Guy's and St Thomas' NHS Foundation Trust

5. Dr S complains about the care and treatment she received from the Trust during an admission to hospital between 14 August and 24 August 2024. Specifically, she complains that the Trust:

• failed to recognise and investigate critical cardiovascular (heart and blood) symptoms and potential heart valve disease (problems with the heart valves) • incorrectly recorded that she had been reviewed by a cardiologist • dismissed raised clotting risks despite repeated abnormal D-dimer results (a blood test which can help determine if a person has a blood clotting condition) • failed to communicate critical clinical information to her GP and specialists • denied access to Martha’s Rule (specifically in relation to the right to request a review from a different team) and inadequately responded to her request for a second opinion • failed to investigate abnormal blood pressure readings and pulse pressure abnormalities • inappropriately attributed symptoms to ‘medically unexplained causes’ without assessment • unsafely discontinued her antidepressant medication, leading to withdrawal symptoms • was not transparent during the complaint handling process and did not provide a meaningful retrospective review.

6. Dr S says delays in recognising her symptoms contributed to a decline in her health, including a later diagnosis of heart valve disease.

7. Dr S describes experiencing emotional distress, a loss of trust in healthcare professionals, and concerns about future emergencies being managed incorrectly. She believes the handling of her symptoms, communication, and the way her concerns were interpreted as medically unexplained symptoms have caused her fear, uncertainty, and significant psychological impact.

8. Dr S is seeking clarification about the absence of cardiology involvement in her treatment team, a retrospective cardiovascular review, and accountability for what she feels were missed opportunities to investigate her symptoms. She would also like improved communication with her GP, acknowledgement that her physical symptoDr Should not have been dismissed as ‘medically unexplained’, assurance that policies will be improved for future patients, and a financial remedy.

9. Dr S was admitted to hospital under the care of the Trust on 14 August 2024 after experiencing chest pain and shortness of breath. Initial investigations were carried out by the emergency department on Dr S’s arrival, and these showed raised D-dimer levels. This result was again recorded the following day.

10. Dr S was also reviewed by a consultant physician, and further assessments took place throughout her stay.

11. The consultant physician noted Dr S has a complex clinical history, including multiple long-term physical health conditions. Dr S also experiences conditions affecting her cardiovascular and autonomic functioning.

12. In addition, Dr S has a respiratory condition, mental health difficulties, a low body mass index, and a history of domestic abuse.

13. Dr S told us she was concerned that these factors influenced how her symptoms were viewed, and that her physical symptoms were dismissed as unexplained without being properly assessed.

14. Dr S also told us she was concerned that some of her symptoms, including her blood pressure readings and elevated clotting markers, were not fully investigated at the time.

15. Following her hospital stay, Dr S continued to experience symptoms and later underwent investigations abroad, including a 24 hour ECG or electrocardiogram (a test that records the electrical activity of the heart to check for abnormal rhythms or signs of heart strain or damage) in February 2025 and an echocardiogram (an ultrasound scan that looks at the heart’s structure and function) on 22 May 2025.

16. These tests noted findings consistent with early heart valve disease. Dr S believes these findings may have been present during her 2024 admission and should have been detected at the time.

17. Dr S made a complaint on 22 August 2024, while she was still an inpatient, raising concerns about the consultant’s conduct and about her attempts to request a second opinion under Martha’s Rule. This is an NHS patient safety initiative in England that gives patients, families, and carers the right to request an urgent review if they are worried that a patient’s condition is deteriorating and feel their concerns are not being listened to.

18. After Dr S was discharged on 24 August 2024, she made further complaints on 1 September, 14 October and 16 October 2024. These concerns related to the interpretation of her investigations, the clinical approach taken, communication about her treatment and discharge, and her experience of raising concerns with staff.

19. The Trust provided a combined response to all four complaints on 23 December 2024.

20. Dr S responded on 26 December 2024 with further comments and additional information, including the results of a blood test she had undertaken in November 2024.

21. The Trust then issued its final response on 17 March 2025.

22. Dr S brought her complaint to us on 18 March 2025 as she remained dissatisfied with the Trust’s explanations and remained concerned about her ongoing health.

26. 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.

