Blackpool Teaching Hospitals NHS Foundation Trust

4. Mrs R complains the first Trust misdiagnosed her father Mr N’s heart attack in November 2022 as angina. She says earlier treatment for a heart attack would have stopped Mr N from experiencing a second heart attack in December 2022, and this would have prevented his premature death in March 2023.

5. Mrs R says as a result of this she was off work with grief and anxiety for over six months and still suffers with panic attacks. She says she has lost faith in the way hospital staff treat elderly patients.

6. Mrs R complains about the following specific issues in relation to the care and treatment the second Trust gave her father between December 2022 and February 2023. She complains: •her father developed flu •the second Trust did not meet his dietary needs.

7. Mrs R says what happened caused her father to lose weight and impacted his overall condition, leading to his sad death. She says as a result of this she was off work with grief and anxiety for over six months and still suffers with panic attacks. She says she has lost faith in the way hospital staff treat elderly patients.

8. The outcomes she seeks from both Trusts are an acknowledgment of the failings identified, an apology and service improvements.

9. Mr N was seen at the emergency department (ED) at the first Trust in November 2022 and was diagnosed with angina (when the heart muscle doesn’t get enough blood, often caused by of an underlying condition, such as blocked arteries).

10. He went back to the first Trust in December with chest pain. The first Trust carried out an assessment and concluded that Mr N had had a heart attack and also had heart failure. The first Trust started Mr N on treatments for both these conditions and discussed his ongoing care with the cardiology team at the second Trust.

11. The next day a senior cardiologist reviewed Mr N. They agreed with the initial assessment and management plan. An echocardiogram confirmed that his heart function showed a significant heart attack. An angiogram two days later confirmed critical coronary disease (blockage in the coronary arteries, which increases the risk of heart attacks or angina). He was referred for surgery and seen by a consultant cardiothoracic surgeon the same day.

12. Mr N was transferred to the second Trust in December for a planned heart operation. He tested positive for flu at the end of December and was treated for this. While he was an in-patient the cardiology and cardiothoracic multidisciplinary meeting (MDT) in January 2023 considered treatment options. The second Trust carried out a coronary artery bypass graft (an operation to improve blood flow to the heart) towards the end of January.

13. Mr N returned to the first Trust towards the end of February. A chest X-ray soon after his transfer showed features of both heart failure and pneumonia. Mr N’s condition deteriorated and sadly he died in mid-March, the cause of death being listed as pneumonia.

18. We understand why Mrs R is concerned about the diagnosis the first Trust made in November 2022, given the fact her father attended a month later having had a heart attack.

19. Our adviser explained a myocardial infarction (MI) is commonly known as a heart attack. This is when blood flow to the heart muscle is suddenly blocked. This prevents oxygenated blood from reaching the heart, which can cause permanent damage or tissue death.

20. The relevant guidance that outlines what a doctor should look for to diagnose a heart attack is outlined in the European Society of Cardiology (ESC) document. This guidance makes clear that for an MI to be suspected there would need to be raised cardiac troponin levels. This is a protein found in muscles. When the heart muscle is damaged, it leaks troponin into the bloodstream.

21. We can see the first Trust checked Mr N’s troponin levels in November, which was in line with the ESC guidance. Troponin levels vary, depending on the specific testing equipment in different NHS hospital trusts. There is no single universal number that says at what level a heart attack should be suspected.

22. The NICE guidance on troponin tests says measurements of what are considered normal troponin levels are anything under 17, and Mr N’s level was 4. Our adviser told us that because of this we can be confident there was no evidence he had had a heart attack.

23. Given Mr N’s medical history, his symptoms that were assessed by the first Trust, and the fact the test results ruled out a heart attack, it was reasonable and in line with the GMC Good Medical Practice guidance to diagnose angina. That guidance says:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a) 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 b) promptly provide or arrange suitable advice, investigations or treatment where necessary.’

24. For this reason we have seen no evidence the first Trust misdiagnosed Mr N, and there are no indications of failings.

25. We looked at what happened at the second Trust to see if we could say there were any indications of failings in the fact that Mr N developed flu.

26. Our adviser explained that the local guidance the second Trust followed was in line with the general accepted guidance at the time, as outlined in the NHS Influenza Toolkit, and that followed by other trusts.

27. This explains when to test for flu:

• ‘Take viral nose and throat swab on admission if influenza is suspected.

