The ward Mr Y was treated on, the doctor who oversaw his care, and the monitoring he received from 23 to 27 December 2022
20. Mr X says that following his father’s (Mr Y’s) surgery to remove a blood clot in his arm, he was moved to a bed on the vascular ward. (This is a ward that treats patients with vascular diseases such as problems with their veins and arteries). He says the Trust performed an echocardiogram on Mr Y (a scan used to look at the heart and the nearby blood vessels) and an angiogram (an X-ray photograph to determine if there had been any damage to Mr Y’s heart).
21. Mr X says after the echocardiogram and angiogram were done, they were told Mr Y’s heart had an ejection fraction of 40%. The British Heart Foundation explains ejection fraction relates to the amount of blood squeezed out of the main chamber of the heart with every beat. It is usually measured as a percentage, and over 50% is considered normal.
22. The British Heart Foundation explains that a score of 40% or less is classed as heart failure with reduced ejection fraction. Mr X says the Trust informed him that Mr Y would be treated with medication for this. Whilst this guidance was updated in 2025, we have referred to it as we have not relied on this to make a finding, and this specific information regarding ejection fraction and heart failure has not changed from 2022 to 2025.
23. Mr X says the Trust advised Mr Y that he should be transferred to a cardiology (heart) ward, where his care could be continued by staff who were experienced in providing cardiology care. Mr X says his father was never moved to a cardiology ward.
24. Mr X says that towards the end of December 2022, his father complained that he had no energy, and that he could not safely stand. Mr X also says his father suffered from bouts of coughing that prevented him from sleeping at night, and his legs were swelling. Mr X says his father’s condition deteriorated during this period.
25. Mr X says he considers his father deteriorated during this time because he was not being treated on a cardiology ward. Mr X also says his father was not treated by a cariologist and he was not monitored during this period.
26. In its response to Mr X, the Trust explained Mr Y could not be transferred to the cardiology ward due to a lack of capacity in the general medical and cardiac inpatient ward areas. The Trust stated that at the time of Mr Y’s admission, its medical bed base was far exceeding its original capacity. The Trust also stated there were flu and COVID-19 outbreaks on seven wards in the hospital, and this led to an increased restriction on the available beds. The Trust said it had to declare a critical capacity incident as the demand for inpatient beds exceeded the number of beds available. This meant Mr Y could not be transferred to the cardiology ward.
27. The Trust stated its cardiology and heart failure lead had reviewed the cardiology input the Trust provided to Mr Y when he was on the vascular ward. The Trust stated the input was comprehensive, with sensible plans, but it acknowledged that Mr Y would have been better supported from a cardiology and medical perspective if he had been on a cardiology ward.
28. The Trust added that Mr Y was under the care of a vascular surgeon whilst he was on the vascular ward. It stated the cardiology team does not have provision to take routine care of patients on other wards, but they are always able to be contacted to review a patient. The Trust stated that for patients needing regular cardiology input, the preferred option is to transfer them to the cardiology ward as soon as possible.
29. The Trust stated the vascular surgeon consultant reviewed Mr Y towards the end of December 2022. The consultant noted Mr Y had become breathless and he was feeling increasingly tired. The Trust said the surgeon requested that Mr Y have a chest X-ray, prescribed Mr Y with antibiotics for a suspected chest infection. The surgeon arranged a telephone consultation with cardiology where changes to Mr Y’s cardiac medications were made.
30. It went on to say Mr Y was seen face-to-face by a cardiology doctor on three times before the end of December 2022, and again at the start January 2023. It also said in addition to this the vascular team spoke to the cardiology team on the phone twice in December 2022. The Trust stated that all doctors and nurses are trained to recognise an acutely unwell patient, then to escalate care and seek appropriate help if they have a clinical concern. The nurses on the vascular ward were able to give Mr Y his prescribed cardiac medications.