Issue 1 – failure to recognise and investigate critical cardiovascular symptoms and potential heart valve disease

27. Dr S says the Trust failed to recognise and investigate symptoms suggestive of cardiovascular disease and potential heart valve problems during her admission in August 2024. She believes her later diagnosis of valve disease indicates that these concerns should have been identified at the time.

28. In its complaint responses, the Trust explains appropriate investigations were carried out in response to Dr S’s presentation. It explained that a CT pulmonary angiogram (a specialised CT scan to detect blood clots in the lungs) was completed, which ruled out a pulmonary embolism (a blood clot in the lungs), and that Dr S’s ECGs and observations did not show abnormalities requiring further urgent cardiac investigations.

29. The Trust also explained that an echocardiogram request was reviewed by a consultant cardiologist, who concluded that this was not clinically indicated based on the information available at the time. Four consultants involved in Dr S’s care agreed that an echocardiogram was not required.

30. We do not doubt Dr S’s distress at later being diagnosed with early heart valve disease. The GMC guidance ‘Good medical practice’ says clinicians should base investigations on clinical need and evidence rather than retrospective outcomes. We have considered whether the Trust’s conclusions were appropriate, based on what was known at the time of Dr S’s admission.

31. The NICE guidance ‘pulmonary embolism’ explains that where a patient presents with symptoms such as chest pain or breathlessness and has a raised D-dimer result, clinicians should arrange appropriate imaging to investigate the possibility of pulmonary embolism. This is commonly done using a CT pulmonary angiogram (CTPA). The guidance also explains that where imaging does not show evidence of pulmonary embolism, this would generally exclude the condition.

32. We can see that the Trust undertook appropriate investigations in line with this guidance. The Trust completed a CTPA, which is the appropriate investigation for suspected pulmonary embolism, in line with Dr S’s raised D-dimer levels and chest pain.

33. We can also see an inpatient echocardiogram was requested by the admitting team. This request was reviewed by a cardiologist, who declined it because it did not meet the referral criteria for urgent inpatient echocardiography.

34. These criteria generally include specific clinical indicators such as signs of heart failure, new cardiac murmurs, suspected structural heart disease, or other findings suggesting significant cardiac dysfunction. Based on the information available at the time, the cardiologist concluded these indicators were not present.

35. Our adviser has considered the later finding of coronary calcification (calcium deposits in the heart’s blood vessels) and valve disease. They explain this does not demonstrate that this condition was clinically apparent or detectable during the August 2024 admission. They also explain that coronary calcification identified on CT can be an incidental finding and that there was no evidence that the absence of an inpatient echocardiogram resulted in harm or a missed opportunity to diagnose structural heart disease at that time.

36. Overall, we therefore found no indications of failings in relation to this concern. We hope our above explanation provides some reassurance to Dr S.

Issue 2 – concerns about cardiology input and absence of specialist review

37. Dr S says the Trust incorrectly recorded that her case had been reviewed by a cardiologist and that she was not assessed by an appropriate specialist.

38. In its complaint response, the Trust explains Dr S was under the care of the general internal medicine team, which it considers was appropriate for her presentation.

39. The Trust said the consultant overseeing Dr S’s care acted appropriately and sought specialist input when necessary. It explains the consultant sought input from a consultant cardiologist, to see whether an echocardiogram was indicated. The Trust explained there is no requirement for all patients with chest pain to be seen face-to-face by a cardiologist, particularly when investigations and observations do not indicate acute cardiac disease.

40. We have considered the Trust’s care in line with the GMC guidance ‘Good medical practice’. This says doctors must consult with colleagues and seek specialist input when indicated.

41. Our adviser explained that the consultant responsible for Dr S’s care was acting in a general internal medicine capacity, and agrees this was appropriate for her presentation. They advised it is standard practice for general internal medicine consultants to manage complex medical admissions and to seek specialist input when clinically indicated.

42. In this case, our adviser confirmed that cardiology input was obtained through review of the echocardiogram request and ECG findings. Our adviser explains there is no national requirement that a patient must be reviewed in person by a cardiologist where investigations have been reviewed and deemed not to warrant further specialist involvement.

