North West Anglia NHS Foundation Trust

3. Mr O complains about aspects of care and treatment the Trust provided to his wife, Mrs O, between March and August 2023. Specifically, he complains the Trust:

• missed an opportunity to carry out a CT scan on his wife in March • treated his wife for heart failure which she did not have • did not fully investigate his wife’s symptoms of difficulties breathing, and swelling in her arms and leg • did not refer his wife for a hysteroscopy soon enough • discharged his wife without a treatment plan or investigations.

4. Mr O says he feels his wife’s prognosis could have been different if the Trust had conducted scans earlier. He says she suffered both physically and mentally without any treatment plan. Mr O says the events have an impact on his mental health, he says he had plans with his wife for later life, and his children and grandchildren have also suffered.

5. By bringing his complaint to us, Mr O is seeking financial remedy for his children and grandchildren who witnessed Mrs O suffer.

6. On 12 March 2023 Mrs O attended the Emergency Care Centre due to experiencing difficulties breathing and swelling in her arms and legs. The Trust suspected heart failure and admitted her to the cardiac ward.

7. On 23 March the Trust discharged Mrs O.

8. On 11 April Mrs O attended the Emergency Care Centre due to experiencing swelling of her body. The Trust suspected hepatic failure (liver disease) and admitted her. The Trust discharged her two weeks later. The swelling had improved on water tablets, but the Trust were unable to reach a diagnosis.

9. At the end of May, Mrs O attended an appointment with a hepatologist (liver specialist) who wanted to admit her for further tests, she declined this admission.

10. On 24 July the Trust informed Mrs O she had suspected uterine cancer (cancer of the uterus).

11. On 26 July, the Trust carried out a hysteroscopy (a test to look inside the womb, using a thin tube with a small camera inside it) on Mrs O.

12. On 20 August Mrs O attended the Emergency Care Centre due to experiencing sudden onset swelling of her legs. The Trust admitted her.

13. On 25 August Mrs O sadly died.

Investigation of symptoms and discharge without treatment plan

18. Mr O feels the Trust did not fully investigate his wife’s symptoms of difficulty breathing and swelling in her arms and leg. In its response, the Trust explained it carried out numerous investigations, and her care involved staff from different specialities.

19. Mr O also states the Trust discharged Mrs O on 23 March without a treatment plan or investigations. In its response, the Trust explained by 23 March Mrs O felt well, was mobilising independently around the ward, and a referral was sent to the gastroenterology and hepatology department requesting a review for Mrs O in the outpatient clinic.

20. On 12 March Mrs O presented at the ED with combination of shortness of breath and peripheral oedema (swelling of the arms and legs due to fluid build up).

21. NICE guidance on breathlessness states when a patient attends the ED with shortness of breath, staff should ensure a set of observations are completed. History should be taken, an examination should be carried out then appropriate investigations should be undertaken.

22. With reference to history taken there is specific mention of the need to enquire about duration and onset, severity, exacerbating or alleviating factors, exercise tolerance, impact on daily activities, any patterns of breathing problems, associated symptoms, comorbidities, recent surgery, drug history and smoking and travel history.

23. Mrs O’s medical records show most of the above questions were asked when she attended the ED on 12 March. Our ED adviser explained this shows a thorough and appropriate history was taken.

24. NICE guidance suggests patients should undergo a cardiovascular, respiratory and neurological examination looking for signs of possible cardiac, pulmonary or other underlying causes of their breathlessness.

25. There is evidence in the medical records that all the above were examined at the time of Mrs O’s presentation at the ED, again this would suggest a thorough and appropriate examination had been undertaken.

26. The medical records also show the Trust carried out an echocardiogram (ultrasound of the heart) during this first admission.

27. Our ED adviser explained in Mrs O’s case the swelling of the hands was an unusual aspect of the presentation and may have led to a query about the presumed diagnosis.

28. Swelling of the hands can occur in congestive cardiac failure (a chronic condition where the heart is unable to pump blood effectively) but is much less common than lower leg oedema (swelling of the lower limbs).

29. Assessment and investigation of peripheral oedema has less nationally agreed guidance associated with it.

30. Guidance from National Library of Medicine on Peripheral Edema states if the oedema is in both sides of the body and associated with other signs and symptoms (such as breathlessness and bilateral crackles (abnormal lung sounds heard in both lungs) on auscultation of the chest (listening to the chest with a stethoscope), then this would tend to dictate the line of investigation that was followed in Mrs O’s case.

31. The Trust admitted Mrs O for further investigations.

32. On 23 March The Trust discharged Mrs O home with diuretics (water pills that promote the removal of excess fluid from the body) to deal with the swelling. It also referred her to the gastroenterology team for an outpatient review.

33. Taking all this into account, these investigations and subsequent treatment and referrals were appropriate and in line with guidance. The Trust investigated Mrs O’s symptoms to look for the systemic causes of the oedema prior to discharging her.

34. In considering the above evidence, we consider the Trust did fully investigate Mrs O’s symptoms of difficulties breathing and swelling in her arms and leg in line with guidance.

