Frimley Health NHS Foundation Trust

3. Ms D complains about aspects of the care and treatment Frimley Health NHS Foundation Trust gave her mother, Mrs D, between June and August 2022. Specifically she says: • after Mrs D’s brain bleed resolved following her admission in June 2022, there was a delay in prescribing blood thinners she had previously been prescribed for her heart condition • doctors prescribed Mrs D the heart medication Imdur on 24 July but did not include this medication on the discharge notice of 25 July.

• when blood thinners were prescribed on 9 August, Mrs D was given too much in a short period of time.

4. Ms D says her mother died prematurely because her heart condition was not medicated properly. Because she was then given too much blood thinning medication shortly before her death, it caused a gastrointestinal bleed which contributed to her premature death. Ms D and her sisters have been caused grief, stress and anxiety.

5. She wants the Trust to acknowledge and apologise for its errors. She also wants financial remedy.

6. Mrs D was in her 80s. She had a history of chronic kidney disease, dementia, blindness in both eyes, type-2 diabetes, hypertension (high blood pressure) and ischaemic heart disease.

7. In the last months of her life, she was admitted three times to hospital between June and August 2022, which started when she collapsed at home. During the first of these (6 June to 6 July), she was diagnosed with a traumatic subdural haemorrhage (bleeding in the brain caused by an injury).

8. On 23 July, seventeen days after discharge, Mrs D was readmitted with chest pain and diagnosed with a minor NSTEMI, a type of heart attack caused by a partial blockage in a coronary artery. She was discharged two days later.

9. Soon after, on 29 July, Mrs D was admitted for the last time, with increasing confusion. She was found to have hyponatraemia (low sodium). She developed chest pains and was also diagnosed with a likely upper gastrointestinal (GI) bleed. Sadly, she was never discharged and died in hospital on 11 August. The cause of death was ischaemic heart disease, with secondary causes of GI bleed and chronic kidney disease.

14. Ms D is understandably concerned about the way her mother’s medication was managed and to what extent it had an impact on her death.

15. Mrs D was taking antiplatelet medication (often called ‘blood thinners’, they reduce clot formation) prior to the first admission due to a long-term history of heart disease. The British Heart Foundation’s website explains ‘Antiplatelet medications, such as aspirin and clopidogrel, are commonly used to reduce the risk of heart attack.’

16. When she was admitted on 6 June, Mrs D was found to have experienced a subdural haemorrhage. Therefore, she now had two conditions for which treatments are at odds with each other; treatment for ischaemic heart disease includes antiplatelet therapy, but this increases the risk of bleeding. For patients who are bleeding, antiplatelets are avoided if possible. Doctors needed to balance the risk and benefits of possible treatments.

17. We have considered whether doctors acted in line with Good Medical Practice, which says:

‘In providing clinical care you must: prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’

18. Doctors initially stopped Mrs D’s antiplatelet medication due to the bleeding. As well as increasing the risk of recurrence, antiplatelet therapy can also make any bleeding more severe.

19. On discharge, hospital doctors write to the patient’s GP to explain what investigations took place, the diagnosis, treatment given and any advice as to how the person might be managed in the community. We saw that on this occasion, the hospital team advised the GP to consider restarting aspirin if appropriate. The discharge notice says ‘Aspirin stopped in light of recent ICH [intracerebral haemorrhage] and GP to restart as deemed appropriate as per guidelines following recent ICH’. So they were asking the GP to consider restarting aspirin depending on the changing risks. Our adviser explains that after such a haemorrhage, it is unlikely that aspirin would be restarted immediately. For patients who have had a recent heart attack or stent insertion, restarting aspirin would be more urgent but neither of these applied in Mrs D’s case at this point.

20. On the second admission of 23 July, Mrs D was reviewed during the post-take ward round (the initial consultant review) at around 2.30pm. He prescribed Imdur. The BNF says this is used for prophylaxis (prevention) of angina (chest pain usually caused by heart disease). In other words, its function is to reduce chest pains. It does not improve survival rate or reduce the risk of heart attacks.

