4. Mr P complains about the care and treatment the Practice provided to his wife between September 2019 and May 2020. Specifically, he says the Practice did not:• make the referral to cardiology for an echocardiogram appropriately• follow up on the referral.
5. Mrs P died following a cardiac arrest on 7 June 2020. Mr P thinks this contributed to her death and it could have been avoided. He says this has caused him distress and suffering.
6. Mr P is seeking service improvements.
7. We have kept the background of events intentionally brief, as we will go into the events in more detail later in our report.
8. On 30 May 2019, Mrs P saw a nurse at the Practice for a routine respiratory review. She had a persistent productive cough (one which brings up mucus or phlegm) which was worse in the mornings. The Practice referred her to the respiratory team, who recommended she have an updated chest X-ray due to her productive cough.
9. Mrs P had a chest X-ray on 22 August which showed she had an enlarged heart. She had an appointment at the Practice on 12 September 2019. The doctor advised that she needed an echocardiogram (a type of scan to look at the structure of the heart), electrocardiogram (ECG, a test that records the electrical activity of the heart) and have her blood pressure taken.
10. An echocardiogram requires a referral to hospital whereas the ECG and blood pressure are investigations that could be completed at the Practice. The Practice says it made the referral for an echocardiogram on 12 September. On 23 September it recorded her ECG was abnormal.
11. On 20 February 2020, Mrs P had a review at the Practice. It was noted she had a lower respiratory tract infection, a cough with dark green phlegm, shortness of breath on walking and facial flushing. She asked about the echocardiogram that was due, and the Practice says it re-sent the referral that same day.
12. On 26 May, Mrs P had an asthma review at the Practice. She asked about the echocardiogram that was due and the Practice said it would chase this. It is documented the Practice looked on the ‘icare portal’ to see if an echocardiogram appointment had been arranged for Mrs P, and it could not see anything. It documented it would ask the secretary to see if the referral had gone through. The Practice made an e-referral to cardiology on 27 May.
13. On 7 June, Mrs P collapsed at home. Mr P called 999 and an ambulance attended. Paramedics gave cardiopulmonary resuscitation (CPR) for 30 minutes but were sadly unable to revive Mrs P. Her cause of death is documented as due to left ventricular hypertrophy (LVH) caused by calcific aortic valve.
14. LVH is a condition where the muscle wall of the heart’s left ventricle (chamber) becomes thickened, and this can make it harder for blood to pump effectively. Calcific aortic valve refers to a condition where calcium deposits accumulate on the aortic valve in the heart. This can cause the valve to become stiff and narrow, a condition known as aortic valve stenosis. This reduces or blocks blood flow from the heart to the rest of the body. This can cause the heart to be enlarged, which was found to be the case on Mrs P’s chest X-ray done in August 2019.
18. Mr P is concerned the Practice did not make the appropriate referral for the echocardiogram between September 2019 to May 2020. The Practice says it referred Mrs P and it would expect the hospital to act on this.
19. It was a national mandate set out by NHS England (NHSE) that all GP surgeries should send all referrals to NHS hospitals via the electronic referral system, e-RS, by October 2018. NHS Digital set out: ‘from October 2018, GPs and hospitals are obliged, via their respective contracts, to ensure that all GP to consultant referrals are made via e-RS’.
20. Our GP adviser told us the 2017/2019 NHS standard contract contains a specific provision (62.A) to the effect that after 1 October 2018, acute (hospital) providers will no longer be paid for any first outpatient attendances which result from them accepting a referral from a GP practice, made other than through e-RS. The national paper switch off programme run by NHSE and NHS Digital supported the NHS in ensuring the transition to a fully digital referral system was managed safely and on time.
21. As part of our investigation so far, we have spoken with the local hospital trust to understand more about the cardiology referrals process in place at that time. It explained paper referrals were no longer accepted into cardiology from GP surgeries from 1 October 2018. After this date, all cardiology referrals had to be made via NHS e-RS.
22. The hospital trust explained communications were sent out by national teams to all primary care (GP) services to advise them of the change in process. They confirmed it was communicated to all primary care services that referrals not received by e-RS would be rejected.
