MRI scan
22. On 1 April 2022, the Trust admitted Mrs D with a diagnosis of atrial fibrillation (a type of heart rhythm problem where the heartbeat is not steady). She explained she had experienced increasing breathlessness over many months.
23. On 2 April, it discharged Mrs D home, with a plan to review her in cardiology clinic in four to six weeks.
24. On 29 April, the Trust carried out a cardiac MRI scan. It reported this four months later on 2 September. The report showed the presence of cardiac amyloid (amyloidosis).
25. Mrs D proactively chased the MRI scan report on 9 August. The Trust’s Patient Advice and Liaison Service (PALS) asked the radiology department to prepare the report for Mrs D’s September cardiology appointment. It was reported by an external company to speed this up.
26. Mrs D’s medical notes show the Trust suspected a diagnosis of amyloidosis on her discharge on 2 April. Our cardiology adviser explained the Trust ordered appropriate blood tests and an MRI scan to make this diagnosis. This was in line with the ESC’s ‘Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC working group on myocardial and pericardial diseases’ which provides guidance on diagnostic tests.
27. Our adviser helped us to understand the Trust should have reported the MRI scan earlier than it did and reviewed Mrs D’s blood tests results earlier than it did. The Royal College of Radiologist guidelines, ‘Standards for the communication of radiological reports and fail-safe alert notification’ from the time of the complaint states that all radiological reports should be ‘produced, read, and acted upon in a timely fashion’.
28. We acknowledge the Trust explained it had a long backlog of scans being both performed and reported. We appreciate this is an ongoing problem for many Trusts. It also told us there was a software problem and to mitigate this it outsourced scans to an external provider.
29. Current (2023) NHS guidelines state that ‘priority’ imaging should take no longer than four weeks to report. Our haematology and cardiology adviser explained the guidelines show the Trust should have reported the MRI much sooner than it did. We have used the current guidelines and our advisers’ views to help us determine how soon the Trust should have reported the scan.
30. We consider the Trust should have reported the scan by 27 May (four weeks after the date of the MRI scan). It did not do this until 2 September. We find this was a failing to act in line with the Royal College guidelines. This resulted in a delay of just over three months in Mrs D receiving her MRI results. We go on to consider the impact of this on Mrs D and her family later in this report.
Cardiology review
31. During Mrs D’s inpatient stay the Trust carried out blood tests (including a troponin test) which it reported in June but did not review until September.
32. Our haematologist adviser explained Mrs D had a troponin score of 31. They explained this meant she had stage two cardiac amyloid. This result indicates a progression of the disease and that it may need more aggressive treatment and monitoring.
33. There is no specific cardiology guideline on when to offer an appointment. However, the GMC’s ‘Good Medical Practice’ says doctors must:
‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
34. It is clear from the Trust’s complaints response that it identified errors in its handling of the blood test results due to a change in staff. We agree that this was a failing. We note that had the Trust reviewed the blood test results earlier than it did, this would likely have prompted an earlier cardiology appointment. We have found, the Trust did not follow the above GMC guidelines when reviewing the blood test result.
35. Additionally, our cardiology adviser explained, the Trust should have offered Mrs D a cardiology appointment within four to six weeks as per her discharge plan. This was usual practice, and we consider it would have been in line with the GMC’s guidelines to do so. This would have meant a cardiology review between late April and mid-May. This would have been approximately four months earlier than the appointment she had in September.
36. The Trust did not do this and we have found this was a failing. This resulted in a delay in her having a cardiology review of approximately four months. We go on to consider the impact of the delays we have found on Mrs D.
Overall Impact
37.Ms L says, the delays in MRI scan reporting and cardiology appointment in turn delayed the Trust’s diagnosis and treatment of her mother’s myeloma and amyloidosis.
37. We have found an overall delay of approximately four months in the Trust reporting Mrs D’s MRI scan results, reviewing her blood test results and in it reviewing her in a cardiology appointment.
38. Our cardiology adviser explained an earlier cardiology appointment would have meant the Trust reviewed Mrs D’s symptoms and provided medication to improve her symptoms earlier than it did.
39. We agree with our adviser. We have also found it would also have meant a cardiologist reviewed Mrs D’s blood test results which would have likely confirmed the diagnosis of myeloma. This would have prompted an earlier referral to haematology resulting in earlier chemotherapy.
40. In addition, we have found, an earlier cardiology appointment, would have prompted the Trust to chase Mrs D’s MRI scan result and potentially get the result back earlier than it did. This would have likely led to an earlier diagnosis of cardiac amyloidosis.
41. Our cardiology adviser explained following Mrs D’s cardiology review in September, the Trust made a prompt referral to haematology (she had an appointment in 19 days). They further explained the Trust started chemotherapy in a timely manner (October) following a bone marrow result which confirmed her diagnosis.
42. Therefore, we consider the failings we have found in the Trust’s actions led to a total delay of four months in the Trust providing Mrs D with a diagnosis of myeloma and cardiac amyloidosis. We find Mrs D experienced the same four month delay in accessing her treatment including chemotherapy.