43. We therefore did not see indications of failings in the Trust’s actions in relation to this concern and consider this was in line with the GMC guidance.

Issue 3 – dismissal of raised clotting risks despite abnormal D-dimer results

44. Dr S says the Trust dismissed her raised clotting risk despite repeatedly elevated D-dimer results. She says this meant she sought further investigation independently.

45. In its complaint response, the Trust explains that Dr S’s raised D-dimer levels were appropriately investigated during the admission. It explains a CT pulmonary angiogram (CTPA) was carried out, which ruled out a pulmonary embolism.

46. The Trust also confirmed that the medical team consulted Dr S’s rheumatologist, who agreed common causes of an elevated D-dimer had been excluded and that no clear cause had been identified. The Trust said Dr S received standard venous thromboembolism prophylaxis (preventative treatment to stop blood clots), and her blood tests did not indicate an ongoing acute clotting event.

47. We have considered the Trust’s care in line with the NICE guidance ‘Pulmonary embolism’. This guidance explains that D-dimer testing should be used alongside a clinical assessment to determine whether imaging is required. It states that if pulmonary embolism is suspected and the D-dimer is raised, diagnostic imaging such as a CTPA should be arranged. It also explains that a negative CTPA is generally sufficient to exclude pulmonary embolism.

48. Our clinical adviser explained that a raised D-dimer is not a diagnosis in itself. It is a marker that may indicate the need for further investigation but can be elevated for a number of reasons, including inflammation or underlying medical conditions.

49. The records show the Trust arranged a CTPA during the admission, which did not show evidence of pulmonary embolism. In line with NICE guidance, this investigation would ordinarily exclude an acute pulmonary embolism. The medical team also considered other potential causes of elevation.

50. We can also see Dr S received venous thromboembolism (VTE) prophylaxis during her admission. NICE guideline for venous thromboembolism recommends that hospital inpatients are assessed for VTE risk and offered preventative treatment where indicated. We understand provision of prophylaxis in this case is consistent with that guidance.

51. Overall, we have not seen indications of failings in the care provided at this time and have not seen evidence to suggest Dr S had a missed pulmonary embolism. We also note this was not diagnosed at a later time. We hope this is reassuring for Dr S.

Issue 4 – failure to communicate critical information to the GP and specialists

52. Dr S says the Trust failed to provide her GP with adequate information about her admission, investigations and treatment, leaving her without appropriate follow up.

53. In its complaint response, the Trust says relevant information was shared appropriately, as a discharge summary was sent to the GP and further findings were available to community clinicians through the shared care record.

54. The Trust confirmed that several consultants reviewed Dr S’s investigations and noted that while inpatient prophylactic anticoagulation was administered, this does not usually appear in discharge summaries because it does not continue after discharge.

55. We have considered the Trust’s communication in line with the GMC guidance ‘Good medical practice,’ which provides information about communication and continuity of care. This says doctors should provide clear and relevant information and should take a proportionate approach to the level of detail.

56. We reviewed the discharge summary and supporting information. We consider the discharge documentation provided was clinically appropriate and contained relevant information for both the GP and the patient.

57. Our adviser also provides further context around the information included, as they explain that some treatments, such as short-term inpatient anticoagulation given as prophylaxis, are not always included in discharge summaries because they do not continue after discharge.

58. We therefore did not see indications of failings in relation to this concern and will not be taking any further action. We hope Dr S finds our explanations reassuring.

Issue 5 – denial of access to ‘Martha’s Rule’ and request for a second opinion

59. Dr S says she was denied access to ‘Martha’s Rule’ and that her request for a second opinion resulted in her being reviewed by the same doctor rather than an independent specialist.

60. We have considered this concern in line with the GMC guidance ‘Good medical practice’ and the ‘Martha’s Rule’ guidance.

61. Martha’s Rule is made up of 3 core components:

• Patients will be asked, at least daily, about how they are feeling, and if they are getting better or worse, and this information will be acted on in a structured way.

• All staff will be able, at any time, to ask for a review from a different team if they are concerned that a patient is deteriorating, and they are not being responded to.

• This escalation route will also always be available to patients themselves, their families and carers and advertised across the hospital.

