University Hospitals Dorset NHS Foundation Trust

3. Mr R complains the Trust staff failed to recognise his mother, Mrs R, had a severe heart condition when she attended its ED in October 2024. He also complains that this means the Trust discharged her from its care before it should have done.

4. Mr R says his mother died at home on the day of her discharge, and this was avoidable. He adds that his mother has been deprived of extra years of life, which the family can no longer enjoy with her, and the family was distressed by the nature of her death. He also says that he and his sister-in-law performed cardiopulmonary resuscitation (CPR), with his brother assisting, which was a traumatic experience they never expected to go through.

5. Mr R is seeking a financial remedy, apologies and service improvements.

6. Mrs R was almost 90 years old at the time of these events. She had been ill with Covid19, but had recovered from her main symptom of a bad cough. She still complained of tiredness, a metallic taste in her mouth and poor appetite. When her breathing became shallow and fast she attended the Trust’s ED via ambulance. Trust doctors decided to keep Mrs R in for further tests. They diagnosed her with atrial fibrillation (AF - an irregular heart rhythm) and mild anaemia (iron deficiency). Her heart rate stabilised with medication and she was discharged the next morning.

7. On the evening of her discharge Mrs R became unwell again, with rapid breathing. She also complained of feeling warm and being in pain. Mr R called for an ambulance but before paramedics arrived, Mrs R became unconscious. The 999 operator told Mr R and his brother how to perform CPR. The paramedics arrived and took over CPR. Although they managed to revive Mrs R twice, she was unable to sustain her heart rate on her own. The paramedics advised against a third attempt and Mr R and his brother agreed their mother should not suffer any further or risk a brain injury if she did recover.

8. Sadly, Mrs R died at home, shortly after CPR was stopped. Her cause of death was found to be a blocked left coronary artery – a heart attack.

Recognising Mrs R’s heart condition

12. Mr R was concerned the Trust overlooked signs his mother had something seriously wrong with her heart and therefore was about to have a heart attack. The Trust said there was no indication of any problem beyond Covid-19, AF, and anaemia. As her heart rate had stabilised with medication, it said there was no reason to keep her in hospital. We understand this was a worrying time for Mr R.

13. Mrs R’s symptoms were investigated in the ED. Clinicians in this area should be working to the standards set out in the RCEM Best practice guideline: ‘Patient care in the ED’ (the RCEM guideline). Section 22 says that there should be early use of appropriate point of care tests.

14. As Mrs R was an older person, the EMJ practice review: ‘Emergency department management of older people living with frailty: a guide for emergency practitioners’ (the EMJ guideline) also applies to her care. This says that older people with frailty need holistic assessment of their medical needs, cognitive, functional, and social capabilities. Clinicians should also take into account what the patient wants.

15. Doctors noted that Mrs R had been experiencing shortness of breath, diarrhoea, nausea, tiredness and fatigue. She had a history of high blood pressure. Mr R suspected she had Covid-19, which doctors soon confirmed with testing. More generally they documented her living circumstances and rated her clinical frailty as level four – not dependent on others for daily help, but may be ‘slowedup’ or tired during the day. Mrs R told doctors she would like to go home.

16. Doctors quickly carried out an electrocardiogram (ECG) which measures the electrical impulses to look for heart problems. They carried out blood tests to check for abnormalities, to check Mrs R’s liver and kidneys were functioning properly, and to check for evidence of inflammatory processes. A chest X-ray was ordered to check for signs of pneumonia and nurses carried out regular observations – checks of Mrs R’s breathing rate, blood oxygen levels, blood pressure, pulse and temperature. Our ED adviser said that these were the appropriate tests and examinations for Mrs R’s symptoms. Therefore we think this was in line with the RCEM guideline.

17. The tests found that Mrs R had AF (a common condition in people of Mrs R’s age), Covid-19 and anaemia. The chest X-ray confirmed Mrs R did not appear to have pneumonia, but it did show her heart was enlarged. Our geriatrician adviser explained an enlarged heart can be caused by a lot of conditions, including AF and high blood pressure which Mrs R had. They said neither AF nor an enlarged heart are a reason to be in hospital.

18. The most relevant tests for heart problems were the ECGs and observations. The RCUK guideline: ‘Adult tachycardia’ (the RCUK guideline) says doctors should look for life threatening features in patients, like Mrs R, with a rapid heart rate. Specifically, they should look for shock, loss of consciousness, reduced blood flow to the heart, and severe heart failure. Doctors carried out three ECG tests on Mrs R, which our advisers both agreed only showed evidence of AF.

19. Mrs R did not complain of chest pain and she did not have low blood pressure, which could both indicate a serious issue. In particular, our geriatrician adviser explained there was no evidence of a blocked left coronary artery. If this had been present, Mrs R would already have been feeling very unwell. They did say Covid-19 is known to increase the risk of a blood clot (and therefore a heart attack). This in itself is not a reason to suspect a heart attack and we cannot say this is why Mrs R went on to have one.

20. The RCUK guideline says patients with AF should have their heart rate controlled with beta-blockers. Doctors gave Mrs R bisoprolol, a type of beta-blocker, and after this her heart rate reduced. The Trust’s actions appear to be in line with relevant guidance, and we saw no indication that doctors overlooked a serious heart problem or could have anticipated that she would soon go on to have a heart attack.

Discharge

21. Doctors must follow DHSC statutory guidance: ‘Hospital discharge and community support guidance’ (the DHSC guideline). Annex D sets out the circumstances in which they should consider discharging patients from hospital, and includes a number of questions. If the answer to all these questions is ‘no’, doctors should actively consider discharge.

22. Throughout Mrs R’s time in hospital, the only question to which the answer was sometimes ‘yes’, asked whether her NEWS2 score was greater than three. NEWS2 is a tool which assesses how ill a patient is by measuring breathing rate, temperature, blood pressure, heartrate, and how conscious the patient is. A higher score usually means a person is more ill.

23. Mrs R’s NEWS2 score was five when the Trust admitted her. It was regularly monitored by nurses while she was in hospital. The score dropped to two and three, with one brief increase to four, which reflected a brief increase in her heart rate. The DHSC guideline tells doctors to use clinical judgement in patients with AF. Our adviser explained that this is because their increased heartrate can increase the NEWS2 score without them being unwell or more unwell. Before her discharge the scores had returned to two and three, which meant the answer to all questions was no. This means it was appropriate for doctors to actively consider discharging Mrs R.

24. Doctors had diagnosed Mrs R with AF and anaemia, which our advisers said did not require hospital treatment. NHS information about AF tells the public to see their GP if they think they have symptoms of AF. These conditions do need further investigation and treatment and the Trust planned to arrange outpatient appointments for Mrs R for this. Our geriatrician adviser said that the discharge was appropriate and also in line with Mrs R’s wish to go home. We saw no indication that the Trust was wrong to discharge Mrs R.

25. We have decided not to take further action about Mr R’s complaint. We recognise he had a very unfortunate and traumatic experience when his mother had a heart attack at home. We hope he finds our explanations helpful in bringing a measure of closure to these events.

1. We have carefully considered Mr R’s complaint about the Trust. We have seen no indication the Trust missed signs his mother, Mrs R, had a serious heart problem before it discharged her from its emergency department (ED).

2. We are sorry to learn Mrs R sadly died after she had a heart attack at home. Mr R told us he was involved with attempts to resuscitate his mother and his memories of this, understandably, cause him distress. While we know that nothing can change what happened, we hope he finds our explanations about the care his mother received reassuring.