23. Records show the Practice determined Mrs P needed an echocardiogram on 12 September 2019. The Practice sent this as a paper referral. It is unclear how this form was sent, or who it was sent to, as there is no address on the form and it was not sent electronically. The Practice re-sent this same referral on 20 February 2020, using the same paper format. It then sent an online e-RS referral on 26 May 2020.
24. We spoke with the Practice to check what its local process was from September 2019 onwards, and if it was aware of the information communicated by NHSE. The Practice said when it receives a request for an echocardiogram, it actions this by sending an e-RS referral to cardiology as urgent.
25. As the Practice used a paper referral in September 2019 and February 2020, we cannot categorically say or know when or where this referral was sent. It is impossible to know whether the Practice sent it or not, or where it was sent to, based on the information available. This is for both instances, as the same paper form seems to have been used twice.
26. In response to the complaint, the Practice said it would expect the hospital to take responsibility for the next steps, after it sent the referral. We agree that the receiving organisation holds the responsibility once a referral is appropriately received. In this case, we have seen no evidence to show the Trust ever received the paper referrals, meaning it could not act on this.
27. In its response to Mr P’s complaint, the Practice said at the September 2019 appointment: ‘Mrs P was aware this referral [to cardiology for an echocardiogram] had been made’. She was also told the Practice had referred her for blood pressure monitoring and an ECG. Subsequently, both of those investigations took place. Mrs P left this appointment having been told referrals were made for three further investigations, and as two of those then went ahead, it is reasonable she expected the Practice had followed due process and made all three necessary referrals appropriately.
28. There is no safety netting advice documented by the Practice. We cannot see it advised Mrs P of an estimated timeframe to wait to hear from the hospital, or what to do if she did not hear from it after a certain period. We would expect this to have been explained and documented in the records.
29. With evidence she was told the referrals had been made, and without evidence of any safety netting advice about expectations, we would not expect the responsibility for follow-up to have been Mrs P’s. She did still follow-up with the Practice on those two further occasions when she attended for reviews, in February and May 2020.
30. This aside, the format used to send the referral was incorrect. Digital referrals should have been in place from October 2018. Even if these were rolled out slowly in certain areas, we think it reasonable to expect this should have been in place by September 2019. The national position by NHSE made clear that only e-referrals would be accepted from 1 October 2018, and the Practice has accepted and told us it was aware of this at the time.
31. We have very carefully considered information the Practice has given to us to provide some clinical context around what was happening at the time.
32. The Practice was going through a very large merger with four Practices merging into one in 2019. This was a huge transition for the Practice, and we understand different processes and systems would have been being combined.
33. The Practice also explained its understanding at the time was that the hospital was still accepting some paper referrals, despite the e-RS referral process being in place. It told us this was inconsistent. It provided evidence to show the hospital had accepted some other referrals for different patients by different means to the e-RS, and this had worked. As a result, it said it expected the hospital to act on its paper referral.
34. We understand the Practice’s explanation about what was happening at the time, and its views about why it made the referral in the way it did. We acknowledge the Practice was acting in good faith and we do not dispute that it felt it was taking the appropriate action to allow for the next steps in Mrs P’s healthcare.
35. We have very carefully looked for any evidence to support that either paper referral was sent, to where, and by what means. There is no record. The Practice does not have any evidence of this, the hospital trust has confirmed it did not receive anything on or around either date, and we know an appointment was not made as a result. Weighing up all the evidence, if we cannot see it got to the hospital, it could not then be acted on.
36. We have also carefully considered the action the Practice took in February 2020. When Mrs P highlighted that she was still waiting, the Practice told us it re-sent that original referral. The Practice did not follow-up directly with the hospital. If a referral had been made and existed in the system, our lead clinical adviser says the appropriate process would be to chase this initial referral up rather than making a new referral. This is because starting again by re-sending the referral, would have put the patient many months behind by not locating and chasing up the initial referral.
37. We appreciate the Practice should not be held responsible for chasing every referral it makes. Due to the sheer volume, this would not be reasonable. That said, our lead clinical adviser says if a patient contacts their GP practice to say they have not yet had an appointment following referral, especially after several months has passed, it would be reasonable to expect the GP practice to look into this further.
