Manchester University NHS Foundation Trust

5. Dr N complains about the service he received from the Trust between 9 and 10 September 2024.

6. Specifically, Dr N said the Trust:

• unnecessarily admitted him to the Ambulatory Care Unit (ACU) and the Clinical Decision Unit (CDU) after he told the Trust he did not want to be admitted, due to being in the UK on a visitor’s visa • did not communicate the admission to his family.

7. He told us because of this the Trust charged him £837.00 for the admission and treatment. This was because he was an overseas visitor. He said he was left very frustrated and stressed on hearing about the charges. He also told us if he does not pay the charges, he will be unable to obtain any future visitor’s visas to the UK or Australia. This means he will not be able to visit his family.

8. In bringing his complaint to us, Dr N is looking for the charge to be cancelled.

9. This brief background is intended to place the key events in context.

10. Dr N lives in Bangladesh and was in the UK travelling on a visitor’s visa. This entitles him to free emergency treatment only.

11. He has a diagnosis of angina (a type of chest pain caused by the heart not getting enough blood) and has a pacemaker fitted. (A pacemaker is a medical device that helps regulate the heart’s rhythm by sending electrical impulses to the heart muscle, ensuring it beats at a normal rate).

12. In early September 2024, a GP advised Dr N to attend the ED (the emergency department at hospital) the same day for assessment. This was due to electrocardiogram changes (ECG) (an electrocardiogram is a diagnostic test that measures the electrical activity of the heart) and chest pain he was having multiple times a day.

13. Dr N also had significant ST and T wave abnormalities (these are crucial components of an ECG that reflect the heart’s electrical activity and can indicate various heart conditions. The ST wave is the short period between the heart contracting and resetting. The T wave is the period of the heart muscle recharging after each beat) and an issue with atrial sensitivity (the minimum myocardial voltage required for a pacemaker to detect atrial activity. This is crucial for effective cardiac pacing).

14. In the early afternoon Dr N attended the ED with his family. The Trust completed an ECG which identified a new deep inferior T wave inversion (damage to the heart muscles). The Trust completed a troponin blood test (troponin is a protein found in muscles, including the heart. When the heart is injured or damaged, troponin is released into the blood) and reported it as normal.

15. A few hours later, the Trust transferred Dr N to the Ambulatory Care Unit (ACU) with a treatment plan. It requested a chest X-ray.

16. In the early evening, the Trust admitted Dr N to the Clinical Decision Unit (CDU) with a plan for the acute chest pain team to review him.

17. The following day, the Trust overseas team called Dr N’s son in law and told him it would be charging Dr N for treatment. This was because he was an international visitor and the Trust had admitted him. He was travelling on a visa that allowed him to access free emergency treatment only.

18. At 2.17pm Dr N self-discharged, to seek a private cardiology opinion.

21. 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.

Unnecessary admission to ACU and CDU

22. Dr N complains the Trust unnecessarily admitted him to the Ambulatory Care Unit (ACU) and the Clinical Decision Unit (CDU) after he told the Trust he did not want to be admitted, due to being in the UK on a visitor’s visa. He knew he would be charged for any treatment he received if the Trust admitted him. He said when he was in the ED, his daughter repeatedly asked the Trust if he would stay overnight on a ward. He said The Trust told them no.

23. Dr N believes the Trust did not provide any treatment outside of the free emergency treatment scope.

24. The Trust said all attendances at ED are free to all. It is at the point of admission costs will be charged for anyone not entitled to free NHS treatment.

25. The Trust admitted Dr N to the ACU mid-afternoon, on a day in early September. This was based on his ECG results from ED. The plan was to start him on medication to prevent chest pain symptoms and a spray for fast relieve of chest pain. At 4.50pm the Trust requested a chest X-ray. At 6.03pm it transferred him to the CDU. The tests carried out in ACU and CDU were part of Dr N’s inpatient management plan.

26. The Trust said when it transferred Dr N to the ACU from the ED it considered he had been admitted. He was then outside the scope for free treatment.

27. Dr N’s medical records note at 12.29pm the day after he presented in ED, he said he would rather self-discharge than wait to be reviewed by the acute chest pain team. He wanted to seek a private opinion. The Trust provided safety netting advice and he self-discharged at 2.17pm. This was after the Trust had already admitted him as an inpatient.

28. Our adviser noted Dr N had a history of left-sided chest pain/discomfort when walking. This was relieved when resting. They told us this is classical angina (chest pain coming from the heart as a result of a problem in the blood supply to the heart muscle).

29. Dr N’s medical records show on the morning of the ED attendance, he had had prolonged chest pain. This was for five minutes at rest. Then he had chest pain on minimal exertion in the ED. Our adviser explained this would be very concerning. It could suggest a possible heart attack or unstable angina (unstable angina is unpredictable and can occur at rest. It indicates a higher risk of a heart attack).

30. NICE CG95 says recent onset chest pain and risk factors in previously stable angina suggest a coronary syndrome (sudden blockage to a heart valve).

