North West Anglia NHS Foundation Trust

6. Mr R complains about the care and treatment he received from the Trust in 2023. He complains the Trust missed several opportunities to diagnose his heart condition. As a result, he says he was not provided with care to prevent his further two heart attacks.

7. Mr R says he suffered two heart attacks unnecessarily. This caused pain and distress. He says that he has been left with reduced capacity on both sides of his heart which leads to frequent physical exhaustion. As a result of his experience, Mr R says he has been diagnosed with PTSD, anxiety and depression.

8. Mr R would like an acknowledgement of wrongdoing, an apology, service improvements and a financial remedy.

9. In 2009, following a heart attack, Mr R had a procedure to unblock his right coronary artery (RCA), where a stent was inserted. The RCA is a blood vessel which supplies the heart with blood. A stent is a tube placed in the artery to prevent it from narrowing again.

10. In September 2022 Mr R’s GP referred him to the Trust. Mr R had been experiencing fatigue, weight gain and feeling unwell. The Trust sent Mr R an appointment to attend its cardiology department at the end of February, as an outpatient.

11. Early in February 2023, Mr R presented to the Trust’s emergency department (ED). He was experiencing chest pains, shortness of breath and tingling down his left hand side, arms and fingers.

12. The ED assessed Mr R. Tests showed Mr R’s troponin levels to be elevated at 21-23ng/L. Troponin is a protein released by the heart muscle when it has become damaged and can indicate that enough blood is getting to the heart. A normal level for a healthy adult is around 14ng/L.

13. A blood test showed Mr R’s NT-proBNP level to be 107pg/ml. NT-proBNP is a protein released from the heart’s left ventricle when it is stretched due to its weakening ability to pump blood. An X-ray showed there was no fluid on Mr R’s lungs.

14. The Trust carried out an electrocardiogram (ECG) at 9.40am and repeated this at 11.34am. An ECG shows the heart’s electrical activity and how much blood flow is getting to the heart. It documented there were no changes.

15. The Trust documented two potential conditions which could be causing Mr R’s symptoms. It recorded ACS and worsening left ventricular systolic dysfunction (LVSD). LVSD is when the left ventricle of the heart is unable to pump enough blood around the body. It is a type of heart failure and is not an ACS.

16. NSTEMI and STEMI are both types of acute coronary syndrome (ACS). This is when the heart becomes damaged, usually because a coronary artery is blocked. NSTEMI is when there is no persistent ST elevation on the ECG, indicating blood flow to the heart is partially blocked. STEMI is when there is persistent elevation on the ECG, indicating blood flow to the heart is fully blocked.

17. It noted it was treating Mr R’s presentation as an ACS and started him on anti-platelet and anti-clotting medications. It referred Mr R to its acute medical team, who assessed Mr R and referred him to cardiology.

18. A cardiology nurse assessed Mr R. They documented Mr R’s clinical history and carried out a physical examination. They also reviewed Mr R’s ECG, noted a T wave inversion (a sign on the ECG of previous damage to the heart) and noted this was in keeping with Mr R’s previous heart attack.

19. The Trust discharged Mr R with probable systolic dysfunction. It stopped Mr R’s heart medications and referred him for an echocardiogram to be carried out before his scheduled cardiology appointment. An echocardiogram scans the heart to show how well the heart is pumping blood around the around the body.

20. Three weeks later, Mr R attended his planned cardiology appointment. The consultant cardiologist referred Mr R for tests for carpal tunnel syndrome (when a nerve in the wrist is under pressure causing tingling) and sleep apnoea (when breathing starts and stops during sleep). It advised he wait for his echocardiogram.

21. In April 2023, the Trust booked an appointment for the echocardiogram to take place in May.

22. In May 2023, Mr R presented to the Trust with chest pain. It carried out an ECG which showed a new change. This change indicated a coronary artery was becoming blocked. The Trust started him on medications to prevent his blood from clotting and transferred him to another NHS Trust for further management.