38. When Mrs P informed the Practice for a second time in May 2020 she had still not heard anything, the medical records say ‘patient asking about ECHO that is due, advised will chase it up’. This supports our view, that the correct process is to chase an existing referral once it has been made.
39. The staff member then wrote ‘looked for echo appointment, can’t see anything’. An e-RS referral was then made. This suggests the Practice staff member could not locate either the September or the February referral, as otherwise they would not have proceeded to make a new, e-RS referral. We think if the Practice was confident either of those earlier referrals had been successfully made, then these existing referrals would have been chased. Making a new referral in both February 2020 and again in May 2020 put Mrs P at the back of the queue, five and eight months behind, respectively.
40. We think this supports our thinking, that neither paper referral had been previously made correctly, as neither would have needed to be made again. We know when the e-RS system was then used in May, it worked how it should have done.
41. We recognise this was an extremely challenging time for the Practice. We are aware that the Practice’s intention was to do the right thing by Mrs P at the time, and we acknowledge the wider context of the Practice merger and inconsistent process at the hospital trust.
42. Taking all of this into account, there is no evidence to show the referrals in September 2019 and February 2020 were sent, by any method. The first evidence of the referral being sent was in May 2020, and this aligns with when the hospital first received anything from the Practice. This is not in line with guidance and these are failings.
43. We know this will be extremely upsetting for Mr P to read. We acknowledge he has serious concerns about how Mrs P’s referral was made, and if the outcome could have been avoided with more timely intervention.
44. We have taken advice from our cardiology adviser to consider how these failings impacted Mrs P’s chances of recovery. We have carefully considered if she could have survived had she been correctly referred to the hospital trust.
45. GMC guidance says doctors must promptly arrange suitable advice, investigations or treatment where necessary, and refer a patient to another practitioner when it serves the patient’s needs.
46. In line with the above, Mrs P’s referral for an echocardiogram should have been made to the Trust, correctly via e-RS, on 12 September 2019. If it had been, the date for the echocardiogram would have been six weeks ahead. This is an NHS target provided by NHS Digital, which sets out less than 1% of patients should wait six weeks or more for a diagnostic test. Considering this, it is more likely than not that Mrs P would have had the echocardiogram completed by 24 October 2019.
47. Considering what we know of Mrs P’s later clinical condition, our cardiology adviser explains this echocardiogram would have shown severe aortic stenosis. With a diagnosis of aortic stenosis, Mrs P would have been referred for surgery. There would have been two surgical options available, the first being open heart surgical aortic valve replacement (open cardiac surgery), and the second being a replacement of the aortic valve (valve repair).
48. Based on her age, general health, lack of disease or multiple conditions, our cardiology adviser explains it is highly likely Mrs P would have been considered a candidate for open cardiac surgery. We do not see any evidence to suggest she would not have been suitable for this option, which is the standard treatment.
49. The general target for treatment is 18 weeks, as set out in the NHS constitution. Considering this, we think it likely Mrs P would have had this surgery by 27 February 2020. We have no reason to consider the standard timescales would not have been followed.
50. Our cardiology adviser says depending on the findings on echocardiogram, there is a possibility this treatment would have been carried out much sooner than this. Mrs P’s postmortem shows her heart problems were becoming severe, as they were the cause of her death. Our cardiology adviser explains in this circumstance, over time, the heart comes under more and more stress. It is reasonable to think it would have been quite severe by October 2019, looking at what the postmortem shows. Based on this, it we think it likely the surgery might have been done much sooner than the 18 weeks.
51. Even if we use the 18-week target as a reasonable timeframe, Mrs P would have had the opportunity to have this surgery much sooner than when she died in June 2020. Whilst we acknowledge there can be difficulties in individual hospital trusts meeting the national 18-week target, there were 14 additional weeks, after the first 18, before Mrs P died. Considering this, alongside the strong possibility of significant findings on echocardiogram and being symptomatic, it may have meant her surgery was expedited. We think on the balance of probabilities she would have had surgery before the time she sadly died.
