County Durham and Darlington NHS Foundation Trust

The complaint

3. Ms O complains about aspects of care and treatment her auntie, Mrs I, received from the Trust in December 2023, when it admitted her for shortness of breath.

4. Specifically, Ms O said the Trust did not do a thorough investigation for Mrs I’s symptoms on both hospital admissions.

5. Ms O said as a result of the claimed failings she believes her auntie’s death was avoidable. Mrs I was her last living auntie. She had to identify Mrs I which she found distressing. She says her auntie was not listened to and disregarded.

6. Ms O is looking for financial remedy, explanation and service improvements.

Background

7. Mrs I was an 81-year-old lady who had a medical diagnosis of mitral regurgitation. This is a heart valve problem where blood leaks backward in the heart instead of flowing the right way. She also had tricuspid regurgitation. This is another heart valve leak but happens on the right side of the heart. Additionally, Mrs I also had aortic regurgitation. This is a heart valve leak where blood flows back towards the heart, after it should have moved forward. As well as these heart issues Mrs I also had diagnoses of anxiety, hypertension and asthma. Anxiety is ongoing worry, nervousness or fear which effects daily life. Hypertension is high blood pressure. Asthma is a lung condition that makes breathing harder because airways get tight and inflamed.

8. Before December 2023, Mrs I’s GP referred her for spirometry testing (to check lung function) and cardiology (heart) review, for further investigation for her pre-existing medical conditions.

9. At the beginning of December 2023, Mrs I attended the Trust with shortness of breath and vomiting. The Trust did a chest X-ray, blood tests and an electrocardiogram (ECG). All the tests came back within normal range. An ECG is a test which records the electrical activity of the heart.

10. The Trust discharged Mrs I, later that day. The plan was for her to follow up with her GP for a spirometry test and cardiology appointments that were still outstanding.

11. The next day, Mrs I reattended the Trust, as her shortness of breath symptoms had got worse. The Trust assessed Mrs I. It tried to prescribe Mrs I medication to help with anxiety and alcohol withdrawal. Mrs I declined the medication. The Trust discharged her.

12. Two days later, sadly, Mrs I died of a pulmonary embolism (PE). This is a clot on the lungs.

The Trust failed to do a thorough investigation into Mrs I’s symptoms on both hospital admissions.

16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complaint about had a negative effect which the organisation has not put right. Having do so we cannot link the events complained about with the negative impact Ms O has claimed.

17. Mrs I attended the Trust with shortness of breath and vomiting. The Trust did a chest X-ray, blood tests and an ECG. All the tests came back within normal range.

18. The Trust discharged Mrs I, later that day, with a plan for her to follow up with her GP for her spirometry test and cardiology appointments that were still outstanding.

19. The next day, Mrs I reattended the Trust, as her shortness of breath symptoms had got worse.

20. The Trust reassessed Mrs I. The Trust noted in her medical records that her shortness of breath increased in the afternoon, after going shopping. The Trust also noted that she said drinking whiskey resolved her symptoms.

21. The Trust assessed Mrs I by listening to her chest, which was clear. It diagnosed her with alcohol withdrawal. This was because she said she drinks whiskey every night and it subsides her anxiety. The Trust completed an alcohol use disorders identification test. Mrs, I scored a nine. This indicates hazardous or harmful drinking. It is clinically classified as increased or medium risk of alcohol related harm. The Trust attempted to prescribe Mrs I chlordiazepoxide. She refused treatment as she did not want to wait for the medication. From what we can see, the Trust did no further investigations or treatment. The Trust discharged Mrs I with a plan for her to contact her GP to speak about her alcohol intake.

22. Two days later, sadly, Mrs I died of a pulmonary embolism.

23. Ms O said Mrs I was not listened to and the Trust overlooked her. She also said the Trust did not do adequate investigations into Mrs I symptoms. She believes Mrs I’s death was avoidable.

24. The Trust responded to Ms O’s complaint. The Trust said after it completed Mrs I’s assessments, it had no concerns. It believed her symptoms may have been related to her anxiety. The Trust said Mrs I was keen to go home. It discharged her with a plan for Mrs I to wait for her referrals to cardiology and spirometry testing, as organised by her GP.

25. The Trust said based on her presentation on both attendances it did not suspect a pulmonary embolism. It said Mrs I did not present with typical symptoms of a pulmonary embolism. The typical symptoms of this appear suddenly and include shortness of breath, sharp chest pain, coughing up blood and a rapid heart rate. Mrs I’s medical records show she had shortness of breath for over a month. Her medical records also show she did not have any other symptoms of a pulmonary embolism.

26. The Trust further said on Mrs I’s second admission, it should have completed a risk assessment for a blood clot. This is known as a D-dimer test. This is a blood test which measures protein fragments left behind when blood clots dissolve. It is used to rule out a pulmonary embolism. The Trust said Mrs I’s medical records show it did not complete this test.

27. The Trust said it had identified areas of Mrs I’s care and treatment which fell below the standard it would expect. It has apologised for this. It said it had identified learning and this will be reflected in an action plan. An action plan is a formal document where the Trust outline specific measurable steps to address failings identified in a complaint. This is to prevent reoccurrence and is often known as service improvements.

28. The Trust provided a second response. The Trust said it only recorded one set of observations for Mrs I’s two admissions. It said a further set should of observations should have been completed based on the time Mrs I was in A&E.

29. The Trust also acknowledged Mrs I’s second attendance was a short period of time after her first admission. It said it should have discussed Mrs I’s re-attendance with a senior clinician and further investigation would have been appropriate.

