A practice in the Shropshire area

3. Mrs D complains about aspects of the care and treatment of her father, Mr K, by the Practice between February 2018 and March 2024. She specifically complains the Practice failed to diagnose or treat Mr K’s symptoms of heart failure and diabetes.

4. Mrs D considers there were missed opportunities to diagnose and treat her father which could have led to a better outcome. She says her father suffered in pain and struggled to walk due to his symptoms since 2021. This made day-to-day tasks hard for him and meant he missed out on lots of family events.

5. Mrs D says her and her family, especially Mr K’s grandchildren, have been left heartbroken by his death, and that she has unanswered questions and concerns about his care which makes it difficult to move forward. She considers her father could have still been with her if a correct diagnosis and treatment was given.

6. As an outcome to her complaint, Mrs D is seeking a second opinion, explanation, and service improvements.

7. Mr K had symptoms of ulcers on his feet since 2018. His symptoms progressed over the years, and in 2021 he presented with swollen legs and rashes. The Practice carried out B-type natriuretic peptide (BNP) blood tests (BNP is a hormone that indicates how hard the heart is working to pump blood) which showed Mr K had elevated BNP levels of 517 on 21 April 2021, and 458 on 2 February 2024. Mrs D had concerns that Mr K’s symptoms could be related to diabetes or heart failure, however the Practice said this wasn’t the case, and Mr K was pre-diabetic.

8. Mr K’s condition deteriorated over time, and he struggled with pain and completing normal tasks like getting out of bed. He went to the Emergency Department (ED) at Trust A on 11 March 2024. It carried out blood tests which confirmed his kidney function was high.

9. Trust A moved Mr K to Trust B the next day, 12 March. It diagnosed him as being in acute kidney failure, with complete heart block and heart failure. He sadly died on 19 March with the cause of death as heart block and heart failure.

13. 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.

Missed diagnoses

14. Mrs D complains the Practice missed diagnoses of heart failure and diabetes in her father, Mr K. Mrs D considers her father’s death could have been avoidable if a diagnosis of heart failure was confirmed and treatment provided.

15. In its complaint response, the Practice explained details of echocardiogram results (a scan that uses ultrasound waves to see how well your heart is working) from 2014 onwards. It noted an echocardiogram in October 2019 did not find any significant valve disease which can be corrected with surgery if needed and explained the heart rhythm was regular. It explained an echocardiogram in 2021 showed mild impairment of the left side.

16. NICE heart failure guidance says a diagnosis of heart failure is less likely if a BNP level is less than 400ng/l. For a BNP level between 400–2000 ng/l, you should refer for specialist assessment and echocardiography to be seen within six weeks.

17. Mrs D says over the years, Mr K’s symptoms and observations made by the Practice suggest he had heart failure, including raised BNP levels over 400 on two occasions.

18. Our GP adviser explained a BNP blood test is used to determine if an echocardiogram should be carried out. They explained a raised BNP suggests a probability of heart failure, rather than confirming it, and an echocardiogram is the most useful way to determine heart failure.

19. We have seen evidence Mr K had echocardiograms in 2016, 2019, 2021 and 2024. We reviewed the medical records with the help of our adviser. They explained an echocardiogram in 2016 did not indicate heart failure. A further echocardiogram in 2019 showed bilateral enlargement (the enlargement of both sides of the heart) but the heart function was ok. They explained heart failure is defined in terms of the heart’s function, therefore this meant that there was no heart failure but that the heart had been under strain.

20. Mr K presented with symptoms of swollen legs and feet in April 2021. The Practice carried out blood tests including a BNP test. The test showed a BNP level of 517ng/l. The Practice referred Mr K for an echocardiogram which took place approximately two weeks later. We consider the Practice acted in line with the above guidance by referring Mr K for an echocardiogram within six weeks in response to the elevated BNP level.

21. The echocardiogram results confirmed mild impairment of the left side with no mention of right-side heart failure. Our adviser explained this is when heart failure was confirmed. In response, the Practice prescribed furosemide (a diuretic used to treat fluid retention) and stopped naproxen (non-steroidal anti-inflammatory drug used to reduce swelling and pain).

22. Naproxen can worsen heart failure and put a strain on the kidneys. The Practice rechecked Mr K’s kidney function in May with a view to increasing heart failure treatment. Our adviser explained this is good practice as the medication to treat heart failure can worsen kidney function.

23. The Practice carried out a further BNP test in February 2024 which showed a raised level of 458. It made a referral for an echocardiogram on 21 February. Mr K sadly died on 19 March.

24. Mrs D also complains the Practice missed a diagnosis of diabetes in Mr K, as he had symptoms including ulcers on his feet since 2018. The Practice said Mr K was pre-diabetic. Pre-diabetes is where sugar control is not quite in the normal range but is not poor enough to merit a diagnosis of diabetes.

25. NICE diabetes guidance says persistent hyperglycaemia (high blood sugar level) is defined as HbA1c of 48 mmol/mol (6.5%) or more. It says repeat testing of HbA1C is sensible to confirm a diagnosis of diabetes.

26. A HbA1c test measures glucose levels, giving an average of your blood sugar levels over the past two to three months. It is the primary tool used to screen for pre-diabetes, diagnose diabetes, and monitor how well long-term blood sugar is being managed.

27. We can see the Practice carried out several HbA1C tests between July 2018 and November 2023.

28. We reviewed the results with the help of our adviser. They confirmed the regular blood tests showed the sugar control was not in the diabetic range, and Mr K did not have diabetes but was pre-diabetic.

Summary

29. We acknowledge how devastating the events complained about have been for Mrs D and her family, and we were very sorry to hear of the death of Mr K. We understand she was left with questions about his condition prior to his death.

30. Based on the evidence we have seen, we think the Practice considered heart failure multiple times and carried out appropriate investigations in line with applicable guidelines. We also think the Practice acted appropriately in the investigations it carried out relating to diabetes.

31. We will therefore not consider the complaint further. We hope this statement provides reassurance to Mrs D that the care and treatment provided by the Practice was appropriate.

1. We have carefully considered Mrs D’s complaint about the Practice. We know this complaint is important to Mrs D and we offer our sincere condolences on the death of her father, Mr K.

2. We have seen no indication that anything went seriously wrong with the care and treatment of Mr K. We will therefore not consider the complaint further. We have explained the reasons for our decision below.