52. If Mrs P had surgery by February 2020, her mortality rate for open heart surgical aortic valve replacement surgery would have been 1.2%, using the national adult cardiac surgery audit. This means her chances of survival were 98.8%. Considering this, we think it highly likely Mrs P would have survived surgery.
53. Our cardiology adviser explains Mrs P’s recovery would have been expected to be full. The surgery she was a suitable candidate for is standard surgery, she had no other chronic or multiple conditions, and it is likely her health would have improved afterwards.
54. We have also carefully considered the impact of the second missed opportunity for the referral to be sent via e-RS on 20 February 2020.
55. As explained, less than 1% should wait longer than six weeks for an echocardiogram. Had the referral been made correctly on 20 February 2020, it is highly likely Mrs P would have had this by 2 April. The echocardiogram would have shown severe aortic stenosis and she would have been referred for surgery. It is possible the echocardiogram at this time may have shown even more severe disease in view of her progressive deterioration.
56. Sadly, as Mrs P died on 7 June, there was less time within the 18-week window for her to have had surgery on this second occasion. This is because there were 9 weeks between 2 April and Mrs P’s sad death. Based on this, we cannot say it is more likely than not that surgery would have gone ahead. However, it is possible, as the findings of the echocardiogram may have meant this was expedited more urgently.
57. As our cardiology adviser has previously explained, it is reasonable to consider Mrs P’s heart would have been in a worse condition at this point and this may have prompted urgent surgery. Had it gone ahead, the same understanding that she would have made a full recovery applies. This is a second missed opportunity for a potentially different outcome.
In summary 58. Based on Mrs P’s clinical condition and history, and the known morality risks that applied in her case, had her referral been made as it should in September 2019 it is more likely than not her death would have been avoided. We conclude Mrs P would have survived if the referral had been made in line with due process in September. We conclude there was a second missed opportunity for this or a different outcome had the referral been made as it should in February 2020. We acknowledge how devastating this will be for Mr P to learn.
59. The complaints standards say organisations should give meaningful and severe apologies and explanations that openly reflect the impact on people’s concerns. The standards also say organisations should take action to make sure any learning is identified and used to improve services.
60. We have identified failings and explained the outcome we think resulted. We are yet to see the Practice has acknowledged or taken action to remedy this. We do not think the Practice has recognised the significance of where things have gone wrong or taken learning as a result. We therefore propose recommendations.
1. We have very carefully considered Mr P’s complaint about the care his wife, Mrs P, received between September 2019 and May 2020. We would like to extend our condolences to Mr P and are mindful of the significant distress he has experienced.
2. We have found failings in how the Practice managed Mrs P’s referral in September 2019 and February 2020. On both dates, the referral should have been made electronically. We think if this had happened, it would have led to her getting further treatment that is likely to have saved her life. Our view is that Mrs P’s subsequent death was avoidable. We recognise the considerable distress this will cause, and we do not underestimate the devastating impact of this on Mr P.
3. Therefore we uphold the complaint. We have asked the Practice to write to Mr P to apologise and acknowledge where it got things wrong, and pay him £12,500 in recognition of the impact. We have also asked the Practice to create an action plan to prevent the same things happening again.
61. 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.
62. 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.
63. In line with this, we recommend the Practice create an action plan, within three months of the date of our final report. The action plan should look at the failings we have identified with the referral and clearly set out: • the reason(s) for the failing (where possible) • the learning taken and what it will do differently in the future (or does do differently now) • who is/was responsible, the timescale for completion and how it will be/is monitored
64. The Practice should share the action plan with us, Mr P, and the CQC.
65. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, that within three months of the date of the final report, the organisation should pay Mr P £12,500 in recognition of the considerable distress he has suffered in relation to his wife’s care and now knowing his wife’s death was avoidable. The Practice should send us evidence this payment has been made.
In conclusion 66. Very sadly, nothing can change the very sad events surrounding Mrs P’s death. We hope our investigation has been helpful to Mr P and can provide some comfort in the actions we have asked the Practice to do, to prevent this happening to anyone in the future