Admission
17. Mrs A says that Mr B had to wait for 10 hours to see a doctor when he went to hospital at approximately 5.30pm on 23 February 2022. He then had to wait until approximately 3pm on 25 February 2022 before he was admitted to hospital. Mr B spent much of this time on a trolley as there were no beds available.
18. The records indicate that Mr B initially made his own way to a hospital which is part of the Trust on 23 February 2022, arriving at approximately 8.45pm where he was triaged promptly by a nurse. Mr B reported shortness of breath for the last few months and said he was on antibiotics due to a chest infection. He had seen his GP the previous day. Mr B’s fingers were blue in colour, and he reported that he suffered from poor circulation. It was documented at the time that Mr B had a background of aortic stenosis. Mr B had a National Early Warning Score (NEWS2) of 6 which is medium risk. This meant he needed an urgent review by a ward-based doctor or acute team nurse to decide on escalation to a critical care team.
19. At approximately 9.40pm, the records indicate that Mr B was seen by a doctor which was approximately one hour after the records indicate he arrived at hospital. The doctor noted Mr B’s previous symptoms and documented that he had no chest pain or cough. On examination, Mr B was alert and speaking in full sentences, he denied any pain. He still had peripheral cyanosis (blue fingers). Mr B had good airway exposure and no crepts or wheezes which are sounds that can be associated with heart or respiratory problems.
20. Nevertheless, the doctor concluded that as Mr B had worsening shortness of breath and peripheral cyanosis, he should be sent to A&E at another hospital which is part of the Trust by ambulance. Mr B arrived at the hospital at 12.05am on 24 February 2022. He was not triaged until 2.45am on 24 February 2022 due to a lack of capacity in A&E. Mr B was still reporting shortness of breath but, by 3am, his NEWS2 score had reduced to 2. Mr B was seen by emergency medicine staff at 8.30am. He still had shortness of breath but had no other significant concerns at this time. The plan was for observations, blood tests, Electrocardiogram (ECG), and a chest X-ray. Mr B would be reviewed once the Trust had the results from these investigations and he continued to be monitored throughout 24 February 2022.
21. At approximately 5.30am on 25 February 2022, Mr B was seen by cardiology who diagnosed his condition as severe aortic stenosis that was now decompensating which means his condition was getting worse. The advice from cardiology was for a repeat echo to be undertaken. During the rest of the morning and early afternoon on 25 February 2022, Mr B continued to be monitored in A&E. Unfortunately, from when Mr B was transferred to this hospital the previous day, there were no beds available for him to be admitted to the ward, and he spent most of this time on a hospital trolley. This must have been frustrating and uncomfortable for Mr B, given his condition, and concerning for his family who would have been anxious and worried about him. We note that Mr B was eventually admitted to the MAU at approximately 3pm on 25 February 2022.
22. The Trust apologised to Mrs A for both delays. This was due to the high volume and acuity of patients in the A&E department at the time which resulted in delays seeing a doctor and getting a bed. To ensure patients in this type of situation are as comfortable as possible, the Matron on the ward is now making regular checks to ensure staff are placing patients waiting to be admitted to the ward onto a hospital bed whilst in A&E.
23. We consider that the length of time taken for Mr B to be admitted to hospital on 24 and 25 February 2022 was far from ideal. While we accept this would have caused Mr B some frustration and discomfort and his family some worry and anxiety at the time, we are reassured from the records that Mr B was being regularly monitored while he waited. Furthermore, our adviser says there is no evidence in the records that these initial delays had a significant negative clinical impact on Mr B’s condition. We acknowledge that delays are inevitable in a busy NHS A&E department. The Trust has apologised, and we are reassured by the remedial action taken to make patients more comfortable when this type of situation arises. As such, there is no further action for us to take on this point.
Communication
24. Mrs A says the Trust’s communication with her family about Mr B’s care was inadequate when he was in hospital. The Trust has acknowledged that it failed to effectively communicate with Mr B’s family about his care. For example, it failed to explain the heart valve replacement process and the overall severity of Mr B’s clinical situation. The Trust apologised for its inadequate communication in its complaint response.
25. The GMC guidance on communicating with those close to a patient state: ‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.
26. The hospital records contain entries which document discussions with Mr B’s family, but our adviser has told us overall communication with the family during this episode of care was scarce, lacking in regularity and updates. The GMC guidance applies in all cases when a patient has people close to them such as friends or family.
