A practice in the Camden area

4. Mr L complains about the care and treatment his father, Mr A received from the Practice on 12 November 2024 when he attended an urgent appointment suffering chest pains. He complains the GP:

• did not perform an ECG • did not refer him for blood tests • did not refer him for urgent care at hospital • did not provide proper safety netting advice • dismissed his symptoms as acid reflux and prescribed lansoprazole (stomach medication) without adequate investigation.

5. Mr L says as the Practice did not act on his symptoms and risk factors to rule out cardiac causes and he suffered a preventable STEMI heart attack the following day which has led to long term heart failure. This has permanently reduced his quality of life as he now experiences breathlessness and fatigue on a daily basis. Simple tasks such as walking short distances, climbing stairs or bathing are now a struggle.

6. He says his life expectancy is reduced, and he suffers constant fear and anxiety of further deterioration. Mr A’s family have had to take on a caregiving role to support him. He has lost independence, and the ongoing financial and emotional toll has had an irreversible impact on his and his family’s wellbeing.

7. As a result of bringing this complaint to us Mr L is seeking an apology, service improvements and level 6 financial remedy.

8. Mr A’s health conditions at the time of events complained about were type 2 diabetes, hypertension (high blood pressure), hypercholesterolemia (high cholesterol), and peripheral vascular disease (narrowed arteries that reduce blood flow to the legs).

9. Mr L says he had stage 3 kidney failure which has now progressed to stage 4 as a result of what happened.

10. On 12 November 2024, Mr A called the Practice complaining of chest pains and shortness of breath. He attended for an urgent face to face appointment and the GP concluded his symptoms were likely caused by acid reflux and suggested he increase his anti-acid medications.

11. In the early hours of 14 November 2024 Mr A went to A&E with 'new onset shortness of breath' for the last 6 hours and he was diagnosed with a heart attack. He was then transferred to another hospital where he underwent angioplasty with stent insertion (procedure to open blocked arteries).

12. Mr A was diagnosed with congestive heart failure (condition where the heart is unable to pump blood effectively round the body) in November 2024 and had a double heart bypass operation in October 2025.

13. Mr L complained to the Practice on 11 August 2025. The Practice sent its response on 29 August and Mr L brought the complaint to us on 6 September 2025.

17. Mr L says on 12 November 2024 his father, Mr A presented to the Practice with textbook cardiac symptoms of central chest pain, exertional pain, relief with rest, shortness of breath and known risk factors. He says an acute STEMI (a type of heart attack) diagnosis was already coded in his records earlier that day by the first doctor he spoke to. He says despite this, during the face-to-face consultation, no ECG or blood tests were done as they should have been.

18.He also says there was no urgent referral to A&E or Cardiology, his symptoms were dismissed/misdiagnosed as acid reflux and no safety netting advice was provided. He says this breaches NICE guidelines advising urgent investigation and referral for his risk patients with chest pain.

19. Mr L says had timely action been taken much of his father’s cardiac damage and his extended hospital stay could have been avoided. He says as a consequence of the Practice’s actions, he now suffers with severe anxiety and chronic heart failure which has significantly reduced his quality of life. He says this could have been avoided if proper assessment and treatment protocols had been followed without delay.

20. In its complaint response, the Practice acknowledges that Mr A had many risk factors for a heart attack. It says at the time he was seen on 12 November 2024 he had been experiencing intermittent chest pains for two weeks that could have been triggered by his heart, stomach, or both, but he did not have a heart attack until the day after.

21.It says that reflecting on what could have been done at that point, it says a referral to cardiology could have been considered but it would not have led to an appointment for a few weeks and would not have avoided the outcome. It says sending him to A&E on the 12 November would likely have led to a normal ECG and blood test as the results from these tests would only change after a full heart attack.

22. The records show that on 12 November 2024, Mr A called the GP Practice asking to speak to a GP about chest pains and shortness of breath. He was added to the emergency list to be triaged by the duty doctor. The duty doctor spoke to Mr A the same morning and Mr A reported experiencing 5 minute chest pains on his left side for the previous 2 weeks, when walking and this was combined with shortness of breath. The duty doctor then arranged an urgent face-to-face appointment for later the same morning with a different doctor.

23. Mr A attended his face-face-appointment at the Practice accompanied by his son and was assessed in person. The GP took his history and examined him. The GP concluded that Mr A’s symptoms were more likely to be caused by acid reflux than angina and suggested he try to increase his anti-acid medications.

24. The GMC guidance says when providing clinical care doctors must adequately assess a patient’s condition, taking account of their history, including symptoms, the patient’s views, and carry out a physical examination where necessary. It also says to promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

25. We can see from the records Mr A spoke to the Practice about his symptoms over the telephone and following this the Practice provided an appointment for him the same day. During the appointment, the GP carried out a physical examination and made a treatment plan based on their assessment. These actions were in line with the GMC guidelines above.