62. We note the ‘Martha’s Rule’ guidance came into effect in May 2024 and Dr S’s admission was in August 2024. We can see the Trust has also referenced this in its complaint response and says this guidance was still in the process of being implemented and information about this was not yet displayed on the wards. We consider this was reasonable in light of the timeframe between the guidance coming into effect and Dr S’s admission.

63. We have next considered if Dr S’s circumstances met the criteria set out in ‘Martha’s Rule.’ This says:

‘Martha’s Rule recognises that those who know the patient best may be the first to notice changes that could be an early sign of deterioration, and the importance of listening to and acting on the concerns of patients, families and carers. It is being implemented in both adult and children’s inpatient settings in England.’

64. Our adviser explains Martha’s Rule applies where there is clinical deterioration requiring urgent critical care review. We can see Dr S’s observations and assessments were carried out in line with the GMC guidance, and these do not suggest Dr S was experiencing an acute clinical deterioration requiring escalation during her admission.

65. Our adviser also explained that Dr S’s echocardiogram was reviewed by a consultant in heart failure and cardiac imaging. Additionally, it was noted that Dr S was reviewed by four different medical consultants during her admission, and they did not believe an echocardiogram was indicated in this case.

66. We consider this was appropriate and note there is no requirement under NHS England’s Martha’s Rule guidance for a second opinion to be from a particular specialty in the absence of clinical deterioration.

67. We therefore found no indications of failings in relation to this aspect of the complaint.

Issue 6 – failure to investigate abnormal blood pressure and pulse pressure abnormalities

68. Dr S says the Trust failed to investigate abnormal blood pressure readings and pulse pressure abnormalities, which she believes contributed to delayed diagnosis of early heart valve disease.

69. We have considered this concern in line with the NHS England guidance ‘Guidance to support better clinical prioritisation of patients referred for echocardiography’ (GIRFT guidance).

70. This guidance sets out the clinical indications and prioritisation criteria for echocardiography. Its purpose is to ensure echocardiograms are requested and performed when there are appropriate clinical indicators of structural heart disease or cardiac dysfunction, while avoiding unnecessary imaging where there is no clear clinical benefit.

71. We can see Dr S has a documented history of autonomic dysfunction and episodic hypotension (low blood pressure). Our adviser explains that low blood pressure alone is not an indication for inpatient echocardiography and does not necessarily indicate underlying cardiac problems. This view is consistent with GIRFT guidance on echocardiography prioritisation, which supports targeted use of imaging based on clinical indicators.

72. We therefore found no indication that the Trust failed to act appropriately in response to Dr S’s blood pressure readings.

Issue 7 – inappropriate attribution of symptoms to medically unexplained causes

73. Dr S says her symptoms were inappropriately attributed to medically unexplained causes without assessment and that this was discriminatory.

74. In her complaint correspondence, she expressed concern that being a woman, having a history of mental health difficulties, living with complex long-term health conditions, and having experienced domestic abuse may have influenced how clinicians interpreted her presentation.

75. Dr S feels these factors contributed to her symptoms being viewed through a psychological lens rather than being fully investigated as potential physical pathology, which she believes reflects bias in her care.

76. The Trust’s position is that Dr S’s symptoms were thoroughly investigated, and that no medically unexplained diagnosis was made. It explained that clinicians explored psychological factors only as part of a holistic assessment, informed by previous documentation noting emotional vulnerability.

77. The Trust confirmed there was no record of a medically unexplained diagnosis in the notes.

78. Our adviser explained that current clinical practice avoids the term psychosomatic, which Dr S refers to, and instead uses the concept of medically unexplained symptoms, which should only be considered after appropriate investigation.

79. In Dr S’s case, we can see clinicians undertook relevant investigations before raising the possibility that functional or non-organic factors may have been contributing to her symptoms.

80. We also note Dr S has a complex clinical history involving both physical and psychological factors. We consider it was appropriate for clinicians to take Dr S’s wider health history into account when assessing her symptoms. The GMC guidance Good medical practice states that doctors should take a holistic approach to patient care and consider relevant psychological, social and other contextual factors alongside physical symptoms when making clinical assessments and decisions. Considering these factors does not mean physical symptoms are dismissed but rather forms part of a comprehensive clinical assessment.