23. The other NHS Trust carried out an angiogram and found Mr R’s RCA was one hundred percent blocked with no blood flow getting to his heart. Mr R had experienced a STEMI. The other NHS Trust tried to unblock Mr R’s RCA but this was unsuccessful. It decided to manage him with medication and a referral for rehabilitation (exercise, education and psychological support). The other NHS Trust discharged Mr R four days later.

24. Mr R presented to the Trust six weeks later, in July, with chest pain. It carried out an ECG which showed a new change. It prescribed anti-clotting medications and transferred Mr R to the other NHS Trust for further management.

25. The other NHS Trust completed an MRI scan, which shows detailed images of the heart. This showed no new heart attack. The other NHS Trust discharged Mr R four days later.

29. Mr R says the Trust missed several opportunities to diagnose his right coronary artery (RCA) had become blocked. He says if it had carried out further investigations it could have prevented his two subsequent hospital admissions and the physical and emotional effects he continues to experience.

30. The Trust said there was nothing to indicate Mr R was in imminent danger of a heart attack in February. It said if an echocardiogram had been performed in early February, it would not have provided any information to show Mr R’s stent was becoming blocked. It said this vessel is too small to be visualised by an echocardiogram.

31. NICE guidelines say following a diagnosis of NSTEMI, and after anti-clotting and anti-platelet medications have been offered, clinicians should assess the patient’s future risk of adverse cardiovascular events using an established risk scoring system. For example, the Global Registry of Acute Cardiac Events (GRACE). The Trust has told us its updated guidelines reflect the History, ECG, Age, Risk Factors and Troponin (HEART) risk scoring. Both are widely used risk prediction tools in patients with acute coronary syndrome.

32. The NICE guidelines say clinicians should use this score to guide clinical management. The risk assessment should include taking the patient’s full clinical history, a physical examination, ECG results and troponin levels.

33. We can see the nurse recorded Mr R’s clinical history and carried out a physical examination, which is in line with NICE guidelines.

34. However, our nurse adviser said as Mr R had been started on the ACS pathway due to his raised troponin levels, it was the nurse’s role was to confirm or exclude a diagnosis of ACS and assess Mr R’s risk.

35. Our nurse adviser said Mr R’s ECG taken at 9.40am showed a subtle ST change which can indicate the heart is not getting enough blood. This is not documented in the records. There is also no documentation in the notes to show Mr R’s elevated troponin was considered. There is also no documented overall risk score.

36. Our nurse adviser said Mr R’s NT- proBNP test did not indicate he had LVSD. They explained that levels of 300pg/ml and above are associated with heart failure. Mr R’s test result was 107pg/ml, indicating LVSD was not the cause of his symptoms. They said this along with a no consideration or explanation of Mr R’s elevated troponin meant there was not enough evidence to dismiss the diagnosis of ACS.

37. We have found the Trust has failed to act in line with the NICE guidelines. It did not properly assess and fully consider Mr R’s risk using all the information it had available. We think if the Trust had acted in line with the NICE guidance, it would have recognised ACS could not be excluded.

38. The NMC Code says nurses must make a timely referral to another practitioner when any action, care or treatment is required.

39. We think if the Trust had properly assessed and considered Mr R’s risk, in line with the NMC Code, the nurse should have discussed Mr R’s case with a cardiologist. We have found the Trust did not act in line with the NMC code when it did not refer Mr R to a cardiologist.

40. We have found that at this point in February 2023, the Trust should have referred Mr R to a cardiologist in line with the NMC Code. We have gone on to consider what should have happened if the Trust had done this.

41. The GMC’s Good Medical Practice says doctors must provide a good standard of care. If they assess or diagnose patients they must adequately assess the patient’s condition, taking account of their history and promptly arrange suitable investigations where necessary.

42. Our cardiology adviser said the Trust’s diagnosis of LVSD was not supported by the evidence. They said Mr R’s NT- proBNP levels did not support a diagnosis of LVSD. Fluid buildup in the lungs is a common sign of LVSD. Our cardiology adviser said the lack of fluid on Mr R’s lungs as shown on his clear X-ray, did not support the diagnosis of LVSD.