26. The NICE guidance on chest pain say to determine the cause of chest pain: • take a detailed medical history • examine the person • organise appropriate investigations based on the suspected cause, unless immediate hospital admission is necessary.

27. The same guidance also says the initial aim of assessment is to identify or exclude a serious cause of chest pain which needs immediate hospital admission such as coronary syndrome. It says to suspect coronary syndrome if: • pain in the chest or other areas (for example the arms, back or jaw) lasts longer than 15 minutes • chest pain is: dull, central, and/or crushing, associated with nausea and vomiting, sweating or breathlessness, or a combination of these associated with a haemodynamic instability (for example the person has a systolic blood pressure less than 90 mm/Hg) • the chest pain is of a new-onset, or is the result of an abrupt deterioration of stable angina; with pain occurring frequently with little or no exertion, and often lasting longer than 15 minutes

28. The first GP Mr A spoke to took history of his symptoms and noted that over the last two weeks, he had experienced left sided chest pain, associated with breathlessness, that eased after 5 minutes rest. He was not currently experiencing pain. The GP arranged an urgent face-to-face appointment so that a more detailed assessment could take place.

29. The second GP also took a history of Mr A’s symptoms. They established that he was experiencing sharp or burning central chest pain which came on after meals. It was present when walking after the meal and eased with rest. There could be an associated feeling of breathlessness. At other times, Mr A experienced a sensation of water coming into his mouth.

30. The NICE guidance on chest pain state that in taking a history, doctors should ask about the nature, onset, duration, site and radiation of chest pain. As above, the GPs asked about the type of pain, its location and whether it was affecting any other areas of the body and how long it lasted.

31. The NICE guidance on chest pain also advises to ask about factors that exacerbated or relieved the pain and the GPs established that eating and exercise both triggered the pain.

32.The NICE guidance on chest pain also advises to ask about associated symptoms and the GPs found that the pain was accompanied by breathlessness and there was a sensation of water coming into the mouth. Therefore, we consider the GPs took a history of Mr A’s symptoms in line with this guidance.

33. The second GP carried out an examination of Mr A’s blood pressure, chest and abdomen. His blood pressure was slightly raised (but not of concern). Chest examination including assessment of heart sounds and lungs was normal. There was some tenderness over the upper abdomen. This assessment was in line with the NICE guidance on chest pain that advises carrying out a physical examination in patients presenting with chest pain.

34. Our adviser says the fact the pain Mr A described was recurrent, short lived and examination was normal meant there was no sign Mr A was experiencing an acute coronary syndrome (or heart attack) and there was no indication he needed immediate admission to hospital.

35. As there was no suggestion on initial assessment that this was a heart attack, the GP then had to consider the most likely cause of the chest pain.

36. The NICE guidance on chest pain says there are many different potential causes of chest pain including angina (reduced blood flow to the heart), gastro-intestinal (arising from the digestive tract such as gullet or stomach), respiratory (relating to lung conditions) and musculoskeletal (related to joints and muscles). The guidance also says no cause is identified in around 16% of people presenting to primary care with chest pain.

37. We can see both the GPs appropriately considered whether the chest pain could be arising from Mr A’s heart problems.

38. The NICE guidance on chest pain says typical angina presents with all three of the following features:

• precipitated by physical exertion • constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms • relieved by rest of glyceryl trinitrate (GTN) within about 5 minutes.

39. Mr A described to the GP’s how his pain came on with physical exertion and was relieved by rest but also came on after meals. Our adviser said the nature of the pain was sharp or burning and was not typical of angina pain.

40. The fact that the pain was burning or sharp in nature, was brought on by eating, was associated with sensation of fluid coming into Mr A’s mouth, and the upper abdomen was tender on examination, led to the GP’s conclusion that the origin of the pain was most likely to be the digestive tract.

41.Our adviser says the medication that Mr A was taking which included clopidogrel and occasional naproxen, also increased the risk of upper gastro-intestinal symptoms. The GP’s subsequent action of increasing the lansoprazole for four weeks was in keeping with a diagnosis of gastro-oesophageal reflux (heartburn).

42. However, our adviser says Mr A’s symptoms were also consistent with atypical angina (e.g. more unusual or not-typical presentation of angina). Mr A had two of the symptoms of typical angina in that he had pain on exertion that was relieved with rest. He also had other symptoms that were typical of heart-related pain including breathlessness and gastro-intestinal symptoms.

43. The NICE guidance on chest pain says ‘assess for cardiovascular risk factors (such as older age, male sex, smoking, hypertension, diabetes mellitus, increased cholesterol and other lipid levels, and a family history of cardiovascular disease) – risk factors increase the likelihood of significant coronary artery disease’.