35. We also consider the Trust discharged Mrs O with a treatment plan including onward referral and adequate medication.

Treatment for heart failure

36. Mr O states the Trust treated Mrs O for heart failure which she did not have when she attended the ED on 12 March.

37. In its response, the Trust explained after assessment and investigations in the ED, it suspected Mrs O was suffering from heart failure. The Trust admitted her and transferred her to the cardiac ward.

38. On 12 March Mrs O presented with symptoms of breathlessness on exertion and swelling of her lower legs and arms/hands over the period of one month. This was associated with some orthopnea (breathlessness when lying flat). On examination she had a slight high heart rate and had peripheral oedema of her lower legs and hands and bilateral basal crepitations (abnormal crackling or popping sounds heard at the base of the lungs) were heard on auscultation of her chest.

39. NICE guidance on suspected heart failure lists most of the symptoms Mrs O had.

40. Guidance from National Library of Medicine on diagnosis and management of acute heart failure recommends a thorough history and examination as part of working towards a diagnosis.

41. This guidance goes on to suggest that treatment of patients showing symptoms of acute heart failure is diuretics.

42. In considering this and speaking to our ED adviser, given the information available to the team within the ED when Mrs O presented on 12 March, a diagnosis of acute heart failure was not unreasonable and treatment with intravenous diuretics was an appropriate initial step.

43. We have not found any indications of failings in the Trust’s decision to initially treat Mrs O for heart failure when she attended the ED on 12 March. The Trust also admitted her at this point for further investigations.

CT scan

44. Mr O feels the Trust missed an opportunity to carry out a CT scan on Mrs O in March.

45. In its response, the Trust explained during Mrs O’s admission in March there was nothing in her presenting symptoms that indicated a CT scan would be helpful in reaching a diagnosis. During these admissions, the focus was on alleviating her oedema, fluid retention, shortness of breath and determining if there was a cardiac cause for her symptoms.

46. BJN guidance does not explicitly state a CT scan is required for someone who is showing symptoms of bilateral oedema and difficulty in breathing.

47. Mrs O’s medical records from 22 March highlight a clinician told Mrs O she may require a CT scan based on her weight loss symptoms. Mrs O declined this due to being claustrophobic. Our physician adviser explained an ultrasound scan could have been an alternative option, however it is difficult to say if this would have picked anything up.

48. Our physician adviser explained based on Mrs O’s presentation, there was no clinical need to carry out a CT scan in March, as the clinical team was still working on systemic causes of generalised oedema.

49. In considering the above, we have not found any indication of failings in the Trust not carrying out a CT on Mrs O in March.

Hysteroscopy

50. Mr O states the Trust did not refer his wife for a hysteroscopy soon enough. Mrs O was under the care of different specialisms at different points between March and August.

51. The Gastroenterology and Hepatology department referred Mrs O for a hysteroscopy on 19 July.

52. In its response, the Trust explained when Mrs O initially presented with her symptoms, there was no evidence of her showing any gynaecological conditions. In the absence of these symptoms, there was no suspicion of any gynaecological disease.

53. As shown above, Mrs O initially presented to the Trust with symptoms of bilateral limb oedema and difficulty in breathing. In line with BJN guidelines, a hysteroscopy is not a relevant procedure to assess these symptoms.

54. A CT scan was organised by the outpatient gastroenterology clinic on 10 June. The scan results came back showing thickened cystic endometrium (a condition where the lining of the uterus becomes excessively thickened due to hormonal imbalances), and this team referred Mrs O for a hysteroscopy as well as gynaecology team to review in their multidisciplinary team meeting.

55. Our physician adviser explained the clinical indication to refer Mrs O for a hysteroscopy only arose from the CT scan report. There was not a clinical need to refer Mrs O for a hysteroscopy from the symptoms of oedema she was showing.

56. The medical records show at no point during any of the three ED attendances did Mrs O complain of abdominal or pelvic pain, abnormal vaginal bleeding or discharge or any change in bladder or bowel habits. On all ED attendances Mrs O’s abdomen was examined and was soft, non tender with no palpable masses felt. These things may have suggested gynaecological cancer, in line with NHS guidance, but were not present.

57. We do not consider there was a clinical need for the Trust to refer Mrs O for a hysteroscopy sooner than it did.

58. We appreciate this has been an extremely difficult and sad time for Mr O and his family, we hope they can be reassured that we have taken their concerns seriously.

1. We have carefully considered Mr O’s complaint regarding North West Anglia NHS Foundation Trust’s (the Trust) investigations into his wife, Mrs O’s, symptoms. We are very sorry to hear about Mrs O’s experience and how quickly her condition deteriorated. We recognise how strongly Mr O feels about this complaint, and we are very sorry for his loss.

2. We have seen no indication that anything went seriously wrong with the way the Trust assessed Mrs O’s symptoms, or with the treatment provided. We also did not find any indication of failings with the timescale in which the Trust referred Mrs O for a hysteroscopy, or with the investigations carried out prior to her discharge.