18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Heart failure diagnosis
19. Miss K says Mrs B’s leg swelling began in October 2023, during a hospital admission. The Trust decided the cause was the fluid provided in her PICC line. Miss K says on 30 December, an Out of Hours (OOH) GP said her leg swelling was caused by heart failure. Miss K says the Trust failed to diagnose this during her admission.
20. The Trust said despite managing the fluid intake during Mrs B’s admission, her leg swelling continued. It said the swelling was probably caused by fluid collections in her pelvis. It said chest X-rays, and CT chest scans performed in October, showed no sign of heart failure.
21. A CT scan is a scan which can show detailed images of the body using radiology and computer technology. An X-ray is when radiation is used to create images of the body. It is helpful to make images of bones and can capture diseases and some tissues.
22. Our adviser said the relevant standards are the GMC’s Good Medical Practice. It says doctors must, ‘adequately assess the patient’s condition, taking account their history,’ and ‘promptly provide or arrange suitable advice, investigations or treatment where necessary.’
23. A review of the records shows Mrs B went to A&E on 17 October because she was suffering with abdominal pain. It provided IV fluids, antibiotics and arranged a CT scan and a chest X-ray. On the 19 October a clinician documented the results of the CT scan. It showed a presacral collection and small bowel dilation. Their provisional diagnosis was small bowel obstruction (SBO).
24. A presacral collection is fluid that has collected in the space between the rectum and sacrum. There can be multiple causes of this. An SBO is a medical emergency. It can be treated with fluids, a nasogastric tube to remove fluid and possibly surgery.
25. The Trust planned to refer Mrs B to the colorectal department, speak with gynaecology, provide regular medications and request drainage for the fluid collection. However, Mrs B’s fluid collection was not large enough to be drained.
26. On 21 October, a clinician noticed Mrs B had a swollen left calf. They arranged a doppler test and an MRI.
27. On 23 October, the doppler results were reported. It showed no evidence of DVT. On 27 October, a clinician found Mrs B was having breathing difficulties. They documented a plan to do a COVID-19 test, chest X-ray and possible referral to the respiratory team. Mrs B’s chest X-ray was clear. Another clinician wrote that they were going to treat Mrs B for a new infective exacerbation of COPD (NEICOPD). NEICOPD is when an infection causes a flare up of COPD. The next day she was diagnosed with COVID-19.
28. Mrs B was monitored and on 30 October she was discharged home, with outpatient appointments arranged.
29. We have also looked at what happened on 30 December, when Miss K says the family were told her mother may have heart failure. Ambulance records show paramedics attended and noted Mrs B had had swollen legs, was short of breath and had a raised heart rate. The paramedics advised Mrs B to come to hospital, but she did not want to. They arranged an OOH GP to come and assess her.
30. The OOH GP diagnosed respiratory distress and noted the cause could be either cardiac or respiratory issues. They discussed putting a DNAR in place and planned to provide ‘as needed’ end of life medications. A DNAR is a document confirming a medical decision not to resuscitate a patient if they deteriorate.
31. The NHS sets out the usual symptoms of heart failure in ‘Symptoms: Heart Failure’. This includes breathlessness, leg swelling, tiredness and light-headedness.
32. We asked our adviser when the colorectal team should suspect a patient has heart failure. They said if the patient had significant breathlessness on lying down, chest crackles when listening to their chest or a raised a JVP. JVP is jugular venous pressure. It is measured by visually and manually checking the vein in the neck between the ear and clavicle.
33. Records says on admission Mrs B had mild chest crackles and was in mild respiratory distress. We recognise these are potential red flag symptoms as highlighted by our adviser and the NHS information.
34. We also know that clinicians must consider symptoms and think about the likely cause, based on the patient’s history (in line with GMC guidance). Mrs B had COPD which causes breathlessness. In addition, she had an infection in her pelvis which could cause general illness. We think the Trust made an appropriate assessment, when it considered that these symptoms were linked to preexisting conditions and the abdominal pain and infection she was suffering. We do not think she was showing signs of probable heart failure and needed to be referred to cardiology at that stage.
35. The next relevant moment in the admission is on the 21 October. Mrs B developed new leg swelling on this date. We can see a doctor ordered a doppler test to check if Mrs B had developed DVT. The results showed she did not have a DVT. Our adviser said Mrs B was at risk of DVT and therefore suspecting DVT was appropriate. The doctors arranged an appropriate investigation which ruled it out. The Trust acted in line with GMC guidance at this point as it promptly ordered the right investigations.
36. The next relevant point in the timeline was when Mrs B became increasingly breathless on the 27 October. Mrs B was diagnosed with COVID-19 the next day. She was not noted to have a raised JVP. On this day the Trust also provided an X-ray.
37. The NHS website on Heart Failure says an X-ray is one way of identifying possible heart failure. An X-ray will show if the heart is enlarged, if there is fluid in the lungs or, a lung condition is causing the symptoms, instead of heart failure.
38. We reviewed the X-ray report from 27 October. It says Mrs B’s lungs were expanded as expected in patients with COPD. It said there were no signs of an enlarged heart or fluid accumulation on or around the lungs. We can see there were no signs on the X-ray that Mrs B had heart failure. For this reason, the Trust did not consider heart failure could have been a cause at the time. A referral to cardiology would not have been appropriate based on Mrs B’s clinical background. The Trust also did prompt investigation when Mrs B experienced breathlessness. This was in-line with GMC guidance.
39. The Trust considered Mrs B’s breathlessness to be caused by NIECOPD. On the 28 October, she was diagnosed with COVID-19. Both conditions cause breathlessness. The X-ray report ruled out possible heart failure. We think the Trust acted appropriately when it continued to treat Mrs B for her pelvic fluid collection and adapted her PICC line fluid to help manage her leg swelling.
40. The evidence tells us that the Trust met the relevant GMC standards when Mrs B was cared for in October 2023. She developed leg swelling and other symptoms which could be indicative of heart failure. However, the Trust’s investigations confirmed alternative diagnoses (such as COVID-19) and ruled out anything more severe (such as a doppler for DVT and X-ray for heart failure).
41. We recognise an OOH GP considered Mrs B’s leg swelling and respiratory distress could be caused by a cardiac issue. We did not see heart failure mentioned in the record, but Miss K has told us this was what the OOH GP said. She has also shown us whatsapp messages from the time in which she shared the GP’s working diagnosis with a friend.
42. We think on the balance of probabilities the OOH GP did suggest heart failure as a possible cause of Mrs B’s illness. However, this was not a definitive diagnosis. This is shown by a statement in the notes. It says, ‘respiratory distress ? cause resp vs cardiac.’ This means the GP thought the respiratory distress was either caused by a respiratory or heart issue.
43. We can understand why Miss K has been distressed, considering the information shared by the OOH GP. Mrs B did have some symptoms which are seen in patients with heart failure. However, our assessment has shown that those symptoms were related to other conditions. In particular, the X-ray report, provides convincing evidence that Mrs B did not have heart failure during her admission.
44. We do not see any indication that the Trust failed to diagnose Mrs B with heart failure in October 2023. We hope this information provides Miss K with some relief that her mother did not suffer with an undiagnosed condition. We also hope it reassures her that the Trust’s decision to monitor and limit feeding through the PICC line was not done unnecessarily.
45. We would like to thank Miss K for giving us the opportunity to independently assess her complaint. We are grateful for the opportunity to ensure that the proper care was provided to her mother and that other patients will continue to receive the right care. We hope our assessment helps to bring the family some peace, following a very painful time and we wish them all the best.