31. The Trust concluded that the cardiology team has more experience in managing the review and titration (adjustment) of his heart failure medications and therefore, Mr Y would have been better supported from a cardiology and medical perspective on a cardiology Ward. It stated data from the National Heart Failure Audit says that patients with heart failure have better outcomes if managed on a cardiology ward and by a cardiology specialist. The Trust said this is why it had requested that Mr Y be transferred to a cardiology ward. The Trust said if Mr Y had been treated on a cardiology ward and therefore, reviewed by the cardiology team on a regular basis, it may have been possible to optimise his medications and fluid overload more quickly.
32. To determine if the Trust managed Mr Y’s care appropriately with regards to the ward he was treated on and how he was monitored, we have carefully reviewed his clinical records. We have also obtained clinical advice on this from our cardiology adviser (the adviser), and we have reviewed the GMC Good Medical Practice guidance.
33. Section 14 of the GMC guidance stated that clinicians must recognise and work within the limits of their own competence. Section 15 of the GMC guidance states clinicians must provide a good standard of practice and care, and if they assess, diagnose or treat patients, they must promptly provide or arrange suitable advice, investigations or treatment where necessary, and refer a patient to another practitioner when this serves the patient’s needs. This guidance is relevant to Mr Y as it relates to which clinician should be treating the patient, depending on the patients’ needs.
34. Mr Y’s December echocardiogram report shows his heart was found to have an ejection fraction of 40%, this means he was found to have heart failure. Mr Y’s nursing notes dated after the echocardiogram state that he was awaiting a bed on the cardiology ward. This shows the Trust had tried to refer Mr Y to the cardiology ward.
35. Mr Y’s nursing notes of the following day state he was feeling tired, complaining of being out of breath. They also stated that the vascular team had a telephone consultation with the cardiology team on that day, and Mr Y could be transferred to the cariology ward if the vascular team were happy with this. Mr Y’s notes show he was reviewed by the vascular nurse a day later, and the plan was still for him to be transferred to the cardiology ward.
36. The notes of the next day show Mr Y was again reviewed by the vascular doctor, and the plan was still for Mr Y to be moved to the cardiology ward. The notes also stated Mr Y had an ongoing chest infection, and his cough had not gotten any worse.
37. The Trust also stated Mr Y had atrial fibrillation (a fast heartbeat that does not pump blood efficiently). The outreach team telephoned the ward to say it was happy Mr Y was stable, and it would not be reviewing Mr Y unless he was unstable. The notes up until the end of the December 2022, show Mr Y was reviewed by the vascular team, and he was awaiting transfer to the cardiology ward. Mr Y was monitored by the vascular team daily up until the end of December.
38. The notes show the Trust had intended for Mr Y to be transferred to the cardiology ward, but this did not happen due to a bed not being available. The notes also show Mr Y was reviewed by the cardiology team, but he was not seen by the cardiologist again until the very end of December.
39. Our adviser stated delivery of care can take place anywhere in a hospital setting, but ideally, Mr Y should have been transferred to a cardiology ward. Our adviser stated the Trust should have ensured that Mr Y was being treated directly by a cardiologist, but once the treatment plan and medications are decided by a cardiologist, the delivery of this can take place on any ward by any qualified personnel. Our adviser added that outliers (patients placed on inappropriate wards) are common in all hospitals, and the cardiology team should look after that patient directly, regardless of where they are based.
40. After carefully considering the evidence we have seen, along with section 14 and 15 of the GMC guidance we have referred to at paragraph 33, and the clinical advice, we have identified a failing with the Trust’s management of Mr Y’s care. It is clear the Trust wanted to transfer Mr Y to the cardiology ward as he needed direct care from the cardiology team.
41. We understand that the Trust did not have capacity on the cardiology ward to facilitate Mr Y, however, we do consider that Mr Y should have been cared for and monitored directly by the cardiology team in December 2022, regardless of where in the hospital he was based. We understand this must have been a very upsetting and distressing time for Mr X and his father. We will discuss the impact of this failing later in the report.
Mr Y’s diagnosis of a chest infection and COVID-19
42. Mr X says the Trust misdiagnosed his father with a chest infection and COVID-19, when he was suffering with heart failure. Mr X says his father was suffering from debilitating bouts of coughing, which he believes to be a typical symptom of heart failure brought on by fluid in the lungs.