• Take viral nose and throat swab from inpatients if they develop symptoms of influenza • DO NOT take viral swabs if the patient does not have any symptoms • Exposed patients that do not have symptoms should not be swabbed – only swab if the patient develops symptoms’.

28. We can see this happened. Our adviser told us there was nothing to suggest influenza should be suspected on admission. When Mr N had a headache the second Trust carried out a flu test, in line with the guidance, and this was negative.

29. When Mr N showed symptoms of flu at the end of December the second Trust undertook the correct action by testing, moving him to a side room and treating him with Tamiflu (antiviral medication). This was in line with the NHS England antiviral guidance, which explained those steps should be taken for patients with flu.

30. Our adviser explained it is not possible for a hospital to completely prevent a patient developing influenza, as this can be spread by any visitors or support staff. They said it appears the second Trust took sensible precautionary measures. For these reasons we would not be able to say Mr N developed flu because of anything the second Trust did or did not do.

31. Government surveillance statistics for the time there were high levels of influenza within the population, and so it is possible for a patient to contract this, no matter what actions a hospital takes.

32. For these reasons we would not be able to say Mr N developed flu because of anything the second Trust did or did not do and we have found no indications of failings.

33. We understand how worrying it was for Mrs R when her father was in hospital, and that seeing him not wanting to eat increased her concerns. We looked at what the second Trust did about this.

34. There is clear evidence in the records that the second Trust tried to meet Mr N’s dietary needs and preferences. The food charts show the staff encouraged Mr N to eat.

35. The NICE guidance on nutrition support says:

‘local arrangements to ensure that people who are malnourished or at risk of malnutrition are offered a management care plan that aims to meet their complete nutritional requirements including underlying conditions, specific circumstances and associated needs.’

36. Our adviser told us the records do not show any issues that mean the second Trust needed to make these local arrangements. There was no evidence of any clinical, communication or cognition issues that would affect dietary intake that the second Trust needed to take action on.

37. The relevant screening tool for malnutrition is the Malnutrition Universal Screening Tool (MUST). We can see that Mr N was low risk for malnutrition according to this when he was admitted. He had no risk factors identified by MUST, no recent weight loss, was considered to have a healthy BMI and there had not been ‘no nutritional intake for more than five days.’

38. The MUST tool also says a trust should act if a patient loses more than 5% of their body weight. The second Trust regularly weighed Mr N and at no time did he lose this amount, his weight fluctuated up and down by a maximum of 3 kgs. Mr N did not reach the level of weight loss to mean that a specialist referral was needed.

39. Our adviser told us it is common for patients to lose weight while in hospital. A BAPEN survey found that in hospitals, 44% of patients were at risk of malnutrition. This can be for a variety of reasons such as not wanting to eat because they feel unwell, depression, not liking the food, or a general loss of appetite due to lack of activity and lack of enthusiasm.

40. The food charts suggest Mr N was choosing not to eat, and the records show the staff encouraged him. Ultimately it is the decision of the patient whether to eat the food provided, and whilst the staff can offer encouragement, they cannot force a patient to eat.

41. We can see the second Trust tried to meet Mr N’s dietary needs in line with guidance quoted. We would not be able to say the actions of the second Trust in relation to his dietary needs caused Mr N to lose weight which impacted his overall condition, leading to his sad death.

42. This is because Mr N was an elderly gentleman with multiple health issues. He had had a serious health condition and had a significant surgical procedure when he had the heart surgery. For these reasons we would never be able to say his sad death almost three weeks later was due to the second Trust not meeting his dietary needs.

43. While malnutrition can have an adverse impact on clinical outcomes, Mr N did not meet the criteria to be considered in the ‘at risk category’ according to the MUST guidance. For this reason we cannot attribute his sad deterioration and death to this.

44. We are truly sorry to read about what happened and the impact this had on Mrs R. We hope our statement clearly explains the reasons why we do not consider we need to explore these matters further.

1. We have carefully considered Mrs R’s complaints. We did not see any indications of failings in relation to the actions of the first Trust. In relation to the second Trust, we could not say there were indications of failings leading to the impact Mrs R claimed.

2. For these reasons we have decided not to consider the complaint further.

3. We were sorry to hear about how much this experience affected Mrs R. We hope she will be reassured by the information in this statement that there is no further action we need to ask the trusts to take.