27. In relation to Mr B’s condition when he was in hospital, the Trust’s complaint response states: ‘He looked very frail and withdrawn as he was not retaining information due to overall ill-health.’ This indicates that Mr B may not have always had full capacity when he was in hospital although we cannot see evidence that a capacity test was carried out. Nevertheless, our adviser says this demonstrates why it was necessary for the Trust to communicate with Mr B’s family effectively, providing them with support and information about his condition.
28. Even when a patient has capacity, our adviser says if that patient is in a serious and critical condition which Mr B was, effective communication with the patient’s family is always paramount unless the patient explicitly states that they do not want clinicians to communicate with their family. There is no indication in the records that Mr B made any such request.
29. We consider this to be a communication failing by the Trust due to an overall lack of information being provided to Mr B’s family about his heart condition including the severity of his condition and treatment options, as acknowledged by the Trust, which is contrary to the GMC guidance. This caused Mrs A and her family some uncertainty about Mr B’s care including his clinical pathway and the potential severity of his situation. While we welcome the Trust’s apologies for this, we consider that further action is required. We have made recommendations to the Trust about this.
Cardiology care
30. Mrs A says that Mr B was not seen by a consultant cardiologist until 7 March 2022, and his proposed transfer to another hospital was delayed and then never happened before he died.
31. The Trust said that Mr B was reviewed by the cardiology team including input from a consultant at 8.04am on 25 February 2022 after the delays in him being admitted to hospital from 23 February 2022 onwards. The Trust acknowledges that this was approximately 23 hours after referral. The NICE guidance on consultant review recommends ‘10. For people admitted to hospital with a medical emergency, consider providing the following, accompanied by local evaluation which considers current staffing models, case mix and severity of illness:
• Consultant assessment within 14 hours of admission to determine the person’s care pathway’.
32. Mr B had critical aortic stenosis with decompensated heart failure which our adviser says is a potential medical emergency. The plan was for a repeat echo cardiogram to be undertaken, and Mr B would be ‘worked up’ for valve replacement at another Trust. This process usually takes 2 to 3 weeks. The Trust said Mr B then received a senior cardiology registrar review on 1 March 2022, at which time he was white-boarded. This means he was put on the list for transfer to another Trust and they were aware of his case.
33. The Trust said that the first time Mr B met the consultant cardiologist was on 2 March 2022. Therefore, Mr B received a senior cardiology review 4 days (1 March 2022) after he was admitted to hospital, and he received a review from a consultant cardiologist 5 days after he was admitted to hospital on 2 March 2022. The records support that Mr B was not seen by the consultant cardiologist until 2 March 2022, not 7 March 2022 as Mrs A has suggested. In the circumstances, it is perhaps not ideal that Mr B did not see a consultant cardiologist for five days after admission, but we are unaware of any specific guidance as to how long this type of speciality review should take. When Mr B saw the consultant cardiologist on 2 March 2022, the plan was to transfer him to the other Trust for heart surgery. There is no specific reference to him being unfit for transfer at this time.
34. We know that Mr B had a background of aortic stenosis pre-admission which is a failing heart valve and is a potentially serious condition. The complaint response and information from Mrs A confirm that Mr B also had symptoms of breathlessness, weight loss, and generally feeling unwell pre-admission and this led to him going to hospital on 23 February 2022. By 25 February 2024, it was established that Mr B had critical aortic stenosis and decompensated heart failure resulting in liver and renal impairment. He also had suspected myocardial infarction which is a type of heart attack. We appreciate from the records that Mr B’s condition fluctuated over the next few days, but it is noted from the Trust’s complaint response that he suffered an acute deterioration on 1 March 2022 and had to be transferred to the Coronary Care Unit (CCU).
35. The Trust says Mr B came into hospital in a poor condition. Mr B had had stenosis for many years and was very poorly when he was admitted. Therefore, Mr B was not a surgical candidate at the time he came into hospital. The Trust says the risk of any procedure would have been high. It felt that Mr B needed some degree of stabilisation prior to any intervention; he required work-up, and he also needed general medical care including renal input to make him stronger and better generally. As we have already acknowledged, the records indicate that Mr B’s liver and renal functions were impaired.