44. Mr A had a history of Type 2 Diabetes, Peripheral Vascular Disease, high blood pressure and he had previously smoked. Although he was under 50 years old, his medical conditions and risk factors meant his risk of heart disease was significantly increased.

45. Our adviser says taking into account all of the above, the diagnosis of the cause of his chest pain was not straightforward and it would have been appropriate for the GP to consider referring him for investigations to look for an underlying heart condition.

46. The NICE guidance on chest pain say blood tests and ECG should be considered, depending on the suspected cause of the chest pain.

47. The NICE guidance on angina says ‘for people in whom stable angina cannot be excluded on the basis of the clinical assessment alone, organise a resting 12-lead ECG as soon as possible after presentation, depending on local availability’.

48. The records show the first GP noted it would be possible to arrange an appointment for an ECG the following day, but it is not clear when blood tests could have been arranged. Our adviser said as Mr A had no symptoms to suggest a heart attack there was no indication that he required urgent investigations on the same day he was seen.

49. In line with the NICE guidance on chest pain and angina, we consider the Practice should have requested an ECG and blood tests to investigate the cause of Mr A’s chest pain. The Practice did not do this, and we consider this is an indication of a failing.

50.However, as neither of these investigations would have been carried out, or the results available, within a day, we do not consider this would have changed his management by the Practice.

51. Mr A had no symptoms to suggest acute coronary syndrome or heart attack on 12 November 2024 as his symptoms were recurrent, short-lived, eased with rest and had not been worsening over the two weeks. He had no chest pain when he was seen at the surgery and examination was normal other than a mildly raised blood pressure and upper abdominal tenderness. Therefore, our adviser said there was no reason to admit Mr A to hospital the same day.

52. The NICE guidance on angina says, ‘if the person has typical or atypical angina pain, refer them to a specialist chest pain service to confirm, or exclude the diagnosis of stable angina’.

53. Therefore, given Mr A’s symptoms were suggestive of atypical angina, in line with the NICE guidance on angina the Practice should have referred Mr A to the Local Rapid Access Chest Pain Clinic, run by the cardiology (heart specialist service) to arrange further investigations. The Practice did not do this, and we consider this is an indication of a failing.

54. Our adviser says the length of time to receive an appointment for this service varies between regions. It has been two weeks in the past but in many areas the wait is substantially longer, taking months in some cases. Therefore, even if Mr A had been referred at this point, he would then have had to wait some time for further investigations.

55. We asked our adviser what if any safety netting advice the Practice should have given to Mr A. The British Journal of General Practitioners article from 2019 says, ‘it should include a discussion with the patient on the problem of uncertainty, advice on potential red-flag symptoms, the likely time course of the illness, advice on accessing further medical care, follow-up, and the management of investigations. Safety netting may also include other factors such as providing written information and documenting advice in the medical notes.’

56. Given this, it would have been appropriate for the Practice to document a plan for follow up for Mr A’s symptoms and the circumstances in which he should seek urgent review. The Practice did not do this, and we consider this is an indication of a failing.

57.However, despite the lack of safety netting we can see that Mr A appropriately attended A&E on 14 November when his symptoms worsened so we cannot see any impact from this.

58.Therefore, we have seen indications of failings in that in line with the NICE guidance on chest pain and angina the Practice should have requested an ECG and blood tests, and should have referred him to a Local Rapid Access Chest Pain Clinic, and in line with the British Journal of General Practitioners, should have provided safety netting advice.

59.However, as Mr A deteriorated quickly and had a heart attack the next day, we consider that even if the Practice had taken the above actions, we cannot say that this would have led to any different care or treatment being provided that could have prevented this heart attack. Therefore, we cannot conclude that these indications of failings had any impact on Mr A. As such, we will not be investigating this complaint any further.

60. We understand the quick deterioration of Mr A’s condition and heart attack were a shock for him and his family and do not underestimate the impact this had. Complaints give us a valuable insight into the organisations we investigate. We thank him for bringing this complaint to us and hope he is reassured by our thorough consideration of his complaint and understands why we are taking no further action.

1. We have carefully considered Mr L’s complaint about the Practice. We were very sorry to hear of the difficult time his father, Mr A, has had since suffering a heart attack.

2. We have seen some indications of failings in that the Practice could have offered an ECG, blood tests and referral for further urgent cardiology investigations. It could also have provided safety netting advice. However, we do not consider these things made any difference to the outcome. We cannot see there were any actions taken by the Practice that would have prevented his subsequent heart attack. Therefore, we cannot conclude these indications of failings led to any impact.

3. We do not wish to downplay the seriousness of the issues involved and thank Mr L for bringing his concerns to our attention. We hope the following consideration reassures him we have considered this matter fully and carefully before reaching our decision to take no further action on this complaint. We hope reading this statement does not cause undue upset, as this is not our intention.