43. In its response, the Trust stated it suspects Mr Y’s X-ray showed fluid on his lungs and a chest infection was not present at the time of his X-ray. The Trust stated at the start of January 2023, Mr Y had a rising white cell count, he spiked a temperature and his chest X-ray findings from that day were reported by a radiologist as showing bilateral severe pneumonia and sepsis with an element of heart failure.
44. Pneumonia is a serious lung infection affecting both lungs, causing inflammation often leading to difficulty breathing or respiratory failure needing a ventilator. Sepsis is a potentially life-threatening condition that causes the body to respond incorrectly to an infection and to injure to its own tissues and organs.
45. The Trust stated management for a chest infection and ongoing heart failure management was appropriate. It added that patients with heart failure can become breathless and may develop a cough because of fluid on the lungs. The Trust stated that unfortunately, Mr Y developed hospital acquired pneumonia whilst he was on the ward, and he deteriorated significantly at the start of January 2023.
46. To determine if the Trust appropriately diagnosed Mr Y with pneumonia and COVID-19, we have reviewed Mr Y’s clinical records, and we have received clinical advice on this from our adviser. We have also referred to the NICE guidance on pneumonia in adults.
47. We have robustly reviewed Mr Y’s records and we could not see any evidence that the Trust diagnosed Mr Y with sepsis. However, as this is not mentioned in the scope of the complaint, we have not specifically investigated whether Mr Y had sepsis.
48. The NICE guidance on pneumonia in adults outlines that pneumonia is an infection of the lung tissue. When a person has pneumonia the air sacs in their lungs become filled with microorganisms, fluid and inflammatory cells and their lungs are not able to work properly. Diagnosis of pneumonia is based on symptoms and signs of an acute lower respiratory tract infection and can be confirmed by a chest X-ray showing new shadowing that is not due to any other causes.
49. Mr Y had a chest X-ray at the start of January 2023. The respiratory medicine note dated two day later stated Mr Y had been admitted to the intensive care unit for treatment of heart failure and pneumonia. The medicine note stated Mr Y required increasing oxygen, he had a dry cough, and he had had two temperature spikes within 24 hours. (This means a significant rise in body heat which is usually a sign that the immune system is fighting an infection).
50. The medicine note outlined Mr Y’s chest X-ray showed bilateral upper and mid zone (infection/inflammation in the upper and mid part of the lungs) consolidation (lung tissue that normally contains air becomes dense and solid due to fluid, pus, or cells, appearing white on X-rays and can be a sign of pneumonia, as outlined in the above paragraph) and right plural effusion (a build-up of excess fluid causing symptoms such as shortness of breath and chest pains) and this is in keeping with bilateral severe pneumonia.
51. The note added that Mr Y was found to have tested positive for COVID-19 at the end of December, but a PCR test (Polymerase Chain Reaction test - a lab test that amplifies genetic material such as saliva that can test for COVID-19) later showed Mr Y did not have COVID-19.
52. This note is consistent with Mr Y’s microbiology results at the end of December 2022 that show COVID-19 was initially indicated. Therefore, whilst the Trust had initially suspected Mr Y had COVID-19, a further PCR test ruled this out. We have therefore seen no evidence or indication that the Trust wrongly diagnosed Mr Y with COVID-19.
53. In its response, the Trust has acknowledged Mr Y did not have a chest infection, but the clinical records show he had pneumonia. The NICE guidance on the diagnosis and management of pneumonia in adults says that pneumonia that develops 48 hours or more after hospital admission (which happened in the case of Mr Y) is usually confirmed by a chest X-ray. We can see from the clinical records that the Trust performed a chest X-ray on Mr Y at the start of January 2023, and this then led to the diagnosis of bilateral severe pneumonia. We are satisfied that the Trust followed the guidance here with regards diagnosing Mr Y with pneumonia.
54. We also received clinical advice on this from our adviser. They stated they agreed with the Trust’s report, and there would have been no harm with treating Mr Y for a chest infection, and the chest X-ray was reported as showing Mr Y had heart failure and bilateral severe pneumonia. Our adviser stated this would be in keeping with a good standard of care.
55. Based on the evidence we have reviewed, the guidance we have referred to, and the clinical advice we have received, we have not seen any evidence to show that the Trust wrongly diagnosed Mr Y.