31. NICE NG185 says the history of the patient is important in relation to the nature of the chest pain and the presence of cardiovascular risk factors.

32. Our adviser noted Dr N had several high-risk factors for a heart attack. These were his ethnicity, age, pre-existing diabetes and hypertension (high blood pressure).

33. NICE NG185 also says someone with a sudden deterioration in previously stable angina (as was the case here) is an indication of an acute coronary syndrome. Our adviser said this would also be the case here as Dr N’s chest pain occurred with little exertion while he was in hospital.

34. Although Nice NG185 says you should not assess patients’ symptoms of chest pain in different ethnic groups differently. Our adviser said as Dr N had several high-risk factors, his baseline risk for heart problems was significantly increased. They said this meant the seriousness of Dr N’s symptoms was increased.

35. NICENG185 says you should use a risk assessment score such as a GRACE score (this is the Global Registry of Acute Coronary Events. It is a tool used in cardiology to estimate risks including the risk of heart attack. It combines clinical factors such as age, heart rate, blood pressure and other markers). Our adviser noted the GRACE score for Dr N indicated a 6% probability of death from admission to six months. NICE NG185 guidelines would place him in the intermediate category. NICE NG185 also says this would need admission to hospital to consider angiography (checking the arteries supplying blood to the heart and opening these if needed).

36. Our adviser told us Dr N should have been admitted to hospital as an emergency. They said this was not an excessive treatment decision. His medical history, symptoms and test results suggested there was a significant risk he could have a heart attack imminently and required emergency treatment.

37. Base on the evidence we have seen, we consider the decision to treat Dr N admit him as an inpatient was in line with the above NICE guidance. While our adviser explained DR N required emergency treatment, this was outside the scope of the ED and needed to be provided as inpatient care. We have seen no evidence of an indication of failings in the Trust’s action. We will take no further action.

38. We recognise it was not clear to Dr N that ACU and CDU were classed as an ‘admission’ to the hospital. Given the care in these areas was provided on an urgent basis, this does not change our view on the decision to provide treatment in those hospital areas.

Inpatient admission not communicated to Dr N’s family

39. Dr N complains the Trust did not tell his family about the inpatient admission.

40. He said the Trust moved him from the ED to the ACU then the CDU without notifying his family. He told us a Trust ED doctor told his family they wanted a Trust chest pain nurse to check Dr N. He said the ED doctor said it was nothing to worry about. They told him it might be good to stay and see the chest pain nurse in the morning.

41. Dr N said his family confirmed it was not a ward he would be staying on. He told us the Trust ED doctor said it was not an admission.

42. Dr N is unhappy as the ED doctor was told he did not want to be admitted as he would be charged. He told us his family then left the hospital.

43. The following day the Trust overseas team called his family. They told his son in law Dr N would be charged for the treatment he received.

44. The Trust said ED staff are not responsible for informing patients, who are visiting the UK, about the costs that may be incurred once they are admitted to a hospital ward. Given the results of the ECG, it was necessary to admit Dr N to the ACU. This was to start a treatment plan and further investigations.

45. GMC Good medical practice says ‘you must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options.

46. In providing clinical care you must:

• propose, provide or prescribe effective treatment based on the best available evidence • refer a patient to another suitable qualified practitioner when this services their needs.

47. GMC Good medical practice further says:

‘You must recognise a patient’s right to choose whether to accept your advice and respect their right to seek a second opinion.’

48. The Trust explained its decision to transfer Dr N from the ED to the ACU. The family did not reject this transfer.

49. When Dr N said he wanted to seek private care the following day, the Trust provided safety netting advice. He self-discharged in the early afternoon.

50. Based on the evidence we have seen, we consider the decision to treatment Dr N was in line with GMC Good medical practice. The movement to the ACU was communicated to his family. We are satisfied the Trust acted appropriately. We have seen no evidence of an indication of failings in the Trust’s action. We will take no further action.

51. We recognise this has been a stressful and frustrating time for Dr N. We do not doubt his information and thank him for bringing the complaint to us.

1. We have carefully considered Dr N’s complaint about Manchester University NHS Foundation trust (the Trust). We were sorry to hear his concerns about the service he received from the Trust in September 2024.

2. Dr N is concerned the Trust admitted6 him to the Ambulatory Care Unit (ACU) and the Clinical Decision Unit (CDU) after he told it he did not want to be admitted as an inpatient. This was due to him being in the UK on a visitor’s visa. Based on the information we have considered, it appears the Trust followed relevant guidelines. We have seen no indications that anything went wrong. We have decided to take no further action on this aspect of the complaint for this reason.

3. Dr N also complains the Trust did not communicate the admission to his family. Based on the information we have considered, it appears the Trust followed relevant guidelines. We have seen no indications that anything went wrong. We have decided to take no further action on this aspect of the complaint for this reason.

4. We recognise how important this complaint is to Dr N. We would like to this opportunity to thank him for bringing his complaint to our attention. We hope our explanation below shows how we have considered this complaint and provides him with some reassurance the Trust followed relevant guidelines.