36. Whilst on the CCU from 1 March 2022, the Trust says Mr B received regular daily inputs from cardiologists whilst awaiting transfer to the other Trust. On 4 March 2022, the Trust says it received a telephone call from the cardiac co-ordinator at the other Trust requesting a Computed Tomography scan of the Thorax, Abdomen and Pelvis (CT TAP) report for Mr B. This was provided that day. On 7 March 2022, the Trust performed an angiogram and the following day Mr B was deemed well enough to transfer to the cardiology ward. On 8 March 2022, the other Trust called to say their cardiothoracic surgeon would visit Mr B on 11 March 2022 as part of his inpatient reviews that week.
37. Therefore, the Trust said: ‘Mr B had already been considered for transcatheter aortic valve implantation (TAVI) or surgery, hence his referral (whiteboard) to the other Trust on 1 March 2022. He was awaiting transfer there for their decision as the experts and their surgeon had planned to review Mr B on 11 March 2022. From a referral pathway perspective, it is the other Trust’s decision on who and when patients are transferred to their care and operated on, we have no control over this.’
38. While we note the chronological explanation provided by the Trust, our own consideration of Mr B’s records from 2 to 10 March 2022 indicates that the overall strategy at this time was for him to be transferred to the other Trust for heart surgery. There is little evidence in the records that indicates Mr B was too unwell for transfer up until the day he died on 10 March 2022. We also note from the records that the cause of Mr B’s kidney issues, heart failure, and liver congestion (which the Trust has highlighted) was thought to be his heart valve. Therefore, we consider that fixing the valve through surgery or TAVI was the only meaningful way that his condition would improve.
39. We approached the other Trust for its input regarding Mr B’s care. It said Mr B was referred to them on 2 March 2022 (which is the same day he first saw the consultant cardiologist) through Strata which is a referral pathway for consultant review for potential cardiac surgery. The referral was actioned on the 4 March 2022. The other Trust told us there were safeguards in place at this time for escalation to the registrar on call for any referrals if they could not wait, but it understood Mr B had not been referred to them sooner (for TAVI or surgery) due to his poor clinical condition.
39.In order to prepare for this review and keep Mr B’s care moving, the other Trust said it asks for all pre operative tests to be completed, and any other relevant tests performed to be uploaded to Strata so that they are available for the consultant review. It requested this information from the Trust on 7 March 2022.
40. The other Trust added that the Strata referral is not a referral for ‘waiting for transfer to the other Trust.’ It said Mr B had not been assessed or accepted by a consultant yet, so he was not waiting for transfer. This conflicts with what the Trust told us about Mr B’s transfer status, as outlined above. Mr B was being worked up for surgery pending a consultant review. If Mr B had been accepted, he would then have been transferred to the other Trust either based on clinical need or 48 hours prior to his operation date once allocated. It should be noted that whilst waiting for reviews by surgeons, district general hospitals can access the registrar on call to escalate any deterioration of patients should they need this for an earlier review. The other Trust said it is unable to comment on whether this happened, but it has confirmed it was not made aware of any escalation as this would have been documented on the Strata referral.
41. Our adviser says they would have expected to see more prompt action by the Trust regarding Mr B’s situation. Even if Mr B’s condition were poor or fluctuating whilst in hospital from 25 February 2022, our adviser says there is no clinical reason Mr B could not have a TAVI or surgery. We appreciate that the preferred option was for surgery and Mr B was being ‘worked up’ for this at another Trust. This process involves various tests including carotid doppler, lung function test, coronary angiogram, and a dental check-up. Some of these tests had been completed, but the process usually takes around 2-3 weeks.
42. Nevertheless, our adviser says that Mr B’s situation was critical and therefore required urgent action by the Trust. Ideally, this would be through a consultant cardiologist making an urgent telephone call to a cardiac surgeon at the other Trust site and highlighting Mr B’s status for immediate heart valve surgery, so he was made a priority. This is regardless of what the waiting list was and is not part of the normal pathway. As indicated above, the other Trust has told us that the Strata referral pathway is flexible in that patients can be escalated if their condition is such that it warrants an earlier review by the specialist cardiology team. We consider that Mr B’s clinical situation warranted such escalation. The Trust has told us there was ‘no significant change in Mr B’s NEWS score at any point to indicate a sudden deterioration triggering a further escalation.’ The Trust added that ‘in severe aortic stenosis with comorbidities, there is a high risk of sudden death due to cardiac arrhythmia.’ ‘Sadly, this is what happened to Mr B.’ ‘Furthermore, urgent intervention in a very unwell patient like Mr B also carries substantial risk and that is why stabilisation is mandatory.’