56. It had initially diagnosed him with COVID-19, but then a PCR test ruled this out. The Trust diagnosed Mr Y with pneumonia based on the results of his chest X-ray at the start of January 2023, we have not identified a failing with the Trust’s actions here.
57. Whilst we have not identified a failing here, we understand that learning Mr Y had developed pneumonia must have been very upsetting and distressing for Mr X.
The medication that the Trust prescribed to Mr Y
58. Mr X says the Trust did not administer his father with appropriate medication to treat his heart failure, and he says the Trust did not prescribe Mr Y with water tablets as early as it should have.
59. In the Trust’s response, it stated it commenced medical management for a heart attack pre-emptively by administering Mr Y with a heparin (a blood thinning medication) in mid-December 2022. The Trust stated Mr Y had a Coronary angiography two days later that showed he had narrowing in all three of his coronary arteries, as well as evidence of some clotting. In response to this, the Trust prescribed Mr Y with aspirin, anticoagulation and clopidogrel for one week, followed by anticoagulation and clopidogrel for 12 months, and then anticoagulation alone lifelong. Regular clopidogrel was commenced on a day later. Aspirin was stopped as per the plan after one week. These three medications are prescribed to help prevent blood clots.
60. The Trust explained that Mr Y’s echocardiogram that was performed on in December 2022 demonstrated that he had impaired heart function. It stated that ramipril (an ACE inhibitor that relaxes and widens the blood vessels and makes it easier for the heart to pump blood around the body) and bisoprolol (beta-blocker medication used to treat high blood pressure and heart failure), used in both the management of patients who have had a heart attack and in the management of heart failure, were commenced on in December 2022. The Trust said heart failure medications are started incrementally (gradually) over several days, and the process of optimising heart failure medication often continues following discharge from hospital.
61. It stated that furosemide, a diuretic used to manage fluid overload was commenced at the end of December 2022. (Diuretics or ‘water tablets’ make the kidneys remove extra salt and water from the body, leading to increased urination to get rid of excess fluid, which helps reduce swelling, lower blood pressure, and ease symptoms like shortness of breath in conditions like heart failure). The Trust said the dose was increased at the start of January 2023, and an additional dose was given on the evening a day later. The furosemide dose was increased and escalated to intravenous therapy the day after that.
62. The Trust stated that dapagliflozin, a heart failure medication known as an SGLT2 inhibitor, was also prescribed at the start of January 2023, to commence on the morning of the next day. It also added that spironolactone, a heart failure medication, was commenced the following day. It also stated that digoxin, for the management of atrial fibrillation with a high heart rate, was given two days later in the early hours.
63. To determine if the Trust prescribed appropriate medication to Mr Y to manage his heart failure, we have reviewed his clinical records, reviewed the NICE guidance on chronic heart failure in adults, and we have received clinical advice from our adviser.
64. Mr Y’s clinical records show the Trust administered heparin to him in mid-December 2022. Mr Y’s notes dated two days later stated he was still being administered heparin. Two days after that the clinical notes stated Mr Y had been prescribed aspirin, anticoagulation and clopidogrel following on from his echocardiogram and angiogram.
65. Mr Y’s clinical records dated a day later show the vascular team had a telephone consultation with the cardiology team. The cardiologist prescribed Mr Y with bisoprolol and ramipril. The cardiologist also advised that Mr Y should continue taking aspirin and clopidogrel as well as clexane (blood thinner to prevent blood clots) for one week, and clopidogrel and anticoagulation after that.
66. Mr Y’s nursing notes dated the start of January 2023 show that the Trust had prescribed him with dapagliflozin and spironolactone. This is consistent with what the Trust had stated in its response.
67. To determine if the Trust prescribed Mr Y with appropriate medication for his heart failure, we have reviewed the NICE guidance on treating people with heart failure that have been diagnosed with heart failure with reduced ejection fraction. This guidance applies to Mr Y as the guidance explains that an ejection fraction of 40% or lower is classed as reduced ejection fraction, and Mr Y’s ejection fraction was 40%.