Amyloidosis
43. We next considered whether the four-month delay impacted Mrs D’s treatment and prognosis. Mrs D had symptoms of breathlessness prior to her hospital admission in March 2022. Our cardiologist adviser explained her collapse and hospitalisation suggested she was already suffering from established cardiac amyloidosis.
44. They explained this presentation is well-recognised and documented in the ESC’s ‘Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC working group on myocardial and pericardial diseases’. This would have meant she had already undergone changes to her heart due to amyloid deposits.
45. Our cardiology adviser further explained, Mrs D’s diagnosis of amyloidosis meant there were no interventions available that could have significantly reversed changes to her heart. Therefore, had she had an earlier diagnosis or treatment, it would have been supportive only. Supportive treatment could have managed her heart failure symptoms of fluid excess, breathlessness and swelling with medication such as diuretics (medication that increases the amount of water and salt the body produces). They helped us to understand this could have marginally improved her breathlessness but not significantly so.
46. We appreciate that the four-month delay meant Mrs D had four months less supportive treatment. Although this might only have helped her symptoms marginally, we find it would have provided reassurance and some comfort whilst she waited for chemotherapy to begin. We have made recommendations to address this later in our report.
47. Our cardiology adviser helped us to understand that Mrs D’s prognosis was poor due to her suffering from established amyloidosis. They went on to explain, earlier diagnosis and treatment would not have significantly impacted Mrs D’s prognosis.
48. Therefore, we cannot say the delay in diagnosis and treatment affected Mrs D’s prognosis regarding her amyloidosis.
Myeloma
49. Our haematology adviser helped us to understand how a delay of four months would have affected Mrs D’s myeloma. They explained that the chemotherapy Mrs D underwent was not curative but could have resulted in an extension to her life.
50. Our haematology adviser told us there was a lower than ten percent chance that Mrs D would have had an extension to her life had she not experienced the delay of four months in her diagnosis and treatment. They worked out this figure from a study, ‘Predictors of treatment response and survival outcomes in patients with advanced cardiac AL amyloidosis’.
51. Our haematology adviser explained it was difficult to estimate the likelihood of an extension to life with any certainty, but that it would be low and in the region of ten percent. They went on to say they could not say how long the extension to her life would have been had she experienced this.
52. Our haematology adviser helped us to understand that normally organ responses lag behind haematological responses. This means even if Mrs D has had an improvement in her haematological health due to earlier treatment, it is likely her organs would not have responded as quickly. This would potentially have led to further complications, and the myeloma would still have progressed in the same way.
53. We have found the Trust missed an opportunity to provide an earlier diagnosis and treatment. This meant there was a missed opportunity for a better outcome for Mrs D. We consider this to be a small chance of a better outcome but recognise that her family will never know whether she could have lived longer and the distress this has caused.
54. In addition, we find the Trust also missed an opportunity to provide supportive medication to Mrs D for four months. Although we have not found this changed her prognosis, we recognise it could have provided reassurance to her and her family and reduced her symptoms slightly whilst she was very unwell.
55. We also find the delay of four months in diagnosing and treating Mrs D caused her and her family additional emotional distress at an incredibly difficult time whilst she remained unwell, and they waited for a diagnosis and treatment. This is evidenced by Mrs D proactively chasing the Trust to get her MRI report as quick as she could.
56. We find Mrs D and her family were aware of the urgency of the MRI report and cardiology intervention. Waiting for this caused them unnecessary distress at a time that they were aware she was very unwell.
57. We next considered what has the Trust already done to put right the impact of the failings we have found.
58. The Trust has apologised and acknowledged failings in the time it took to report and communicate Mrs D’s MRI scan. It has also explained the changes it has made followed this complaint. This includes measures to address the backlog of scans such as greater reporting capacity and a software licence. It also explained it has considered whether the cardiology department could provide additional specialist imaging capacity.
59. Whilst it is understandable that capacity and demand remain an issue for the Trust, we are unclear how the measures it has described will prevent the same delays from occurring. Specifically, it has not explained whether it has implemented additional specialist imaging resources in its cardiology department. For this reason, we go on to make recommendations later in our report.
60. The Trust has acknowledged and apologised for the delay in reviewing Mrs D’s blood test results. It has told us that the test results were not picked up, after one staff member left until it appointed a replacement. It has explained that it has done work to report urgent blood test results and has shared this complaint with the team working on improvements.
61. We appreciate the Trust sharing this information. Despite this we cannot see it has explained how it will ensure when other staff members leave, there is no delay to picking up test results. We have therefore made recommendations to address this.
62. Additionally, the Trust has not acknowledged any failings in its delay to providing a cardiology review. In its complaints response it stated this was because of the delay in the scan result. We have found there was more the Trust should have done in an earlier appointment, whilst it waited for the scan to come back. As such we go on to make recommendations to address the impact of these failings on Mrs D and her family.