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Salisbury NHS Foundation Trust

P-004471 · Statement · Decision date: 15 December 2025 · View Salisbury NHS Foundation Trust scorecard
Complaint (AI summary)
Dr D complains the Trust did not admit him for acute breathing difficulties and potential heart failure needing a pacemaker, forcing him to pay over £6,050 for private treatment.
Outcome (AI summary)
The complaint was closed. The ombudsman found no indication the Trust would have admitted Dr D even if his test results had been discussed with a cardiologist.

Full decision details

The Complaint

3. Dr D complains that on 2 November 2023 the Trust did not admit him for treatment when he was experiencing acute breathing difficulty, potential heart failure, and needed a pacemaker. He complains it sent him back to his GP and told him to attend the emergency department if he became more unwell.

4. Dr D says he experienced an alarming deterioration in his breathing which scared him. He was concerned that if he got any worse, he would die. He says due to the Trust discharging him he had to get private healthcare to get a pacemaker fitted which cost over £6,050.

5. Dr D is looking for the Trust to pay the £6,050 to cover the private healthcare costs.

Background

6. At the time of these events Dr D had been concerned about his heart for some time and had noticed he sometimes had a very low heart rate. He saw his GP, a cardiology nurse and the Trust about these concerns.

7. In October 2023 Dr D decided to see a private cardiologist. The private cardiologist felt he would benefit from a pacemaker and has told us they put Dr D on the NHS waiting list for a pacemaker on 23 October.

8. Dr D attended the Trust’s emergency department on 2 November as he was concerned about his heart. The Trust assessed him and discharged him. It advised him to speak to his GP about a letter to request he got fitted with a pacemaker sooner. It advised him to return to the emergency department if he got worse. The emergency department also contacted the private cardiologist requesting they consider whether he needed a pacemaker sooner.

9. Dr D said he was concerned after being discharged so went to speak to the private cardiologist again about a pacemaker. Dr D was fitted with a pacemaker privately on 8 November.

Findings

13. Dr D says the Trust should have admitted him for treatment on 2 November. He says as he was sent home he was concerned his condition was deteriorating and he had to seek private treatment as he did not know how long he would have to wait for a pacemaker via the NHS.

14. Dr D’s medical records show that when he attended the emergency department he presented with worsening shortness of breath. It notes he had seen a cardiologist previously and was waiting for a pacemaker due to issues with his heart rate and rhythm. The heart rate recorded at triage was 45 beats per minute (bpm).

15. NICE symptomatic bradycardia (a slow heart rate) guidance says symptomatic bradycardia is when the heart beats at a slower rate than normal and can cause faints, falls, dizziness, confusion, palpitations (when the person is aware of the heartbeat), difficulty breathing and chest pain.

16. Dr D presented with dizziness, shortness of breath and struggling to walk. His heart rate of 45 bpm suggested symptomatic bradycardia as it is usually accepted that below 60 or 50 bpm signifies bradycardia. Our ED adviser said symptomatic bradycardia is usually better managed as an inpatient and would benefit from specialist medical review by a cardiologist.

17. Before discharge from the ED the Trust did not request input from a cardiologist on the next steps of his treatment. We considered whether that step would have made any difference to the outcome for Dr D.

18. Although Dr D was experiencing a shortness of breath, there were no test results to indicate that the Trust should have admitted him. Our cardiology adviser said that, had the Trust sought cardiology input, the next steps would have been to arrange an appointment within two weeks for an echocardiogram (a scan used to look at the heart and nearby blood vessels). This is in line with the NHS guidelines on pacemaker implantation.

19. Our cardiology adviser said the Trust would also have needed to arrange to carry out a Holter monitor test, but Dr D opted to have this specific test done privately as part of his private treatment. A Holter monitor is a small, wearable device that records the heart's rhythm, usually for one to two days. It is used to spot irregular heartbeats, also called arrhythmias. A Holter monitor test may be done if a traditional electrocardiogram (ECG or EKG) does not provide enough details about the heart's condition.

20. The Trust ordered a NTproBNP blood test for Dr D. This is to test for specific levels of a chemical released in response to changes in pressure in the heart. High levels indicate heart failure.

21. This specific blood test result returned approximately half-an-hour after the Trust had discharged Dr D. However, our cardiology adviser explained this test result has no relation to a person needing a pacemaker and would not determine the urgency of fitting one.

22. Although the ED did not contact the cardiology department, we cannot say that this would have changed anything for Dr D. There was no need to admit Dr D and the course of treatment that had been arranged by the Trust would have been the same. That is, it would have discharged him. We will therefore not consider the complaint further.

Our Decision

1. We have carefully considered Dr D’s complaint about Salisbury NHS Foundation Trust (the Trust). We have decided to take no further action on his complaint as we can see no indication the Trust would have admitted Dr D had it discussed his test results with a cardiologist.

2. We recognise that this was a distressing time for Dr D, and we are not trying to diminish how he felt at the time.

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