68. Section 1.4.1 of the guidance outlines that clinicians should prescribe an ACE inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter-2 (SGLT2) inhibitor to people suffering from heart failure.
69. An ACE inhibitor relaxes the blood vessels, reduces blood pressure and reduces the hearts workload. Ramipril is an example of an ACE inhibitor.
70. A beta-blocker is a class of prescription-only medicines that primarily treat heart conditions and high blood pressure by blocking the effects of hormones like adrenaline. Bisoprolol is an example of a beta-blocker.
71. An MRA is a class of drug, like Spironolactone or Eplerenone, that blocks the hormone aldosterone, helping the body get rid of excess salt and water while retaining potassium, making them useful for heart failure, high blood pressure, and kidney disease. SGLT2 is a kidney protein that reabsorbs glucose back into the bloodstream, but SGLT2 inhibitors (like empagliflozin, dapagliflozin) are drugs that block this, causing excess sugar to be flushed out in urine and lowering blood sugar.
72. Section 1.7.1 of the guidance states that clinicians should use the person's medical history and findings from their clinical assessment, their frailty status, prognosis and preferences when deciding: • which specific medicines and medicine combinations to use • the order and timing for introducing each medicine • the initial dose of each medicine and any subsequent dose increments • when and how to optimise the dose of each medicine.
73. This means we would not necessarily expect for all four medications to have been prescribed to Mr Y at the same time, and it was not a failing that all four medications were not prescribed at the same time.
74. After carefully reviewing Mr Y’s clinical records, we can see the Trust prescribed each of these medications to Mr Y, and this was in line with the NICE guidance on treating heart failure.
75. We also obtained clinical advice on this from our adviser. Our adviser stated it was appropriate for the Trust to have administered these medications to Mr Y to treat his heart failure. Based on the guidance we have reviewed and the clinical advice we have received, we have found it was appropriate for the Trust to prescribe these medications to Mr Y to treat his heart failure.
76. Mr X also says the Trust delayed in prescribing diuretics to Mr Y. The Trust stated it first prescribed diuretics to Mr Y at the end of December 2022. Mr X considers the Trust should have prescribed diuretics earlier than this. The Trust stated the use of a diuretic was discussed between the vascular and cardiology teams on six days before it was prescribed. However, at that stage, Mr Y’s other medication was increased rather than starting on a diuretic. As with the additional diagnosis of a chest infection, it was not clear whether a diuretic was the right medication. This was why Mr Y’s weight and fluid balance were being monitored as this gave the clinical team an indication of whether excess fluid, rather than infection was causing breathlessness.
77. We can see from Mr Y’s clinical records that the Trust prescribed Mr Y with furosemide to try and help his body get rid of the excess fluid. Notes from the cariology consultation dated six days before the diuretics were prescribed, stated Mr Y was to be prescribed bisoprolol and ramipril, and he was to be prescribed furosemide for any breathlessness.
78. NHS guidance says diuretics (water pills) help the recipient to pass more urine and help relieve ankle swelling and breathlessness caused by heart failure. It states there are many different types of diuretic, but the most widely used for heart failure are furosemide and bumetanide.
79. The NICE guidance we have outlined at paragraph 57 explains that it would not necessarily be appropriate to start multiple medications at the same time, and the timing for starting these medications should be assessed by the clinician. Section 1.9.1 of the guidance recommends that clinicians should use diuretics for the relief of congestive symptoms and fluid retention in people with heart failure and titrate (up and down) according to need using the lowest dose required. We can see this is what the Trust did, as it increased Mr Y’s diuretics dosage at the start of January 2023 as he remained fluid overloaded.
80. Our adviser stated that diuretics are for symptomatic relief, and they have no prognostic effects (i.e. they would not treat the underlying condition itself or impact the outcome). Our adviser stated the diuretics were started when they were clinically indicated and needed. However, our adviser did add that if Mr Y had been reviewed by a cardiologist sooner, diuretics may have been started earlier.
81. We can see the Trust has acted cautiously when determining when to prescribe Mr Y with diuretics. Although it is possible that Mr Y could have been prescribed diuretics earlier than he was, we do not consider this is enough to identify a failing as we cannot say that Mr Y should have been prescribed diuretics at an earlier date.
