London Ambulance Service NHS Trust

3. Miss A complains about the care provided to her by Guy’s and St Thomas’ NHS Foundation Trust (G&S) on 18 July and 8 August 2022. Specifically:

• Miss A presented at A&E on 18 July 2022 due to worsening symptoms of tachycardia, breathlessness, constant dizziness/light headedness, chest tightness, and a persistent cough. After investigations were carried out, Miss A says her symptoms were wrongly put down to anxiety, and she was discharged without any follow-up • Miss A presented at A&E on 8 August 2022 due to a worsening of the same symptoms, as well as sudden and severe swelling and pain in her left leg which her GP thought could be a DVT. After investigations were carried out, Miss A says her symptoms were not put down to anything specific. Miss A says her symptoms were dismissed and she was told she should not have attended A&E.

4. Miss A says that after months of her symptoms being dismissed by the NHS, she had a private scan which showed a cancerous mass. In October 2022, Miss A had private surgery to remove the mass which would have continued to grow and spread if it had not been treated. Miss A says the way she was treated by the NHS has caused significant psychological harm and led to her being diagnosed with PTSD and anxiety which has required therapy. She now has extreme difficulty trusting health professionals. Because of how large and invasive her tumour had become, Miss A says she needed a full median sternotomy, not a minimally invasive VATS procedure which would have been an option if her tumour had been identified sooner. She also required an anterior pericardiectomy because the tumour was attached to her right atrium. Following the sternotomy and pericardiectomy, Miss A says she developed serious wound infections which progressed into chronic sternal osteomyelitis. She now needs a partial or full sternectomy with titanium reconstruction which is her sixth sternum-related surgery in three years. Miss A says she feels like a 'shell of a person'. She is haunted by the thought she could have died and dreads to think what would have happened if she hadn't been lucky enough to have access to private healthcare through work.

5. As an outcome, Miss A wants acknowledgement of failings by G&S and a financial remedy of at least £12,500.

6. Miss A complains about the care provided to her by King’s College Hospital NHS Foundation Trust (KCH) on 22 August 2022. Specifically:

• Miss A presented at A&E due to severe chest pain, ongoing breathlessness, dizziness, persistent cough, and worsening fatigue. After several hours of delay, some investigations were carried out, but Miss A says she was told there was nothing to worry about and her symptoms were put down to anxiety • the complaint response untruthfully claims that the Trust tried to follow up a concern raised by a radiologist about Miss A having a swollen heart. The Trust claimed it tried to call Miss A and her GP about this, but Miss A says that neither of these things happened.

7. Miss A says that after months of her symptoms being dismissed by the NHS, she had a private scan which showed a cancerous mass. In October 2022, Miss A had private surgery to remove the mass which would have continued to grow and spread if it had not been treated. Miss A says the way she was treated by the NHS has caused significant psychological harm and led to her being diagnosed with PTSD and anxiety which has required therapy. She now has extreme difficulty trusting health professionals. Because of how large and invasive her tumour had become, Miss A says she needed a full median sternotomy, not a minimally invasive VATS procedure which would have been an option if her tumour had been identified sooner. She also required an anterior pericardiectomy because the tumour was attached to her right atrium. Following the sternotomy and pericardiectomy, Miss A says she developed serious wound infections which progressed into chronic sternal osteomyelitis. She now needs a partial or full sternectomy with titanium reconstruction which is her sixth sternum-related surgery in three years. Miss A says she feels like a 'shell of a person'. She is haunted by the thought she could have died and dreads to think what would have happened if she hadn't been lucky enough to have access to private healthcare through work.

8. As an outcome, Miss A wants acknowledgement of failings by KCH and a financial remedy of at least £12,500.

9. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

10. During 2022, Miss A experienced symptoms including chest pains, fatigue, dizziness, swollen calf, elevated white blood cells, and breathlessness which she says indicated a mediastinal mass. This is an abnormal growth in the chest cavity between the lungs. Also, Miss A says she experienced the early stages of super vena cava syndrome which is a group of symptoms caused by the obstruction or compression of the superior vena cava. This is the major vein carrying blood from the upper body to the heart.

11. Unfortunately, Miss A says that when she presented to hospital with these symptoms, as recommended by her GP and the 111 service, she was dismissed and told that nothing was wrong with her. Miss A says the clinical staff that saw her thought she was suffering from anxiety, but this was incorrect.

12. After several months of being dismissed by the NHS, Miss A decided to have a private scan as she was still worried about her health. This revealed a large cancerous tumour which had become attached to her right atrium, imposing her super vena cava and right phrenic nerve. In October 2022, Miss A had private surgery to remove her cancerous tumour.

Care on 18 July 2022

17. Miss A says she presented at A&E on 18 July 2022 due to worsening symptoms of tachycardia, breathlessness, constant dizziness/light headedness, chest tightness, and a persistent cough. After investigations were carried out, Miss A says her symptoms were wrongly put down to anxiety, and she was discharged without any follow-up.