43. We therefore think if the Trust had referred Mr R to a cardiologist, the Trust should have assessed Mr R’s condition and reached a diagnosis based on the evidence available, in line with the GMC’s Good Medical Practice. If it had done so, we do not think the Trust would have diagnosed Mr R with probable systolic dysfunction based on the evidence available.

44. ESC guidelines say that chest pain is a leading symptom of ACS. Other symptoms include shortness of breath, epigastric pain (pain below the rib cage) and pain in the left arm. The guidelines say patients who are experiencing NSTEMI might have some changes or no changes on an ECG. This is because the artery is not fully blocked, meaning a smaller area of the heart is damaged which is too small for an ECG to register.

45. The ESC guidelines say a heart attack is diagnosed when a patient meets a combination of criteria. The first criteria is an increase in troponin levels with at least one value above the 99th percentile. This means the patient’s troponin level is at the upper limit of what is considered normal. Then a patient must have at least one the following:

• symptoms that show the heart muscle is not receiving enough blood (chest pain, shortness of breath) • new changes on the ECG which indicate reduced blood flow to the heart • Q waves on an ECG (electrical waves which indicate a past heart attack) • imaging that shows muscle loss to the heart or a new problem with how the heart muscle contracts • a blood clot in the heart.

46. Our cardiology adviser considered the investigations carried out by the Trust during Mr R’s presentation to the ED. They explained Mr R’s troponin level was elevated at 21ng/L and 23ng/L and classed as being above the 99th percentile. They acknowledged troponin can be elevated due to other causes.

47. The Trust’s notes during this admission mentioned Mr R was experiencing cardiac chest pain, but at other times said his presenting symptom was breathlessness without chest pain. Our cardiology adviser acknowledged this would have made assessment more difficult.

48. Our cardiology adviser said an ECG taken on the morning of admission showed a subtle change which had resolved on the ECG taken two hours later. They said these changes are very subtle and would not be diagnostic on their own. They said however, given the context of chest pain, breathlessness and elevated troponin, the ECG would support a diagnosis of coronary artery ischaemia. This is an insufficient supply of blood to the heart muscle caused by a blocked artery.

49. Given Mr R’s history of ischaemic heart disease, elevated troponin levels, subtle changes on the ECG, symptoms of chest pain and breathlessness, our cardiology adviser said his presentation was consistent with an NSTEMI. They noted the Trust did initially consider an ACS as a cause of Mr R’s symptoms and started him on the medications in line with NICE guidelines. These were discontinued on discharge due to the diagnosis of LVSD.

50. We note the Trust documented Mr R had chest pain on admission and no chest pain when the ECG was conducted. We also note the ESC guidelines say breathlessness is equivalent to chest pain as a symptom of the heart not receiving enough blood. The changes on the ECG were subtle and we note the ESC guidelines say patients who have no persistent changes and no changes on ECG may be experiencing an NSTEMI.

51. We therefore think if a cardiologist had reviewed Mr R and had assessed him in line with the GMC’s Good Medical Practice, the Trust should have diagnosed Mr R with an NSTEMI in February 2023 in line with the ESC guidelines.

52. We have also considered what happened at the outpatient appointment Mr R attended three weeks later.

53. When Mr R presented to his outpatient cardiology appointment it is documented he was experiencing shortness of breath and tingling in his left hand. The records document Mr R’s troponin and Pro-BNP tests from three weeks earlier were reviewed. The consultant cardiologist referred Mr R for testing for carpal tunnel syndrome and sleep apnoea. They confirmed an echocardiogram had been arranged. We recognise here that Mr R was later diagnosed with carpel tunnel syndrome.

54. Our adviser said at this appointment there was a further missed opportunity to consider if Mr R was experiencing worsening heart disease caused by lack of blood flow to the heart. They said shortness of breath is a symptom of this, in line with ESC guidelines referred to in paragraph 43.

55. They said that in the absence of a good explanation for Mr R’s high troponin levels and investigations pointing towards an NSTEMI, the Trust should have recommended the appropriate medications and arranged the relevant investigations of Mr R’s coronary arteries. This is in line with NICE guidelines which say patients experiencing NSTEMI should be offered the relevant medications to prevent a heart attack and an angiography to confirm the diagnosis.