82. Based on the guidance we have considered, and the clinical advice we have received, we have not identified a failing with how the Trust medicated Mr Y for his heart failure, and with Trust prescribing Mr Y with diuretics.
The Trust’s communication to Mr X
83. Mr X says the Trust did not inform him that his father was going on to a ventilator. Mr X says his father informed him that he would be going on to a ventilator early on at the start of January 2023. Mr X questions why the Trust did not inform him about this sooner.
84. In its response, the Trust stated the senior sister in critical care explained that in the morning, Mr Y went into atrial fibrillation, this is a common heart condition where the upper chambers quiver instead of contracting effectively, leading to a rapid, irregular heartbeat caused by chaotic electrical signals, often felt as palpitations, tiredness, shortness of breath, or dizziness, and significantly increases stroke risk.
85. The Trust explained Mr Y had a heartrate of 164 beats per minute. It stated that Mr Y required 100% oxygen to maintain an adequate oxygenation, but he rapidly declined, and this resulted in him needing to be intubated (a breathing tube directly into the windpipe via the nose or the mouth).
86. The Trust explained it is likely Mr Y was not contacted at that time due to the pace in which it had happened, and a need to focus on patient care and safety at that time. The Trust said it is usual practice for the family to be contacted soon after, if they are unable to be contacted at the time. The Trust said it is sorry to Mr X that he was not informed of the change in his father’s condition in a timelier way.
87. The GMC guidance on communicating effectively states that doctors must give patients the information they want or need to know in a way they can understand. Doctors should make sure that arrangements are made wherever possible, to meet patients’ language and communication needs. The guidance also states that doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
88. We can see from Mr Y’s clinical records that Mr Y contacted his family to inform them he was going to be transferred to the intensive care unit. There is no evidence in the records to show that the Trust communicated this information directly to Mr X or his family. Our adviser stated that the Trust’s priority was to treat Mr Y as it was an emergency, and there would have been no time to inform Mr Y’s family in advance.
89. Whilst we acknowledge that it would have been ideal for the Trust to have informed Mr X of Mr Y’s situation in advance of Mr Y doing so, we understand this was an emergency situation, and the Trust’s priority was to treat Mr Y. Although the Trust did not inform Mr X directly, we can see it was aware that the family had been informed by Mr Y himself, the day before the transfer. We can also see the Trust has apologised to Mr X for not making sure the family was informed sooner than they were. In these circumstances we think it would be inappropriate to be critical of the Trust’s lack of communication, and for these reasons we have not identified a failing.
90. Mr X also says the Trust wrongly informed him that his father would make a recovery with reduced heart function. In its response, the Trust stated that although Mr Y was independent and active before he was admitted to hospital, he had a blood clot in his left arm, and this caused him to suffer a heart attack. The heart attack damaged Mr Y’s heart muscle function, causing heart failure, and this causes fluid overload in the legs and lungs, and this makes patients more susceptible to developing chest infections. The Trust explained that Mr Y unfortunately developed hospital acquired pneumonia, and this led to him deteriorating.
91. To determine if the Trust inappropriately misled Mr X about his father’s prognosis, we have reviewed the NICE guidance on the patient experience in adult NHS services, and we have obtained clinical advice from our adviser. Section 1.3.10 of the guidance outlines that clinicians should share key information with family members if the patient agrees. Therefore, the guidance would expect Mr X to have been informed appropriately regarding Mr Y’s condition and prognosis, as Mr Y was happy for Mr X to be informed about his healthcare.
92. Based on the clinical advice we have received, we have found that whilst at the start of Mr Y’s admission, it may have been predicted he would make a recovery, Mr Y contracted pneumonia whilst he was in hospital, which the Trust would not reasonably have been able to predict at the time of his admission. This coupled with his heart failure unfortunately led to Mr Y deteriorating in hospital and very sadly passing away. Based on the evidence we have seen, we have not found that the Trust inappropriately misled Mr X about his father’s prognosis from when he was admitted to hospital.