43. If it was not deemed possible to expediate Mr B’s referral to the other Trust, either because Mr B’s ‘work-up’ was incomplete or heart valve surgery was considered too risky for him, our adviser says that TAVI should have been considered (more thoroughly than it was) as an alternative treatment option. TAVI is a percutaneous approach and a definite treatment. It can be a substitute for heart valve surgery. It is less invasive and carries lower risk than surgery particularly in such high-risk surgical patients like Mr B. It is carried out under sedation and local anaesthetic rather than general anaesthesia. The ‘work-up’ for TAVI does require a CT scan of the peripheral arteries as well as the aorta for planning the procedure, but this is usually quick and can be arranged urgently. Surgery requires assessment of the carotid arteries and going on a bypass with open heart approach which is more complex and riskier.
44. Overall, we consider Mr B should have seen a consultant more promptly than he did when he first came into hospital, in accordance with the NICE guidance. Once he saw the consultant cardiologist a few days later, they could have contacted a cardiac surgeon at the other Trust as part of an urgent referral with a view to surgery or TAVI for Mr B. Our consideration of Mr B’s records does not reflect any urgency by the Trust regarding his critical situation, even after he eventually saw the consultant cardiologist on 2 March 2022. We also note that is no mention of TAVI in the Trust’s complaint response when our adviser says it should have been more thoroughly considered as an alternative treatment option for Mr B. TAVI is likely to have been a less risky treatment option for Mr B, but there is little evidence in the records that it was considered in any meaningful way by the Trust, such as discussions with the other Trust, during this episode of care.
45. We consider these to be failings by the Trust as Mr B was not seen by a consultant in accordance with the NICE guidance. Furthermore, he was not given the opportunity to have prompt treatment for his heart condition such as TAVI or surgery at the other Trust, despite being in hospital for almost two weeks before he tragically died. We will explore the wider impact of this below, but no doubt it raises significant concerns for Mrs A about her husband’s care due to the initial delay in him seeing a consultant, the lack of definitive treatment when he was in hospital, and his subsequent death a few days later. We have made recommendations to the Trust about this.
Impact
46. As we have said, Mr B was admitted to hospital with critical aortic stenosis and decompensated heart failure, a serious condition that carries a high mortality rate if it is not treated urgently which it should have been. Our adviser says patients with this condition are also at greater risk of suffering a cardiac arrest which we note caused Mr B’s sad death.
47. Our adviser says that if Mr B had been seen by a consultant cardiologist at the Trust more promptly after his admission to hospital (instead of waiting until 2 March 2022), the severity of his condition would likely have been identified and urgent action taken. As above, this could have involved immediate communication with someone from the surgical team at the other Trust such as a cardiac surgeon with a view to Mr B having surgery or a TAVI. Had either of these procedures been conducted promptly, our adviser says Mr B would have had a better chance of survival. Very sadly, this did not happen, and therefore we consider that Mr B was denied the opportunity to have treatment that may have given him a better chance of survival.
48. Nevertheless, we also recognise that even if the Trust had been more proactive and Mr B had been transferred to the other Trust, we cannot be sure the other Trust would have been able to carry out surgery or TAVI for Mr B before he died. Both procedures would have required further investigations at the other Trust and likely MDT discussions, both of which take time. The other Trust told us that Mr B’s referral was actioned on 4 March 2022, but we do not know if there was a bed available for Mr B at the time. As above, we do not know how long the other Trust’s assessment of Mr B would have taken or whether he would have survived surgery or TAVI. This process would have taken time and there is no guarantee it would have been completed before Mr B died on 10 March 2022.
49. We have considered Mr B’s chances of surviving surgery or TAVI and extending his life, with support from our adviser. Firstly, although we know from the records that Mr B was at times significantly unwell during his time in hospital between 25 February and 10 March 2022, we also know that at the same time he was being ‘worked up’ for surgery, a process that can take 2 to 3 weeks. Sadly, Mr B died before he could be transferred to have surgery which was the Trust’s preferred treatment option. According to the OHJ article, ‘long term survival following surgical valve replacement in patients over 65 years old is excellent and up to 8 years is comparable to the matched general population’. This means that if Mr B were deemed clinically fit enough for surgery, and if he had survived the surgery, it is more likely than not that his life would have been extended.
50. We recognise that Mr B’s aortic stenosis was at an advanced stage by the time of his hospital admission in February 2022, but he had managed his condition successfully for many years. Given the advanced nature of Mr B’s condition, we consider he was a patient at high risk who had an almost 100% mortality rate within 3 months if his condition was not treated promptly. We acknowledge that Mr B was also at increased risk of mortality if he underwent valve replacement surgery due to his aortic stenosis.
