Care and treatment
16. 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.
17. Our adviser explained that from review of the clinical records, Mr H did not demonstrate any symptoms to suggest he had heart failure prior to his cardioversion.
18. The main symptoms for heart failure listed on the NHS website are:
• breathlessness • feeling tired most of the time and finding exercise exhausting • feeling lightheaded or fainting • swollen ankles and legs
19. In their referral to the cardiology team, Mr H’s GP did not mention any of these symptoms. The only symptom mentioned was a fluttering in his chest.
20. Although the NHS website lists palpitations as a less common symptom of heart failure, our adviser explained that in the absence of other symptoms you would not diagnose heart failure based on this alone and with confirmed AF on an ECG.
21. The NICE guidance for AF says to perform an echocardiogram in people with AF:
• for whom a baseline echocardiogram is important for long-term management • for whom a rhythm-control strategy that includes cardioversion is being considered • in whom there is a high risk or a suspicion of underlying structural or functional heart disease (such as heart failure or heart murmur) that influences their subsequent management (for example, choice of antiarrhythmic drug) • in whom refinement of clinical risk stratification for antithrombotic therapy is needed.
22. Our adviser said other than the fact Dr A was referring Mr H for cardioversion, none of the above applies in this case. He explained there was no obvious symptoms suggestive of heart failure or anything else more serious based on his symptoms.
23. Our adviser explained the reason to perform an echocardiogram before cardioversion is to rule out blood clots that could pose a risk during the procedure and could cause a stroke.
24. However, our adviser explained Mr H was on blood thinning medication already and so he would not have had any blood clots. Therefore, there was no requirement to do an echocardiogram. This is in line with the NICE guidance for AF which says an echocardiogram solely for the purpose of further stroke risk stratification in people with AF when they have already started anticoagulation therapy (blood thinning medication) is not necessary.
25. Miss H is concerned the cardiologist relied on the echocardiogram from ten years previously. We have considered this, but we are not persuaded this was the case. The records indicate Dr A had a plan to organise an echocardiogram following cardioversion. Our adviser explained it can be difficult to get an accurate echocardiogram when a patient has an abnormal heart rhythm and so this was reasonable.
26. Specialist cardiac nurses assessed Mr H prior to his cardioversion and identified no problems. Our adviser said a clinic review with the cardiologist is unlikely to have changed his management plan or resulted in any further tests or investigations prior to the cardioversion.
27. Mr H had no background of coronary artery disease, hypertension or diabetes. His GP had checked his cholesterol in November 2023 which was fine. His only symptom was of fluttering in his chest with no chest pain and the GP had confirmed AF on the ECG performed by the GP. Our adviser said based on all of this, the decision to proceed directly to cardioversion was reasonable.
28. In summary, the management of Mr H’s symptoms appears to be in line with the NICE guidance for AF and so we have seen no indications of failures here.
Complaint handling
29. Miss H also complains about delays in the Trust responding to her complaint. She says when she eventually received the complaint response, the Trust did not acknowledge any of the failings in Mr H’s care.
30. Our Principles for Remedy say that organisations should acknowledge when something has gone wrong and take action to learn from complaints to ensure similar mistakes do not happen in future.
31. Because we have not seen anything went seriously wrong in Mr H’s care, we would not expect the Trust to acknowledge poor care either when responding to Miss H’s complaint. We have therefore seen no indicated failings in this aspect of the Trust’s complaint handling.
32. We recognise it took the Trust over a year to provide a written response to Miss H’s complaint. We recognise the frustration and distress this will have caused her.
33. We consider it would be disproportionate to take the concern about the delay in responding to Miss H’s complaint forward by itself.
34. This is because as an Ombudsman, we need to maintain a balance between supporting those who complain to us to get a remedy for the injustice they have experienced and ensuring we use our resources to achieve the most impact.
35. We have checked our records, and we have not upheld any other recent complaints about delays in complaint handling at the Trust. We can also see the Trust has already apologised to Miss H for the delay’s in responding to her complaint. We consider further consideration of this matter would not achieve a worthwhile outcome.
36. We are sorry we are unable to take this part of Miss H’s complaint further and in reaching this decision we are in no way underestimating the upset the delays caused her. We hope we have clearly explained the reasons we have decided not to take this further.