Mr Y’s life-support machine
93. Mr X says the Trust delayed in removing his father’s life support when he sadly passed away in early January 2023, and this added to his distress. Mr X says he was told to tell the nurse when he was ready to remove the life-support by the consultant. Mr X says he told the intensive care unit nurse twice to remove his father’s life-support day of his death, but it was not until the consultant came into the room much later that his father’s life-support was removed. He says he was not told he would need to wait for the consultant to have the life-support turned off.
94. In its response, the Trust stated that Mr Y’s family arrived at the Trust at 1pm, and the family had a discussion with the consultant at 2pm regarding Mr Y being at end-of-life. It was documented that some time would be given for Mr X and his family to spend time with his father, at 2.45pm, the consultant returned, and a collective decision was made to withdraw Mr Y’s end-of-life support. We understand this must have been a very sad and difficult decision for Mr X and family to make. The Trust stated it is usual practice to allow the family to spend some time with their loved one, and it allows the nurse the time to prepare the end-of-life drugs to ensure that comfort is maintained.
95. Section 31 of the GMC guidance on good practice outlines that doctors must listen to patients, take account of their views, and respond honestly to their questions. Whilst Mr X was not the patient, we consider it appropriate to refer to this guidance here as he was making a decision on behalf of his father, who was the patient.
96. We have carefully reviewed all the records the Trust provided us with, and we are unable to see what time Mr X asked for the life-support machine to be turned off, and what time this was done. Our adviser stated that based on the account the Trust has provided, there is no evidence of an undue delay with Mr Y’s life-support machine being turned off. Therefore, based on the evidence we have reviewed, the guidance we have reviewed, and clinical advice we have received, we have not identified a failing here. Whilst we cannot specifically identify a failing with this, we consider the Trust should take care to ensure it can provide records that cover the entirety of a patient’s hospital admission to ensure our office can review all records to so we can ensure our findings are as robust as they can be.
Our findings in relation to impact
97. We have found a failing with the Trust’s management of Mr Y’s care from mid to the end of December 2022, as he was not cared for by the cardiology team.
98. As the Trust has acknowledged in its response to Mr X, if Mr Y had been on a cardiology ward and therefore reviewed by the cardiology team on a regular basis, it may have been possible to optimise his medications and fluid overload more quickly. The Trust outlined it is difficult to know in retrospect whether more rapid optimisation of heart failure medications would have altered the outcome for Mr Y, and whether he may still have developed a severe hospital acquired pneumonia regardless of the location of his care.
99. We have found there was a loss of opportunity for Mr Y to receive more optimal care under the cardiology team. Whilst we cannot say this would have led to a better outcome of Mr Y, on the balance of probabilities we consider this led to a loss of opportunity for the chance of a better outcome for Mr Y.
100. We have found this would have caused added distress to Mr X and Mr Y at what was already a difficult time. Mr X and his family were aware Mr Y needed to be treated on the cardiology ward, and he was not.
101. We can see the Trust has acknowledged this as it stated to Mr X it is sorry if due to the fact Mr Y was unable to be transferred to the cardiology ward, this affected his father’s mental wellbeing and caused him distress.
102. We have also found that Mr X has been left with not knowing if his father would have had a better outcome if he would have been treated directly by the cariology team.
Our recommendations
103. 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.
104.Our Principles for Remedy are reflected in the NHS Complaints Standards UK Central Government Complaint Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
105.Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.
106. We recommend that the Trust should write to Mr X to apologise for the failing we have identified, and the impact we have found this has led to. The apology should be sent to Mr X within one month of the date of our final report.
107.Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.
We recommend the Trust:
• produces an action plan to address the failing we have identified • identify the reason(s) for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will be/was monitored • share the action plan with us, Mr X and the Care Quality Commission within two months of the date of our final report.
Conclusion
108. We are very sorry to learn of the issues Mr X has brought to us. We understand he and his father must have gone through a very difficult and distressing time from the time Mr Y was admitted to hospital until he sadly died. We are very sorry that Mr Y had passed away, and we offer our sincere condolences to Mr Y and his family. We hope the findings in this report help to provide some closure to Mr X on this case. We would like to thank Mr X for giving us the opportunity to investigate this case.