56. In summary, we have found the Trust failed to diagnose Mr R with an NSTEMI in line with guidance during his admission. We have also found the Trust missed a later opportunity to consider if a lack of blood flow to the heart was the cause of Mr R’s breathlessness and earlier raised troponin levels in line with guidance. We have gone on to consider the impact these failings had below.

57. NICE guidelines say when a patient’s GRACE score shows they are at low risk of future adverse cardiovascular events, clinicians should consider coronary angiography with a follow on percutaneous coronary intervention (PCI) if necessary. This is a procedure to unblock the RCA before it becomes fully blocked.

58. They also say clinicians should be aware younger patients whose GRACE score are low may still be at high risk of adverse cardiovascular events, and who may benefit from angiography.

59. Our cardiology adviser calculated Mr R’s GRACE score. They said this is likely to have placed Mr R in the low risk category where coronary angiography is recommended. The NICE guidelines which say younger patients with low mortality scores may still be at high risk of adverse cardiovascular events and so coronary angiography may be of benefit.

60. We think the Trust’s investigations made a diagnosis of LVSD unlikely. We have found Mr R’s symptoms were consistent with NSTEMI in line with ESC guidelines. Our adviser said it is common to offer coronary angiography when troponin is raised, unless there is a clear diagnosis which makes coronary heart disease unlikely.

61. NICE guidelines say clinicians should offer anti-platelet and anti-clotting medications to patients who are experiencing NSTEMI.

62. Our adviser explained if the Trust had diagnosed Mr R with an NSTEMI at his first presentation, it would not have discontinued the medications it initially prescribed. These medications are prescribed for one year and reduce the risk of a heart attack. This is in line with NICE guidelines.

63. We consider if the Trust had diagnosed Mr R with NSTEMI, as we have found it should have done, it should have prescribed the relevant medications to reduce the risk of a heart attack. It should also have referred him for coronary angiography in line with NICE guidelines.

64. Our adviser said an inpatient coronary angiography would likely have shown Mr R’s RCA was becoming blocked, but was not fully blocked. They said this would have resulted in a follow on PCI to unblock his RCA and it is likely the procedure could have been attempted prior to it becoming 100% blocked in May. This is in line with NICE guidelines referred to in paragraph 59.

65. The Trust has highlighted that it does not have on site access to PCI, or urgent angio/PCI. It has explained that it has clear referral pathways in place to facilitate the transfer of high-risk patients to a tertiary centre for intervention.

66. On the balance of probabilities, we think it the Trust had arranged to refer Mr R for PCI, this would have prevented the STEMI Mr R experienced in May, along with his admission in July for chest pains. Our adviser pointed to ESC guidance which says angiography reduces the risk of cardiac endpoints such as heart attacks.

67. The records show Mr R had experienced a STEMI in the bottom and back of the heart. As a result, his heart muscle was damaged, and an MRI revealed his heart’s cardiac function was reduced.

68. The records document Mr R’s left ventricular ejection (the percentage of oxygen rich blood pumped out of the heart with every heartbeat) was 38 percent. A normal level is above 55 percent. This indicates Mr R’s heart is not pumping enough oxygen rich blood to meet his body’s needs.

69. The records document Mr R’s right ventricular ejection (the percentage of oxygen poor blood pumped out of the heart, to the lungs, with every heartbeat) was 33 percent. A normal level is above 47 percent. This indicates Mr R’s heart is not pumping enough oxygen poor blood to his lungs to pick up oxygen.

70. Our adviser said Mr R’s impaired cardiac function of the left and right ventricle is unlikely to improve. Our adviser said although it is difficult to put a figure on Mr R’s morbidity (illness and disease) and mortality (death), the STEMI he experienced puts him at higher risk of heart failure especially affecting the right ventricle.

71. Our adviser said Mr R’s admission with chest pains in July was because of the STEMI he had experienced in May. It is understandable Mr R believed he had a heart attack during this admission, considering the chest pain he experienced. The records document no new heart attack was seen on the MRI. We recognise how worried Mr R would have been during this admission.