30. The Trust provided two action plans in its response that it would complete. The Trust said clinicians are to be reminded when patients represent within 72 hours of attendance, the patient must be discussed with a senior clinician as per RCEM guidelines. The Trust also said staff are to be reminded about repeating observations at the appropriate time required, and before a patient is discharged. The Trust have provided us with evidence of the completed action plans. The Trust also apologised for Mrs I’s experience.

31. GMC Good medical practice says doctors should adequately assess the patients’ conditions, taking into account their history, their views and values. Examine the patient promptly and provide or arrange suitable advice, investigations or treatment where necessary.

32. NICE guidelines say doctors should assess the person’s blood pressure, pulse rate, respiratory rate, temperature, level of consciousness and oxygen saturation when experiencing breathlessness.

33. RCEM guidance says patients who have made an unscheduled return to A&E within 72 hours should be reviewed by a senior clinician and be signed off before discharge.

34. Our adviser said the Trust took a detailed medical history from Mrs I, including information of future referrals. It completed a thorough investigation of her symptoms, on the first admission. The Trust did this to be able to examine the patient appropriately and provide them with the most suitable advice, investigation and treatment. This is in keeping with GMC guidance.

35. The Trust also did blood tests, an ECG, a chest X-ray and observations. Observations are routine in any A&E attendance and include taking readings of the patient’s body temperature, heart rate, respiratory rate, blood pressure and oxygen saturation. This is to monitor a patient’s physical condition and detect early signs of clinical deterioration. This is in keeping with NICE guidelines for breathlessness.

36. The Trust also specifically checked for signs of venous thromboembolism (VTE). This is a serious life-threatening condition that occurs when a blood clot blocks blood flow in a vein. This is because blood clots generally start in the leg before traveling up to the lungs. The Trust noted no signs of this. Mrs I’s symptoms of shortness of breath were described as ongoing for weeks. She said she had no chest pain. Her heart rate and oxygen saturation levels were reported as normal.

37. These investigations were all within acceptable limits. The Trust discharged Mrs I with the plan for her to follow up with her GP for the referrals it had made for her, spirometry testing and a cardiology review.

38. Our adviser said the Trust considered all possible problems or conditions that could have explained Mrs I’s symptoms on the first admission at the Trust. There were no obvious clinical signs to suggest a deep vein thrombosis (DVT) or VTE. A DVT is a blood clot in the leg. The adviser told us there is nothing to suggest that anything went wrong on Mrs I’s attendance at the Trust on the first admission date.

39. Mrs I returned to the Trust the next day with worsening symptoms. Mrs I’s medical records show the Trust referred to the investigations it had completed during Mrs I’s admission, the day before. There is no evidence to suggest the Trust completed blood tests on the second admission.

40. The Trust did note in her medical records her calves were soft, and she did not report any cough, chest pain, palpitations or worsening shortness of breath when lying down. These are all symptoms which would potentially suggest a diagnosis of a PE. Our adviser said it is unlikely there would have been any change from the day before.

41. Our adviser said based on Mrs I’s presentation and medical records for both days of attendance at the Trust, there was no indication that anything was seriously wrong or for the Trust to think that she would die on two days later.

42. Our adviser explained because Mrs I re-attended the following day a senior clinician should have reviewed her, as per RCEM guidance. There is no evidence to suggest the Trust did this. Therefore, the Trust did not act in line with RCEM guidelines.

43. Our adviser said if this was done, it may have led to the Trust considering other diagnoses. Our adviser also said it would not have made a difference to the outcome. Mrs I already had appointments to follow up with spirometry testing and a cardiology consultation.

44. In the Trust response, we can see it has have acknowledged what it got wrong and that the care it provided to Mrs I fell below standards to would have expected. The Trust has apologised and within the response, it provided Ms O with two action plans which we have seen evidence that these have been completed.

45. The Trust also said that it should have done a D-Dimer test. Our adviser explained if the Trust had completed a D-Dimer test, it would probably not have changed its actions. This is because Mrs I did not have the clinical presentation or appropriate symptoms for the test to be done.

46. Our adviser said although the Trust did not have a senior clinician review or repeat Mrs I’s observations, it is unlikely that anything would have changed. There was no evidence within Mrs I’s medical records to suggest that she was going to die.

47. Ms O’s outcomes are financial remedy, explanation and service improvements.

48. Our principles of remedy say an appropriate range of remedies may include an apology, explanation and acknowledgement of responsibility and remedial action.

49. We can see the Trust has explained Mrs Is events at the Trust, as well as us explaining what has happened. We can also see the Trust have acknowledged what went wrong and have apologised for this. It has also completed two action plans for service improvements, and we have seen evidence this has been completed by the Trust.

50. We consider this to be a satisfactory outcome.

51. Based on the available evidence, we believe there is nothing to suggest that Mrs I’s death was avoidable. When she presented at hospital on both days, there was no evidence to suggest that she was going to die. Apart from the senior clinician review, the Trust acted in line with guidance. The Trust have remedied the injustice of the senior clinician review by acknowledging this was not followed, apologising and completing the action plans.

52. Ms O says her claimed impact is that Mrs Is death was avoidable. Based on the evidence we have, we believe there would have not been a difference if the Trust had a senior clinician completed a review. We cannot say the actions of the Trust led to Mrs I’s death. We are unable to link the actions of the Trust to Mrs I’s death. For this reason, would not be able to achieve a financial remedy. We cannot see a linked injustice. We have seen no reason for us to consider this further.

53. We recognise how difficult it can be to make a complaint. We would like to thank Ms O for bringing her concerns to us.

1. We have carefully considered Ms O’s complaint about County Durham NHS Foundation Trust (the Trust). We were very sorry to hear about the death of Mrs I and the distress it has caused Ms O.

2. We have decided we cannot link the events to Mrs I’s death.