81. Taking all the evidence into consideration, we found no indication to suggest Dr S’s symptoms were dismissed or that this consideration led to inadequate care.

Issue 8 – discontinuation of antidepressant medication

82. Dr S says her antidepressant medication was stopped abruptly, leading to withdrawal symptoms, and that this affected how her physical symptoms were interpreted.

83. We can see the Trust has acknowledged and apologised for Dr S’s antidepressant medication being stopped. It says this was a result of a prescribing error occurred and confirmed feedback and learning to the staff member involved to prevent this mistake happening again.

84. We can see the Trust also considered if this mistake had a clinical impact on Dr S. This did not find that this mistake had an impact on the assessment of Dr S’s cardiovascular symptoms or the clinical decisions regarding her clotting risk.

85. We have sought advice from our adviser about the likely impact of this mistake. Our adviser confirms this was a mistake with two missed opportunities for correction. However, they explain they agree with the Trust’s view that this mistake did not impact the assessment of Dr S’s symptoms or the clinical decisions, as these were in line with the relevant guidance and standards, as explained earlier in our report.

86. We have next considered the actions the Trust has taken to address this mistake, in line with our NHS Complaint Standards. These say organisations should acknowledge mistakes openly and honestly, provide clear and evidence-based explanations, apologise where appropriate, demonstrate learning, and take steps to prevent the same issues happening again.

87. The Trust acknowledged the prescribing error, apologised to Dr S, and described the learning and feedback provided to staff to reduce the risk of recurrence. We are satisfied that this response is consistent with the expectations set out in our Complaint Standards.

88. We therefore do not see indications to suggest further action is needed in relation to this concern.

Issue 9 – concerns about transparency and retrospective review

89. Dr S says the Trust failed to provide a meaningful retrospective review and was not transparent in its complaint handling.

90. We have reviewed the Trust’s complaint responses and the associated documentation.

91. The evidence shows that the Trust sought input from multiple senior clinicians and provided two detailed written responses addressing the concerns raised. The responses set out the investigations undertaken, the rationale for clinical decisions, and the Trust’s position on each issue.

92. In relation to Dr S’s concerns about communication and specific interactions with staff, including how her symptoms and requests for further review were discussed during her admission, much of the available evidence consists of contemporaneous clinical notes and the differing accounts provided by Dr S and the clinicians involved. In several instances, there is no independent documentary evidence that allows us to establish precisely what was said or how it was conveyed.

93. Where accounts differ and there is no objective evidence to support one version over another, we must consider whether we can reach a view on the balance of probabilities. In this case, we have not identified sufficient independent evidence to conclude that the Trust acted in a deliberately misleading or non-transparent way.

94. The available records support that clinicians documented their assessments and that concerns were considered during the complaint process. However, we acknowledge that Dr S may have experienced the communication differently at the time.

95. Taking all of the evidence into account, we are satisfied that the Trust engaged with the complaint appropriately and that its review process was consistent with the expectations set out in the NHS Complaint Standards, which state that organisations should investigate complaints thoroughly, provide clear explanations, and respond openly and transparently to the concerns raised.

96. Overall, while there were acknowledged communication shortcomings, we have not seen evidence to suggest the complaint handling itself was inadequate or lacked transparency.

Conclusion

97. We appreciate how distressing this experience has been for Dr S, and we do not underestimate its impact on her. We hope this explanation reassures her that we have carefully considered her concerns and why we have not found evidence that anything went seriously wrong in the care she received.

1. We have carefully considered Dr S’s complaint about the care and treatment she received from the Trust between 14 and 24 August 2024. Dr S says the Trust failed to investigate her heart symptoms, and she is concerned this led to a decline in her health.

2. We are sorry to learn of Dr S’s concerns and recognise how difficult and distressing this experience has been for her.

3. We want to reassure Dr S that we have looked carefully at all the available information. We have seen no indication that anything went seriously wrong with the care and treatment the Trust provided, and we consider the actions taken were in line with relevant clinical guidance, professional standards, and the Trust’s own policies.

4. We hope our explanation below helps Dr S understand how we reached our view.