr D’s and his family’s expectations around his prognosis and chances of recovery.
73. Sheffield’s actions do not appear to be in line with both ESC guidance and section 15 of GMC guidance. We see this as a failing.
74. We will consider what impact this had upon Mr D and Mrs K later in our report where we will also consider what remedy is appropriate.
75. We recognise paragraphs 31 to 33 of this final report set out that Sheffield did not see Mr D was suitable for surgery in either July or October 2022.
76. It must be understood that these views were shared with Mrs K in retrospect during the complaints process in November 2023.
77. While we included Sheffield’s retrospective views in the narrative of our report, there is no evidence we have seen it held such views at the time or that it carried out any surgical evaluation of Mr D prior to his admission to Sheffield on 16 December 2022.
Impact to Mr D and Mrs K 78. Both our cardiologist adviser and our cardiac surgeon adviser agree it is unfortunate Mr D did not receive surgical evaluation in July 2022.
79. It is important to set out here that while we think Rotherham may have missed an opportunity to get a better understanding of Mr D’s condition at this earlier stage and seek surgical evaluation, we cannot link this to his death.
80. This is because our cardiac surgeon adviser explained that even if Mr D had received surgical evaluation in July, he is unlikely to have been considered suitable for surgery.
81. This is because he was suffering from endocarditis and this infection was being actively treated with antibiotics. Our cardiac surgeon adviser says if surgeons did operate at this time, there would be a chance any new heart valve would also become infected. It would not be appropriate to operate until after the infection cleared up.
82. There was a further missed opportunity by Rotherham to seek surgical evaluation between August and October. We think Mr D should have been under the supervision of an endocarditis team during this period. An endocarditis team would likely have included surgical input from Sheffield, which is the surgical centre.
83. While we think there was a further missed opportunity to provide clarity on Mr D’s prognosis, we do not see it can be linked to his death.
84. Our cardiac surgeon adviser says it is unlikely Mr D would have received cardiac surgery prior to his heart attack in October. Following his heart attack, our cardiac surgeon adviser says it is unlikely surgeons would want to operate for around six weeks to allow his heart to recover.
85. Unfortunately, it was during this period Mr D contracted COVID-19, and his psychological condition deteriorated which meant he was no longer a candidate for cardiac surgery.
86. There was a further missed opportunity to obtain surgical evaluation when Mr D attended Sheffield later in October for his coronary angiography.
87. Having discussed this with our cardiac surgeon adviser we can see Mr D was unlikely to have been considered suitable for surgery at this stage either.
88. This is because he was recovering from a heart attack and during his recovery, he developed COVID-19. Both conditions meant surgery was unlikely to have been an option. Sadly, by the time he arrived at Sheffield in December he continued not to be a candidate for surgery due to ongoing frailty and confusion. We understand this will be difficult for Mrs K to read but hope the clarity we are supplying will ease some of her upset.
89. Our cardiac surgeon adviser says Mr D was never in a position where cardiac surgery could have been performed safely with the prospect of a good outcome.
90. For these reasons, we cannot see Mr D’s death can be linked to the missed opportunities identified in this final report.
91. We find earlier surgical evaluation by Rotherham and Sheffield, and the resulting clarity this likely would have given in terms of his prognosis, could have helped Mrs K to better understand the seriousness of her father’s condition.
92. This, in turn, would likely have served to better manage Mrs K’s expectations around her father’s chances of making a recovery.
93. We therefore see a degree of the upset and distress Mrs K describes over the six months between July 2022 and January 2023, when her father was being treated at both Rotherham and Sheffield, can be attributed to those missed opportunities.