72. We think the failings we have identified meant that, on the balance of probabilities, Mr R experienced a STEMI in May and resulted in his further admission with chest pain in July. We think it is likely this could have been avoided if the failings we have identified had not occurred, and appropriate treatment had been provided.

73. We recognise this will be distressing for Mr R. This is in addition to the distress he has already experienced because of his hospital admissions, which could have been avoided. We also recognise that during the May and July admissions, Mr R was experiencing pain, which again, we think could have been avoided.

74. Mr R has been left with reduced heart function as a result of the STEMI, and he is at higher risk of heart failure. We recognise how worrying this is, and continues to be for Mr R. We cannot say that his diagnosis of PTSD, anxiety and depression occurred only due to the failure to diagnose him with the NSTEMI. However, we appreciate the consequences of this failing likely contributed to this.

1. We were sorry to hear of the circumstances of Mr R’s complaint. He told us of the significant distress his hospital admissions caused him. We acknowledge just how frightened he must have been. Mr R also told of the physical and emotional impact he continues to experience to this day.

2. We have found the Trust did not act in line with guidance when he presented to ED in February 2023 with symptoms consistent with NSTEMI. This is type of heart attack, caused by the partial blockage of a coronary artery. The lack of blood flow to the heart causes the heart muscle to become damaged. We have found the Trust should have recognised Mr R’s presentation as an NSTEMI in line with guidance.

3. We have also found the Trust missed an opportunity, three weeks later, to consider heart disease as the cause of Mr R’s symptoms.

4. We have found if the Trust had recognised Mr R’s symptoms as NSTEMI, it would have taken action to investigate this further, and to provide treatment. If it had done so, we think this would have led to Mr R’s subsequent STEMI and his further admission to hospital being avoided. STEMI is a severe type of type of heart attack caused by a complete blockage of a coronary artery that causes significant damage to the heart muscle.

5. We acknowledge how distressing these events have been for Mr R. We recommend the Trust provide a full apology to Mr R which explains and acknowledged its failings and the impact of these. We also recommend the Trust pay Mr R £4,250 in recognition of the distress he suffered and the long term impact of the failings on Mr R’s risk of heart failure. We also recommend the Trust produce an action plan to explain how it will stop similar failings from occurring in the future.

75. Through investigating this complaint we have found the Trust failed to properly assess Mr R’s condition and to refer Mr R to a senior clinician when his diagnosis was unclear. We think this led to the Trust failing to recognise Mr R presentation as an NSTEMI. We have also found the Trust missed an opportunity, three weeks later, to consider heart disease as the cause of Mr R’s symptoms.

76. If these failings had not occurred, and the Trust had treated Mr R’s symptoms as NSTEMI, we have found it should have provided medication to reduce the risk of a heart attack. We have also found it should have undertaken further investigations and provided further treatment. On the balance of probabilities, we think this would have led to Mr R’s subsequent STEMI being avoided.

77. Mr R experienced a STEMI in May and an admission with chest pain in July. We think these failings have led to impaired cardiac function and a higher risk of heart failure affecting his right ventricle in the future, which could have been avoided. We also think these events caused Mr R to experience pain and distress.

78. 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. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

79. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

80. We recommend the Trust produces an action plan to address the failings set out in paragraph 75. This should consider why these failings occurred.

81. The action plan should explain what actions the Trust has taken, or will take, to prevent these failings being repeated. The action plan should also explain who is responsible for each of these actions, when the actions will be completed, and how and when the actions will be reviewed to ensure they have been completed and have had the desired effect.

82. The Trust should produce this action plan within 12 weeks of our final report. A copy of the action plan should be sent to us and Mr R to the Care Quality Commission (CQC), and to NHS England

83. 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.

84. In line with this, we recommend the Trust should write to Mr R to acknowledge the failings in its clinical care. The Trust should accept responsibility for these failings and where possible, explain why these failings occurred and apologise for the impact these had.

85. The Trust should write to Mr R with this acknowledgement and apology within four weeks of our final report. The Trust should also send a copy of this letter to us.

86. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

87. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that within four weeks of our final report, the Trust should pay Mr R £4,250 in recognition of the impact of the failings identified in this report.