51. Therefore, given these risks and the urgency of Mr B’s clinical situation, we consider that TAVI was an appropriate alternative treatment option for Mr B and therefore should have been considered more thoroughly if surgery was considered to be too risky for him. The JAHA article on survival after TAVI acknowledges that TAVI has a 20% risk of procedural mortality. Also, patients with Mr B’s condition remain at increased mortality risk because of their prolonged time in severe aortic stenosis. They have a mortality close to 30% at 1 year after TAVI. Nevertheless, the JAHA article about overall survival rates for patients that have the TAVI procedure indicates a 95.4% survival rate after 30 days: 90.2% after one year, and 83.3% after three years. Based on these statistics, Mr B would have more likely than not survived a TAVI procedure, and therefore his life could have been extended. We recognise that any additional time with Mr B would have been precious for Mrs A and his family.
52. Our view that Mr B should have been considered for a TAVI is strengthened by the NIH and AJC articles about outcomes for patients after having the procedure. The NIH article states: ‘Mortality tended to be highest in HFrEF patients 30 days post-procedure, and it became significant after one year: 10.2% (controls), 13.5% (HFpEF), 13.4% (HFmrEF), and 23.5% (HFrEF) which is Heart Failure with Ejected Fraction. However, symptomatic improvement in survivors of all groups was achieved in the majority of patients without differences among groups. Mr B had 23.5% HFrEF. This equates to him having an 76.5% chance of survival after having a TAVI procedure which strongly supports our view that the Trust should have offered it to him if surgery was deemed too risky.
53. The AJC article states: ‘the Acute Heart Failure (which Mr B had) group had significantly higher all-cause mortality at 30-day and 2-year than the elective TAVI group (8% vs 2%; p = 0.002, and 33% vs 18%; p = 0.002, respectively). In the Acute Heart failure group, 43 (31%) patients underwent early treatment with TAVI. Our interpretation of this is that at 30 days after TAVI, Mr B had an 8% mortality rate (92% survival rate). At 2 years, Mr B had a 33% mortality rate (67% survival rate). Therefore, we consider this data indicates that Mr B had a significant chance of surviving at least two years if he had received early treatment with TAVI when he was in hospital.
54. Having considered this, the studies we have cited demonstrate how successful TAVI’s can be when they go ahead. In Mr B’s case, the clinical opinion from several clinicians at the Trust including a consultant cardiologist is that he was not fit for surgery or TAVI and needed working up first. As such, the counter argument is that the findings from these studies are almost redundant as the issue is whether Mr B was fit for surgery or not, not whether surgery on someone who is fit enough is successful, which seems to come down to clinical opinion. Unfortunately, we cannot be sure how fit Mr B was for surgery or TAVI when he was in hospital. Even though there appears to be insufficient evidence in the records for us to say with confidence that Mr B was unfit for surgery or TAVI, we were not there at the time, so it comes down to clinical opinion.
55. In summary, there is conflicting evidence in the records about Mr B’s fitness for surgery or TAVI when he was in hospital. Although we maintain that more should have been done for Mr B to treat his condition and this may have given him a better chance of survival, the conflicting evidence leaves us in a position where we cannot say if he was suitable for surgery or TAVI, based on the clinical opinions of the Trust at the time against those of our adviser. This recognises our adviser’s view that TAVI was a less risky alternative treatment option for Mr B, one which we would have expected to have been documented in more detail in the records with evidence of more contact with the other Trust to update them on Mr B’s condition. As the Trust never escalated Mr B or updated the other Trust about his condition after his referral was actioned on 4 March 2022, we cannot say the Trust managed Mr B appropriately as we do not know what the other Trust would have done had more information been provided and recorded, but we do know that the clinical opinion at the time was that Mr B was unfit for surgery or TAVI.
56. Finally, we recognise this will be difficult news for Mrs A and her family to hear, even though they always suspected that there were failings in Mr B’s care. They have had to deal with the shock of Mr B’s death, which was unexpected, and now in the knowledge that more should have been done by the Trust which may have given Mr B a better chance of survival. The failings we have identified leave Mrs A with considerable uncertainty and unanswered questions about Mr B’s care which is emotionally distressing for her. This may never go away which we consider to be a significant injustice for Mrs A and her family.