18. We have considered the records with support from our adviser who says the relevant GMC guidance below is applicable:

(15) ‘you must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary.’

(21) ‘clinical records should include:

• relevant clinical findings • the decisions made and actions agreed, and who is making the decisions and agreeing the actions • the information given to patients • any drugs prescribed or other investigation or treatment • who is making the record and when.’

19. Our adviser says that Miss A attended A&E with a history of cough, feelings that her heart was racing, low grade fever, slight headache, and reduced appetite. The discharge diagnoses were suspected viral illness, post infection recovery or related to anxiety. Miss A was safety netted on discharge with GP follow up. Miss A had a chest-x-ray which was reported as normal. She also had a normal ECG.

20. Overall, we consider that Miss A was assessed appropriately when she visited A&E on 18 July 2022, in accordance with the relevant GMC guidance.

Care on 8 August 2022

21. Miss A says she presented at A&E on 8 August 2022 due to a worsening of the same symptoms, as well as sudden and severe swelling and pain in her left leg which her GP thought could be a DVT. After investigations were carried out, Miss A says her symptoms were not put down to anything specific. Miss A says her symptoms were dismissed and she was told she should not have attended A&E.

22. We have considered the records with support from our adviser who says the relevant NICE guidance below is applicable:

1.1.7

For people with a negative proximal leg vein ultrasound scan and a negative Ddimer test result:

stop interim therapeutic anticoagulation, but do not stop:

long-term anticoagulation when used for secondary prevention [2012, amended 2020], or

short-term anticoagulation when used for primary VTE prevention in people with COVID19 (see the recommendations on VTE prophylaxis in the NICE guideline on managing COVID-19) [2023] think about alternative diagnoses [2012, amended 2020]

tell the person that it is not likely they have DVT. Discuss with them the signs and symptoms of DVT and when and where to seek further medical help. [2012, amended 2020]

DVT unlikely (Wells score 1 point or less)

1.1.8

Offer people with an unlikely DVT Wells score (1 point or less):

a Ddimer test with the result available within 4 hours (see the section on D-dimer testing) or

if the Ddimer test result cannot be obtained within 4 hours, offer interim therapeutic anticoagulation while awaiting the result (see the section on interim therapeutic anticoagulation for suspected DVT or PE). [2012, amended 2020]

23. Our adviser says Miss A attended A&E on 8 August 2022 with left leg swelling for a day. Her heart rate was noted to be high, 112 bpm at triage. Miss A’s remaining observations were within normal range. The main concern was the potential of a Deep Vein Thrombosis (DVT). However, blood tests carried out at the time were essentially normal. Therefore, Miss A was discharged back to the care of her GP.

24. Overall, we consider that Miss A was assessed appropriately when she visited A&E on 8 August 2022, in accordance with the relevant NICE guidance.

Care on 22 August 2022

25. Miss A says she presented at A&E on 22 August 2022 due to severe chest pain, ongoing breathlessness, dizziness, persistent cough, and worsening fatigue. After several hours of delay, some investigations were carried out, but Miss A says she was told there was nothing to worry about and her symptoms were put down to anxiety.

26. We have considered the records with support from our adviser who says the relevant NICE guidance below is applicable:

1.2.4 Assessment in hospital for people with a suspected acute coronary syndrome

1.2.4.1

Take a resting 12lead ECG and a blood sample for high-sensitivity troponin I or T measurement (see the section on use of biochemical markers for diagnosis of an acute coronary syndrome) on arrival in hospital. [2010, amended 2016]

1.2.4.2

Carry out a physical examination to determine:

haemodynamic status signs of complications, for example, pulmonary oedema, cardiogenic shock and signs of non-coronary causes of acute chest pain, such as aortic dissection. [2010]

1.2.4.3

Take a detailed clinical history unless a STEMI is confirmed from the resting 12lead ECG (that is, regional STsegment elevation or presumed new LBBB). Record:

the characteristics of the pain other associated symptoms any history of cardiovascular disease any cardiovascular risk factors and details of previous investigations or treatments for similar symptoms of chest pain. [2010]

1.2.5 Use of biochemical markers for diagnosis of an acute coronary syndrome

1.2.5.1

Do not use high-sensitivity troponin tests for people in whom ACS is not suspected. [2016]

1.2.5.2

For people at high or moderate risk of MI (as indicated by a validated tool), perform high-sensitivity troponin tests as recommended in the NICE diagnostics guidance on myocardial infarction. [2016]

1.2.5.3

For people at low risk of MI (as indicated by a validated tool): perform a second high-sensitivity troponin test as recommended in the NICE diagnostics guidance on myocardial infarction if the first troponin test at presentation is positive.

consider performing a single high-sensitivity troponin test only at presentation to rule out NSTEMI if the first troponin test is below the lower limit of detection (negative). [2016]

1.2.5.4

Ensure that patients understand that a detectable troponin on the first high-sensitivity test does not necessarily indicate that they have had an MI. [2016]