21. During a medical review at 10.09am on 25 July, Mrs D’s heart rate was elevated with a pulse of 97. An elevated heart rate is undesirable for a patient with ischaemic heart disease. Consequently, the cardiologist recommended aspirin and an increase in bisoprolol, a type of medication called a beta-blocker medicine used to treat high blood pressure, angina and heart failure. In addition to decreasing heart rate, bisoprolol also lowers blood pressure. Administering it alongside Imdur (which similarly reduces blood pressure) can possibly lead to an excessive drop in blood pressure. Therefore, it is likely that Imdur was now stopped because doctors prioritised bisoprolol, which enhances survival rates in patients with ischaemic heart disease.

22. We can reassure Ms D that Imdur would have no survival benefit and does not reduce the risk of heart attack, so it would not have affected her mother’s risk of death.

23. On 28 July, the day before her last admission, Mrs D had an outpatient appointment with an orthopaedic and trauma surgeon. He noted that her last CT scan showed the subdural haematoma had resolved. He noted that Mrs D’s daughter (who accompanied her to the appointment) was worried about restarting dual antiplatelets as she had recently had a heart attack. The surgeon advised that there was no concern to restart antiplatelet since the hematoma was resolved but Mrs D would need to liaise with cardiology about the benefits and risks of this treatment.

24. Mrs D was admitted to hospital for the next day with chest pains and increasing confusion. She was treated for chronic hyponatraemia.

25. On the morning of 9 August, Mrs D reported ‘crushing chest pain radiating to the right side and arm’. Her troponin level was found to be high. Troponin is a protein found in the muscles. When the heart is injured or damaged, troponin is released into the blood. The most common cause is a heart attack. This was a sign that she had acute coronary syndrome.

26. NICE Treatment Summary ‘Acute coronary syndromes’ says ‘In addition to aspirin, most patients with unstable angina or NSTEMI should be offered a second antiplatelet agent (prasugrel, ticagrelor, or clopidogrel)… Aspirin alone may be appropriate for some patients with a high bleeding risk.’

27. The BNF says that the use of clopidogrel with aspirin increases the risk of bleeding. So doctors had to consider the benefits and risk of treatment. The decision to go for dual action platelet therapy (i.e. adding clopidogrel to the aspirin), single platelet (aspirin only) or none has a subjective element. Evidence in the records shows that several specialists contributed to the decision: cardiologists, neurosurgeons, and geriatricians (doctors specialising in the care of older people). This is in line with Good Medical Practice, which says doctors should ‘work collaboratively with colleagues to maintain or improve patient care.’

28. Mrs D’s risk of further bleeds was recognised. However, the subdual haematoma had resolved and there was no indication at this point she had a GI bleed. Although there remained a risk of bleeding, the immediate danger was her heart condition.

29. Therefore, the situation had now changed and Mrs D was given clopidogrel, and an anticoagulant, fondaparinux, on 9 and 10 August. Doses were in line with the recommendations in the BNF. She then had an episode of upper gastrointestinal bleeding later on 10 August. There was a plan to investigate this with a gastroscopy but later that evening, Mrs D was very unwell and deteriorated further. Her death was confirmed at 1am on 11 August.

30. We do not consider there was a failing in the Trust’s treatment of Mrs D. Evidence shows that Trust doctors considered all relevant factors. She had a background of established heart disease, then a subdural hematoma, and then a heart attack. They considered her management carefully and made appropriate decisions with the evidence they had. Our adviser said the evidence shows that this was not a straightforward choice, but the decision was made after careful consideration of the advantages and disadvantages.

31. As such, management was in line with Good Medical Practice, which says;

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 • …

In providing clinical care you must: • prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence

1. We have carefully considered Ms D’s complaint about the care her mother received from Frimley Health NHS Foundation Trust. We appreciate this was a very distressing time for her and her family.

2. Having carefully considered the relevant evidence, we can reassure Ms D that we have seen no indication there were failings in the Trust’s management of her mother’s health. As such, we do not need to take further action. We explain our decision below.