1.2.5.5

Do not use biochemical markers such as natriuretic peptides and high-sensitivity C-reactive protein to diagnose an ACS. [2010]

1.2.5.6

Do not use biochemical markers of myocardial ischaemia (such as ischaemia-modified albumin) as opposed to markers of necrosis when assessing people with acute chest pain. [2010]

1.2.5.7

When interpreting high-sensitivity troponin measurements, take into account:

the clinical presentation the time from onset of symptoms the resting 12lead ECG findings the pre-test probability of NSTEMI the length of time since the suspected ACS the probability of chronically elevated troponin levels in some people that 99th percentile thresholds for troponin I and T may differ between sexes. [2010, amended 2016]

27. Our adviser says Miss A attended A&E by ambulance with chest pain on 22 August 2022. She had an ECG and blood tests which were within normal range. Miss A’s chest x-ray showed she had an enlarged heart. Therefore, the records indicate the A&E department contacted Miss A’s GP to arrange further investigations as they could not reach her directly.

28. Overall, we consider that Miss A was assessed appropriately when she visited A&E on 22 August 2022, in accordance with the relevant NICE guidance.

Complaint response

29. Miss A says the KCH complaint response untruthfully claims that the Trust tried to follow up a concern raised by a radiologist about Miss A having a swollen heart. The Trust claimed it tried to call Miss A and her GP about this, but Miss A says that neither of these things happened.

30. We have seen evidence on the case file of a letter from KCH to Miss A’s GP dated 25 August 2022 which refers to her visit to A&E on 22 August 2022. It states that the author was unable to reach Miss A (after her visit to A&E) on several occasions but does not provide any further details. It does not state whether the author is a radiologist as their position is not given, but it is noted that the author comments on what appear to be radiological findings.

31. The complaint response letter from KCH dated 8 August 2023 indicates that the author of the letter from the Trust dated 25 August 2022 was an ED registrar, so this may be the member of staff who says they tried to contact Miss A by telephone after her visit to A&E on 22 August 2022. The mobile phone number quoted in the KCH complaint response letter is the same one that we have on our case file for Miss A. KCH also says that it sent an email to Miss A’s GP at the time.

32. Given this, we asked KCH for some further evidence about its attempts to contact Miss A and her GP after she visited A&E on 22 August 2022. Unfortunately, KCH has been unable to provide us with any additional evidence within our deadline. We also asked Miss A if she had any additional evidence to support her concerns about the complaint response from KCH. She provided us with some additional evidence which we have considered below.

33. Miss A has provided a screen short from her mobile phone which shows a list of her incoming voicemails during 2022. The only voicemails received were during December 2022 which is several months after Miss A visited A&E on 22 August 2022. There is no evidence of any voicemails from the Trust around the time of Miss A’s visit to A&E. We appreciate that if the Trust did call Miss A shortly after her visit to A&E in August 2022, it could have left a voicemail message if she did not answer. However, we do not consider that the evidence provided by Miss A indicates, on the balance of probabilities, that the Trust did not try to call her in August 2022.

34. Miss A has also provided evidence that her GP had to chase KCH for her x-ray results from her visit to A&E on 22 August 2022. This was on 15 August 2023, almost a year later. It appears KCH sent the results to Miss A’s GP later that day. Although there was a delay in KCH sending this information to the GP Practice, we do not consider that it indicates, on the balance of probabilities, that KCH failed to call Miss A or contact her GP in August 2022 shortly after her hospital visit.

35. The NHS complaints standards state: ‘Staff give a clear, balanced account of what happened based on established facts.’

36. As KCH has been unable to evidence that it tried to call Miss A after her visit to A&E on 22 August 2022 or that it sent an email to her GP, as outlined in its complaint response letter dated 8 August 2023, we consider this is a failing by KCH contrary to the NHS complaints standards. However, we are mindful that KCH did write to Miss A’s GP on 25 August 2022 shortly after her visit to A&E. In the circumstances, this is the type of action we would expect to see, and it provides us with assurances about follow-up contacts by KCH after a patient visits hospital. As such, there is no further action for us to take regarding this matter.

37. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.

1. We have not seen any failings in the care provided to Miss A by Guy’s and St Thomas’ NHS Foundation Trust when she attended A&E on 18 July and 8 August 2022. Therefore, we will not uphold Miss A’s complaint about Guy’s and St Thomas’ NHS Foundation Trust.

2. We have not seen any failings in the care provided to Miss A by King’s College Hospital NHS Foundation Trust when she attended A&E on 22 August 2022. We have seen a failing by King’s College Hospital NHS Foundation Trust regarding the content of its complaint response. However, we are satisfied that this has already been adequately addressed by action taken shortly after Miss A’s hospital attendance on 22 August 2022. As such, there is no further action for us to take regarding this matter. Therefore, we will not uphold Miss A’s complaint about King’s College Hospital NHS Foundation Trust.